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1.  Awareness, treatment and control of hypertension among the elderly living in their home in Tunisia 
Background
Hypertension is a cardiovascular disorder rapidly emerging as a major public health problem in developing countries. However, the acknowledgement of the prevalence and the significant impact of hypertension in elderly are very important for health policy. The objective of the present investigation was to evaluate the prevalence, awareness and treatment of hypertension among the elderly living in their home in Tunisia at Monastir City. We also examined the impact of socio-demographic characteristics and known risk factors for high blood pressure.
Methods
A community based sample of 598 non-institutionalized elderly (age ≥ 65 years), was selected using probabilistic multistage cluster sampling.
Results
There was a predominance of female (66%) and mean age was 72.3 ± 7.4 years. The prevalence of hypertension was 52% (n = 311), awareness (81%, n = 252), treatment (78.4%, n = 244) and only 30.7% (n = 75) are correctly treated. The prevalence of hypertension was higher for the female population (55.5%) when compared to males (45%). No urban/rural differences were observed and no difference was observed by educational level. Multiple logistic regression analyses identified a higher body mass index, diabetes mellitus and disability as important correlates of the prevalence of hypertension.
Conclusion
These findings provide important information on the prevalence, awareness and control of hypertension in Monastir City and confirm their association with other cardio-vascular risk factors. Effective public health measures and strategies are needed to improve prevention, diagnosis and access to treatment of this elderly population.
doi:10.1186/1471-2261-11-65
PMCID: PMC3234182  PMID: 22044442
Hypertension; Elderly; Prevalence; Awareness; Tunisia; Home living
2.  Hypertension and Related Morbidity among Geriatric Population of Eastern India 
Materia Socio-Medica  2012;24(1):29-33.
Objectives:
To assess the prevalence of hypertension among geriatric population and to find out its association with socio demographic parameters, non communicable diseases and level of daily activities.
Methodology:
Community based cross sectional study was conducted among geriatric population of Tarakeswar town, India. 402 persons were selected from total 2258 elderly persons by systematic random sampling and data was collected using pretested questionnaire followed by physical examination. Data was analyzed using SPSS Version 16.0.
Results:
53.5% respondents were hypertensive. Prevalence of hypertension was significantly more among higher age group (p=0.031). Hypertension was also associated with Diabetes mellitus (p<0.001), cardiovascular diseases (p<0.001), cerebrovascular accidents (p<0.001) and obesity (p<0.001). 38.46% hypertensives were not under medication. Practice of taking antihypertensive medicines was significantly lower in lower income group (30.8% versus 80.6%; p<0.001) and illiterates (34.0% versus 74.8%; p<0.001). Activities of daily living for self-maintenance and level of satisfaction over life were significantly lower among hypertensives.
Conclusion:
More than half of the elderly are suffering from hypertension. Most of the hypertensives are suffering also from other diseases, resulting in significant reduction of daily activities and compromised satisfaction over life. Hypertension, being a treatable ailment, leaves a space for intervention to reduce these geriatric morbidities.
doi:10.5455/msm.2012.24.29-33
PMCID: PMC3732350  PMID: 23922513
Hypertension; Geriatric; Elderly; Activities of daily living.
3.  Association among Education Level, Occupation Status, and Consanguinity in Tunisia and Croatia 
Croatian medical journal  2006;47(4):656-661.
Aim
To investigate the association between education level, occupation status (a proxy for socio-economic status), and consanguinity in 2 large data sets from Tunisia and Croatia countries with different attitudes toward consanguinity.
Methods
The sample of 1016 students, attending 5 university institutions in Monastir, Tunisia, were interviewed about the educational level and occupation status of their parents and the degree of parental relatedness. In Croatia, a sample of 1001 examinees from 9 isolated island populations was interviewed about their own educational level, occupation status, and consanguinity.
Results
Prevalence of consanguinity (offspring of second cousins or closer) among 1016 Tunisian students was 20.1%, and 9.3% among 1001 Croatian isolates. In Tunisia, the association between consanguinity and both parental degree of education and parental occupation status was highly significant in women (P<0.001), but not significant in men. In Croatia, no statistically significant associations were noted, although there was a consistent trend of increased prevalence of consanguinity with lower education level or occupation status in both genders, but more pronounced in women.
Conclusion
Association between education level, socio-economic status, and consanguinity needs to be taken into account in inbreeding studies in human populations. The relationship may be specific for each studied population and highly dependent on the cultural context. It is generally more pronounced among women in most settings.
PMCID: PMC2080442  PMID: 16912991
4.  The Waist Circumference Measurement: A Simple Method for Assessing the Abdominal Obesity 
Introduction
Excess abdominal fat is an independent predictor of the risk factors and the morbidity of obesity related diseases such as type 2 diabetes, hypertension, dyslipidaemia and cardiovascular diseases. The Waist Circumference (WC) is positively correlated with the abdominal fat. Hence, the waist circumference is a valuable, convenient and a simple measurement method which can be used for identifying the individuals who are at an increased risk for the above mentioned diseases.
Objectives
To assess the abdominal obesity by measuring the waist circumference among the women who were aged 20 years and above in an urban slum of Chennai, India.To identify the socio -demographic factors which were associated with the abdominal obesity in the above study population.
Settings and Design
A community based and a cross sectional study was carried out in an urban slum of Chennai, India.
Methods and Materials
The present study was undertaken in an urban slum of Chennai city, among the women who were aged 20 years and above. One slum was selected randomly and the households in the slum were sampled by a systematic random sampling method. A pre-designed and a pre-tested questionnaire was used to collect the information regarding the socio-demographic profile of the women. Their waist circumference was measured by using a flexible inch tape. As per the World Health Organization (WHO), the International Obesity Task Force (IOTF) and the International Association for the Study of Obesity (IASO)(2000), the following cut off values for the waist circumference were used to assess the abdominal obesity for women: WC<80cms – normal and WC ≥ 80cms-abdominal obesity.
Statistical Analysis
It was done by using the Statistical Package For Social Science (SPSS ), version 11.5. The prevalence was expressed in percentage and the Chi square test was used to find its association with the factors.
Results
In the study population, the prevalence of abdominal obesity (WC ≥ 80 cms) was 29.8% (95% Confidence Interval [CI] 25.9–34 %). A significant association was found between the age, religion, a higher socio-economic status and the abdominal obesity. No significant association was noted between the educational status, occupation, marital status, type of family and the abdominal obesity.
Conclusion
Abdominal obesity among the urban slum women is on the rise. The abdominal obesity was found to be significantly higher among the slum women with increasing age and in those who belonged to the muslim religion and to a higher socio-economic status.
doi:10.7860/JCDR/2012/4379.2545
PMCID: PMC3527782  PMID: 23285442
Waist circumference; Abdominal Obesity; slum women
5.  Factors associated with hypertension prevalence, unawareness and treatment among Costa Rican elderly 
BMC Public Health  2008;8:275.
Background
Reliable information on the prevalence of hypertension is crucial in the development of health policies for prevention, control, and early diagnosis of this condition. This study describes the prevalence of hypertension among Costa Rican elderly, and identifies co-factors associated with its prevalence, unawareness and treatment.
Methods
The prevalence of hypertension is estimated for the Costa Rican elderly. Measurement error is assessed, and factors associated with high blood pressure are explored. Data for this study came from a nationally representative sample of about 2,800 individuals from CRELES (Costa Rica: Longevity and Healthy Aging Study). Two blood pressure measures were collected using digital monitors. Self reports of previous diagnosis, and medications taken were also recorded as part of the study.
Results
No evidence of information bias was found among interviewers, or over time. Hypertension prevalence in elderly Costa Ricans was found to be 65% (Males = 60%, Females = 69%). Twenty-five percent of the studied population did not report previous diagnoses of hypertension, but according to our measurement they had high blood pressure. The proportion of unaware men is higher than the proportion of unaware women (32% vs. 20%). The main factors associated with hypertension are: age, being overweight or obese, and family history of hypertension. For men, current smokers are 3 times more likely to be unaware of their condition than non smokers. Both men and women are less likely to be unaware of their condition if they have a family history of hypertension. Those women who are obese, diabetic, have suffered heart disease or stroke, or have been home visited by community health workers are less likely to be unaware of their hypertension. The odds of being treated are higher in educated individuals, those with a family history of hypertension, elderly with diabetes or those who have had heart disease.
Conclusion
Sex differences in terms of hypertension prevalence, unawareness, and treatment in elderly people have been found. Despite national programs for hypertension detection and education, unawareness of hypertension remains high, particularly among elderly men. Modifiable factors identified to be associated with prevalence such as obesity and alcohol intake could be used in educational programs aimed at the detection and treatment of those individuals who have the condition.
doi:10.1186/1471-2458-8-275
PMCID: PMC2519084  PMID: 18681969
6.  Survival of the fattest: unexpected findings about hyperglycaemia and obesity in a population based study of 75-year-olds 
BMJ Open  2011;1(1):e000012.
Objective
To study the relationship between body mass index (BMI) and mortality among 75-year-olds with and without diabetes mellitus type 2 (DM) or impaired fasting glucose (IFG).
Design
Prospective population-based cohort study with a 10-year follow-up.
Participants
A random sample of 618 of the 1100 inhabitants born in 1922 and living in the city of Västerås in 1997 were invited to participate in a cardiovascular health survey; 70% of those invited agreed to participate (432 individuals: 210 men, 222 women).
Outcome measures
All-cause and cardiovascular mortality.
Results
163 of 432 (38%) participants died during the 10-year follow-up period. The prevalence of DM or IFG was 41% (35% among survivors, 48% among non-survivors). The prevalence of obesity/overweight/normal weight/underweight according to WHO definitions was 12/45/42/1% (14/43/42/1% among survivors, 9/47/42/2% among non-survivors). The hazard rate for death decreased by 10% for every kg/m2 increase in BMI in individuals with DM/IFG (HR 0.91, 95% CI 0.86 to 0.97; p=0.003). After adjustment for sex, current smoking, diagnosed hypertension, diagnosed angina pectoris, previous myocardial infarction and previous stroke/transient ischaemic attack, the corresponding decrease in mortality was 9% (HR 0.92, 95% CI 0.86 to 0.99; p=0.017). These findings remained after exclusion of individuals with BMI<20 or those who died within 2-year follow-up. In individuals without DM/IFG, BMI had no effect on mortality (HR 1.01, 95% CI 0.95 to 1.07; p=0.811). The HR for BMI differed significantly between individuals with and without DM/IFG (p interaction=0.025). The increased all-cause mortality in individuals with DM/IFG in combination with lower BMI was driven by cardiovascular death.
Conclusion
High all-cause and cardiovascular mortality was associated with lower BMI in 75-year-olds with DM/IFG but not in those without DM/IFG. Further studies on the combined effect of obesity/overweight and DM/IFG are needed in order to assess the appropriateness of current guideline recommendations for weight reduction in older people with DM/IFG.
Article summary
Article focus
To explore the combined effect of hyperglycaemia and body mass index (BMI) on all-cause and cardiovascular mortality in the elderly.
Key messages
There was a significant inverse relationship in 75-year-olds with type 2 diabetes mellitus (DM) or impaired fasting glucose (IFG) between BMI and rate of all-cause and cardiovascular mortality.
An obesity paradox or reverse epidemiology was found in 75-year-olds with DM or IFG.
Further studies on the combined effect of obesity/overweight and DM/IFG are needed in order to assess current guidelines for weight reduction in older people with DM/IFG.
Strengths and limitations of this study
Restricting our investigation to one age group enabled us to omit age as a confounding factor, allowing meaningful estimation of the relationship between all-cause and cardiovascular mortality and BMI in individuals with and without hyperglycaemia, despite the relatively small number of study participants. Furthermore, because of the high participation rate, the participants are more representative of the population in a defined geographical area than described in most other studies on this topic. These advantages are, however, offset by difficulty in generalising our findings to those in other age groups and from other geographical areas. Nevertheless, it seems likely that our results are applicable to Northern Europeans and white North Americans in their seventies.
A further limitation of the study is the fact that mortality among invited individuals who did not participate in the study (30%) was considerably higher than among those who participated (70%), mainly reflecting a higher prevalence of diseases under treatment among non-participants.
doi:10.1136/bmjopen-2010-000012
PMCID: PMC3191391  PMID: 22021724
BMI; cardiovascular diseases; elderly; fasting glucose; mortality; obesity paradox; epidemiology; Computers; meta-analysis; statistics; BMJ open
7.  Frailty and cardiovascular risk in community-dwelling elderly: a population-based study 
Background
Evidence suggests a possible bidirectional connection between cardiovascular disease (CVD) and the frailty syndrome in older people.
Purpose
To verify the relationship between CVD risk factors and the frailty syndrome in community-dwelling elderly.
Methods
This population-based study used data from the Fragilidade em Idosos Brasileiros (FIBRA) Network Study, a cross-sectional study designed to investigate frailty profiles among Brazilian older adults. Frailty status was defined as the presence of three or more out of five of the following criteria: unintentional weight loss, weakness, self-reported fatigue, slow walking speed, and low physical activity level. The ascertained CVD risk factors were self-reported and/or directly measured hypertension, diabetes mellitus, obesity, waist circumference measurement, and smoking.
Results
Of the 761 participants, 9.7% were characterized as frail, 48.0% as pre-frail, and 42.3% as non-frail. The most prevalent CVD risk factor was hypertension (84.4%) and the lowest one was smoking (10.4%). It was observed that among those participants with four or five risk factors there was a higher proportion of frail and pre-frail compared with non-frail (Fisher’s exact test: P=0.005; P=0.021). Self-reported diabetes mellitus was more prevalent among frail and pre-frail participants when compared with non-frail participants (Fisher’s exact test: P≤0.001; P≤0.001). There was little agreement between self-reported hypertension and hypertension identified by blood pressure measurement.
Conclusion
Hypertension was highly prevalent among the total sample. In addition, frail and pre-frail older people corresponded to a substantial proportion of those with more CVD risk factors, especially diabetes mellitus, highlighting the need for preventive strategies in order to avoid the co-occurrence of CVD and frailty.
doi:10.2147/CIA.S68642
PMCID: PMC4199970  PMID: 25336932
frailty syndrome; cardiovascular disease; hypertension; aged
8.  Study of addiction problems and morbidity among geriatric population in rural area of Aurangabad district 
Journal of Mid-Life Health  2013;4(3):172-175.
Research Question:
What is the addiction problems and morbidity profile pattern of geriatric population in rural area?
Objectives:
i) To study the morbidity profile of elderly. ii) To study the addiction problems among elderly.
Materials and Methods:
The present study was carried out at the field practice area of Rural Health and Training Center (RHTC), Paithan of Government Medical College, Aurangabad during the period of September 1, 2006 to August 31, 2007. Total elderly population according to the definition at the field practice area of RHTC, Paithan was 3128. Enlisting of the study subjects was done by systematic random sampling by using Loksabha electoral list of 2005. A sample of 20% of total elderly population was taken by including every fifth elderly from the electoral list.
Study Design:
Cross-sectional study
Settings:
Field practice area of RHTC, Paithan of Government Medical College, Aurangabad.
Participants:
Elderly above 60 years of age.
Sample Size:
625 which was 20% of total elderly at RHTC, Paithan.
Statistical Analysis:
Chi-square test.
Results:
a) The study found that the prevalence of addiction among males was 68.34%, the prevalence of various addictions were smoking 29.96%, alcohol 18.18%, tobacco chewing 29.29% and among females, 45.42% elderly females use to chew tobacco. b) Prevalence of cataract was 40.16%, joint pain - 23.04%, chronic obstructive pulmonary disorder (COPD) - 7.52%, senescent forgetfulness - 10.88%, hemorrhoids - 8.64%, benign enlargement of prostate (BEP) - 7.20% in elderly males, hearing impairment - 24.8%, hypertension - 21.6%, diabetes mellitus - 13.92%, and anemia - 8.32%.
doi:10.4103/0976-7800.118999
PMCID: PMC3952409  PMID: 24672190
Addiction problems; geriatric; rural area
9.  Alcohol consumption and metabolic syndrome among Shanghai adults: A randomized multistage stratified cluster sampling investigation 
AIM: To examine the relations of alcohol consumption to the prevalence of metabolic syndrome in Shanghai adults.
METHODS: We performed a cross-sectional analysis of data from the randomized multistage stratified cluster sampling of Shanghai adults, who were evaluated for alcohol consumption and each component of metabolic syndrome, using the adapted U.S. National Cholesterol Education Program criteria. Current alcohol consumption was defined as more than once of alcohol drinking per month.
RESULTS: The study population consisted of 3953 participants (1524 men) with a mean age of 54.3 ± 12.1 years. Among them, 448 subjects (11.3%) were current alcohol drinkers, including 405 males and 43 females. After adjustment for age and sex, the prevalence of current alcohol drinking and metabolic syndrome in the general population of Shanghai was 13.0% and 15.3%, respectively. Compared with non drinkers, the prevalence of hypertriglyceridemia and hypertension was higher while the prevalence of abdominal obesity, low serum high-density-lipoprotein cholesterol (HDL-C) and diabetes mellitus was lower in subjects who consumed alcohol twice or more per month, with a trend toward reducing the prevalence of metabolic syndrome. Among the current alcohol drinkers, systolic blood pressure, HDL-C, fasting plasma glucose, and prevalence of hypertriglyceridemia tended to increase with increased alcohol consumption. However, low-density-lipoprotein cholesterol concentration, prevalence of abdominal obesity, low serum HDL-C and metabolic syndrome showed the tendency to decrease. Moreover, these statistically significant differences were independent of gender and age.
CONCLUSION: Current alcohol consumption is associated with a lower prevalence of metabolic syndrome irrespe-ctive of alcohol intake (g/d), and has a favorable influence on HDL-C, waist circumference, and possible diabetes mellitus. However, alcohol intake increases the likelihood of hypertension, hypertriglyceridemia and hyperglycemia. The clinical significance of these findings needs further investigation.
doi:10.3748/wjg.14.2418
PMCID: PMC2705101  PMID: 18416473
Alcohol; Metabolic syndrome; Obesity; Type 2 diabetes; Epidemiology; Chinese
10.  Trends in Hypertension Prevalence, Awareness, Treatment and Control in Older Mexican Americans 1993 –2005 
Annals of epidemiology  2010;21(1):15-25.
PURPOSE
To describe trends in hypertension prevalence, awareness, treatment, and control among older Mexican Americans living in the Southwestern United States from 1993-94 to 2004-05.
METHODS
This is a comparison between two separate cross-sectional cohorts of non-institutionalized Mexican Americans aged ≥ 75 from the Hispanic Established Population for the Epidemiological Study of the Elderly (919 subjects from the 1993–1994 cohort and 738 from the 2004–2005 cohort). Data were collected on self-reported hypertension, measured blood pressure, medications, socio-demographic, and other health-related factors.
RESULTS
Hypertension prevalence increased from 73.0% in 1993-94, to 78.4% in 2004-05. Cross-cohort multivariate analyses showed that the higher odds of hypertension in 2004-05 cohort was attenuated by adding diabetes and obesity to the model. There was a significant increase in hypertension awareness among hypertensives (63.0% to 82.6%) and in control among treated hypertensives (42.5% to 55.4%). Cross-cohort multivariate analyses showed that the higher odds of control in 2004-05 cohorts was accentuated by adding diabetes to the model. There were no significant changes in treatment rates (62.2% to 65.6%)
CONCLUSION
Hypertension prevalence in very old Mexican Americans residing in the Southwestern United States was higher in 2004-05 than in 1993-94, and was accompanied by a significant increase in awareness and control rates.
doi:10.1016/j.annepidem.2010.06.002
PMCID: PMC2994956  PMID: 20727787
Trends; Hypertension; Awareness; Treatment; Control; Mexican American elders
11.  Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001459.
Using data from the Indian Migration Study, Christopher Millett and colleagues examine the associations between active travel to work and overweight, hypertension, and diabetes.
Please see later in the article for the Editors' Summary
Background
Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes.
Methods and Findings
Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58–0.88) or bicycling to work (ARR 0.66; 95% CI 0.55–0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36–0.71) or diabetes (ARR 0.65; 95% CI 0.44–0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found.
Conclusions
Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs) and obesity (excessive body fat) are major threats to global health. Every year, more than 36 million people (including 29 million in LMICs) die from NCDs—nearly two-thirds of the world's annual deaths. Cardiovascular diseases (conditions that affect the heart and the circulation), diabetes, cancer, and respiratory diseases are responsible for most NCD-related deaths. Obesity is a risk factor for all these NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. In 2008, 35% of adults were overweight and 11% were obese. One reason for the growing burden of both obesity and NCDs is increasing physical inactivity. Regular physical activity helps to maintain a healthy body weight and to prevent or delay the onset of NCDs. For an adult, 30 minutes of moderate physical activity—walking briskly or cycling, for example—five times a week is sufficient to promote and maintain health. But the daily lives of people in both developed and developing countries are becoming increasingly sedentary and, nowadays, at least 60% of the world's population does not do even this modest amount of exercise.
Why Was This Study Done?
Strategies to increase physical activity levels often promote active travel (walking, cycling, and using public transport). The positive impact of active travel on physical activity levels and cardiovascular health is well established in high-income countries, but little is known about the patterns of active travel or the health benefits associated with active travel in poorer countries. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers examine the mode and duration of travel to work in rural and urban India and associations between active travel and overweight/obesity, hypertension (high blood pressure, a risk factor for cardiovascular disease), and diabetes. In India, a lower middle-income country, the prevalence of overweight and NCDs is projected to increase rapidly over the next two decades. Moreover, rapid unplanned urbanization and a large increase in registered motor vehicles has resulted in inadequate development of the public transport infrastructure and hazardous conditions for walking and cycling in most Indian towns and cities.
What Did the Researchers Do and Find?
For their study, researchers analyzed physical activity and health data collected from participants in the Indian Migration Study, which examined the association between migration from rural to urban areas and obesity and diabetes risk. People living in rural areas were more likely to cycle to work than people living in towns and cities (68.3% versus 15.9%). Among people who travelled to work by private transport, public transport, walking, and cycling, the prevalence of overweight or obesity was 50.0%, 37.6%, 24.9%, and 24.2%, respectively. Similar patterns were seen for the prevalence of hypertension and diabetes. After adjustment for factors that affect the risk of obesity, hypertension, and diabetes (for example, daily fat intake and leisure time physical activity), people walking or cycling to work were less likely to be overweight or obese than those travelling by public transport, and those cycling to walk were less likely to have hypertension or diabetes. Finally, people with long cycle rides to work had a lower risk of being overweight or having hypertension or diabetes than people with short cycle rides.
What Do These Findings Mean?
These findings suggest that, as in high-income settings, walking and cycling to work are associated with a reduced risk of cardiovascular disease in India. Because this was a cross-sectional study, these findings do not prove that active travel reduces the risk of cardiovascular disease—people who cycle to work may share other unknown characteristics that are actually responsible for their reduced risk of cardiovascular disease. Moreover, this study did not consider non-cardiovascular outcomes associated with active travel that might affect health such as increased exposure to air pollution. Nevertheless, these findings suggest that programs designed to maintain healthy weight and prevent NCDs in India should endeavor to increase active travel in urban areas and to halt declines in rural areas by, for example, increasing investment in public transport and improving the safety and convenience of walking and cycling routes in urban areas.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001459.
This study is further discussed in a PLOS Medicine Perspective by Kavi Bhalla
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, on overweight and obesity and on non-communicable diseases around the world; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health, about obesity, and about non-communicable diseases (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce NCD-related illnesses and death through implementation of the 20082013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); Face to face with chronic diseases is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association provides information on many important risk factors for non-communicable diseases and provides tips for becoming more active
Information about the Indian Migration Study is available
doi:10.1371/journal.pmed.1001459
PMCID: PMC3679004  PMID: 23776412
12.  Obesity and Association with Area of Residence, Gender and Socio-Economic Factors in Algerian and Tunisian Adults 
PLoS ONE  2013;8(10):e75640.
Introduction
The epidemiological transition has resulted in a major increase in the prevalence of obesity in North Africa. This study investigated differences in obesity and its association with area of residence, gender and socio-economic position among adults in Algeria and Tunisia, two countries with socio-economic and socio-cultural similarities.
Methods
Cross-sectional studies used stratified, three-level, clustered samples of 35–70 year old adults in Algeria, (women n = 2741, men n = 2004) and Tunisia (women n = 2964, men n = 2379). Thinness was defined as Body Mass Index (BMI) = weight/height <18.5 kg/m2, obesity as BMI ≥30, and abdominal obesity as waist circumference/height ≥0.6. Associations with area of residence, gender, age, education, profession and household welfare were assessed.
Results
Prevalence of thinness was very low except among men in Algeria (7.3% C.I.[5.9–8.7]). Prevalence of obesity among women was high in Algeria (30.1% C.I.[27.8–32.4]) and Tunisia (37.0% C.I.[34.4–39.6]). It was less so among men (9.1% C.I.[7.1–11.0] and 13.3% C.I.[11.2–15.4]).The results were similar for abdominal obesity. In both countries women were much more obesity-prone than men: the women versus men obesity Odds-Ratio was 4.3 C.I.[3.4–5.5] in Algeria and 3.8 C.I.[3.1–4.7] in Tunisia. Obesity was more prevalent in urban versus rural areas in Tunisia, but not in Algeria (e.g. for women, urban versus rural Odds-Ratio was 2.4 C.I.[1.9–3.1] in Tunisia and only 1.2 C.I.[1.0–5.5] in Algeria). Obesity increased with household welfare, but more markedly in Tunisia, especially among women. Nevertheless, in both countries, even in the lowest quintile of welfare, a fifth of the women were obese.
Conclusion
The prevention of obesity, especially in women, is a public health issue in both countries, but there were differences in the patterning of obesity according to area of residence and socio-economic position. These specificities must be taken into account in the management of obesity inequalities.
doi:10.1371/journal.pone.0075640
PMCID: PMC3792975  PMID: 24116063
13.  The prevalence of pre-hypertension and its association to established cardiovascular risk factors in south of Iran 
BMC Research Notes  2012;5:386.
Background
Pre-hypertension is associated with an increased risk of the development of hypertension and subsequent cardiovascular disease and raises mortality risk. The aim of this study was to determine the prevalence of pre-hypertension and to explore the associations between pre-hypertension and established cardiovascular risk factors in a population-based sample of Iranian adults.
Methods
In this cross-sectional study a representative sample of 892 participants aged ≥30 years was selected using a multistage cluster sampling method. After completion of a detailed demographic and medical questionnaire (gender, age, history of diabetes mellitus and hypertension, taking antihypertensive or hypoglycemic agents and history of smoking), all participants were subjected to physical examination, blood lipid profile, blood glucose, anthropometric and smoking assessments, during the years 2009 and 2010. Variables were considered significant at a p-value ≤ 0.05. Statistical analysis was performed using SPSS version 11.5 software.
Results
Pre-hypertension was observed among 300 (33.7%) subjects, 36.4% for men and 31.4% for women (p > 0.05). The pre-hypertensive group had higher levels of blood glucose and triglycerides, higher body mass index and lower percentage of smoking than did the normotensive group. Multivariate logistic regression analysis showed that obesity and overweight were the strongest predictors of pre-hypertension [odds ratio, 2.74: 95% CI (Confidence Interval), 1.62 to 4.62 p < 0.001; odds ratio, 2.56, 95% CI, 1.74 to 3.77, p < 0.001 respectively].
Conclusions
Overweight and obesity are major determinants of the high prevalence rate of pre-hypertension detected in Iranian population. Therefore, primary prevention strategies should concentrate on reducing overweight and obesity if the increased prevalence of pre-hypertension is to be diminished in Iranian adults.
doi:10.1186/1756-0500-5-386
PMCID: PMC3506467  PMID: 22838639
Pre-hypertension; Cardiovascular risk factor; Obesity; BMI
14.  Health Problems Among the Elderly: A Cross-Sectional Study 
Background:
Estimates of health problems of the elderly in developing countries are required from time to time to predict trends in disease burden and plan health care for the elderly. Developing countries have a poor track record of equitable distribution of health care. Marginalized groups living in urban slums and rural villages have poor penetration of health services.
Aims:
To identify the geriatric health problems in samples drawn from a slum and a village, and also to explore any gender and urban–rural difference morbidity.
Subject and Methods:
A community-based cross-sectional study was carried out by house to house survey of all people aged over 60 years in an urban slum and a village in the field practice area of a teaching hospital. The total elderly population in these two areas was 407, with an almost equal representation from urban slum and rural area. Information (most of them self-reported) was collected in a pre-tested instrument, which has been used earlier in a World Health Organization multicentric study in India. Categorical variables were summarized by percentages. Associations were explored with odds ratio (OR) and 95% confidence intervals (CIs).
Results:
Female elders outnumbered the male elders; widows outnumbered widowers. Tobacco use was very high at 58.97% (240/407). Visual impairment (including uncorrected presbyopia) was the most common handicap with prevalence of 83.29% (339/407), with males more affected than females (OR = 2.52, 95% CI 1.32-4.87). Uncorrected hearing impairment was also common. Urinary complaints were also more common in males (OR = 1.68, 95% CI = 0.93-3.04). More rural elders were living alone than their urban counterpart (OR = 2.87, 95% CI 1.23-6.86). History of weight loss was higher in the rural areas, while tendency to obesity was higher in the urban areas. An appreciable number 29.2% (119/407) had unoperated cataract. Prevalence of hypertension was 30.7% (125/407); 12% (49/407) had diabetes; 7.6% (31/407) gave history of ischemic heart disease, males more than females (OR = 3.75, 95% CI 1.62-8.82). A large proportion, 32.6%, (133/407) had dental problems. Almost half of the population gave history of depression.
Conclusion:
A large number of unmet health needs, such as unoperated cataract, uncontrolled hypertension, uncorrected hearing impairment and tobacco use, exist in marginalized groups. Health interventions for these are needed in developing countries. Preventive services such as tobacco cessation campaigns among the elderly should also get priority.
doi:10.4103/2141-9248.109466
PMCID: PMC3634218  PMID: 23634324
Cross-sectional; Elderly; Geriatric medicine and Asia; Health problems
15.  Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study 
BMC Public Health  2013;13:605.
Background
Population aging leads to increased burden of chronic diseases and demand in public health. This study aimed to assess whether the score of Primary Health Care (PHC) is associated with a) the model of care - Family Health Strategy (FHS) vs. traditional care model (the Basic Health Units; BHU); b) morbid conditions such as - hypertension, diabetes mellitus, mental disorders, chronic pain, obesity and central obesity; c) quality of life in elderly individuals who received care in those units.
Methods
A survey was conducted among the elderly between August 2010 and August 2011, in Ilheus, Bahia. We interviewed elderly patients - 60 years or older - who consulted at BHU or FHS units in that day or participated in a group activity, and those who were visited at home by the staff of PHC, selected through a random sample. Demographic and socioeconomic characteristics, services’ attainment of primary care attributes, health problems and quality of life were investigated. The Short Form Health Survey (SF-12) was used to assess quality of life and PCATool to generate PHC scores. In addition, weight, height and waist circumference were measured. Trained research assistants, under supervision performed the data collection.
Results
A total of 511 elderly individuals were identified, two declined to participate, resulting in 509 individuals interviewed. The health care provided by the FHS has higher attainment of PHC attributes, in comparison to the BHU, resulting in lower prevalence of score below six. Except for hypertension and cardiovascular disease, other chronic problems were not independently associated with low scores in PHC. It was observed an independent and positive association between PHC score and the mental component of quality of life and an inverse association with the physical component.
Conclusions
This study showed higher PHC attributes attainment in units with FHS, regardless of the health problem. The degree of orientation to PHC increased the mental component score of quality of life.
doi:10.1186/1471-2458-13-605
PMCID: PMC3704970  PMID: 23800179
Primary health care; Elderly; Quality of life; Family health; Family health strategy; Hypertension; Family medicine
16.  Study of Prevalence of Type 2 Diabetes Mellitus and Hypertension in Overweight and Obese People 
Context:
In recent years, there has been a marked change in life-style of South Asian countries caused by economic growth, affluence, urbanization and dietary westernization. Few studies on the prevalence of obesity, hypertension and diabetes in the Indian population have been reported. However, there has been scarce literature on the study of prevalence of type 2 diabetes mellitus (DM) and Hypertension in overweight and obese people in India with criteria suggested by World Health Organization (WHO) for Asians. Information on such public health issues would provide evidence based data to develop guidelines and policies on this subject.
Aim:
The aim of this article is to determine the prevalence of hypertension and type 2 DM in overweight and obese people.
Setting and Design:
A cross-sectional study consisted of people selected from the out-patient department and indoors of a large defense hospital in a semi urban area of Assam.
Materials and Methods:
Patients with overweight and obesity, reporting for consultation and medical examination were taken into the study. The data collected was analyzed using the criteria for overweight, obesity, diabetes and hypertension defined by WHO, Joint National Committee VII and International Diabetes Federation, American Diabetes Association. A descriptive statistical analysis has been carried out in the study.
Results:
A total of 300 people were the subject population of this study. Among the subject population, there were 97 overweight and 203 obese. The 56 subjects were found to be diabetic. The prevalence of type 2 DM in overweight subjects was 15.5% and in obese was 20.2% and overall was 18.7%. Prevalence of hypertension in the overweight population was 8.2% and in obese was 22.2% and overall found to be 17.7%.
Conclusions:
The prevalence of type 2 DM, hypertension in the obese group of the study population were found to be 20.2%, 22.2% and in the overweight population were 15.5% and 8.2%, respectively. This indicates that the prevalence of type 2 DM and hypertension increases with increasing weight of the individuals. The prevalence of type 2 DM and hypertension were relatively higher compared with other studies in India and abroad.
doi:10.4103/2249-4863.130265
PMCID: PMC4005195  PMID: 24791232
Hypertension; obesity; overweight; type 2 diabetes mellitus
17.  First nationwide survey on cardiovascular risk factors in Grand-Duchy of Luxembourg (ORISCAV-LUX) 
BMC Public Health  2010;10:468.
Background
The ORISCAV-LUX study is the first baseline survey of an on-going cardiovascular health monitoring programme in Grand-Duchy of Luxembourg. The main objectives of the present manuscript were 1) to describe the study design and conduct, and 2) to present the salient outcomes of the study, in particular the prevalence of the potentially modifiable and treatable cardiovascular disease risk factors in the adult population residing in Luxembourg.
Method
ORISCAV-LUX is a cross-sectional study based on a random sample of 4496 subjects, stratified by gender, age categories and district, drawn from the national insurance registry of 18-69 years aged Luxembourg residents, assuming a response rate of 30% and a proportion of 5% of institutionalized subjects in each stratum. The cardiovascular health status was assessed by means of a self-administered questionnaire, clinical and anthropometric measures, as well as by blood, urine and hair examinations. The potentially modifiable and treatable risk factors studied included smoking, hypertension, dyslipidemia, diabetes mellitus, and obesity. Both univariate and multivariate statistical analyses used weighted methods to account for the stratified sampling scheme.
Results
A total of 1432 subjects took part in the survey, yielding a participation rate of 32.2%. This figure is higher than the minimal sample size of 1285 subjects as estimated by power calculation. The most predominant cardiovascular risk factors were dyslipidemia (69.9%), hypertension (34.5%), smoking (22.3%), and obesity (20.9%), while diabetes amounted 4.4%. All prevalence rates increased with age (except smoking) with marked gender differences (except diabetes). There was a significant difference in the prevalence of hypertension and of lipid disorders by geographic region of birth. The proportion of subjects cumulating two or more cardiovascular risk factors increased remarkably with age and was more predominant in men than in women (P<0.0001). Only 14.7% of men and 23.1% of women were free of any cardiovascular risk factor. High prevalence of non-treated CVRF, notably for hypertension and dyslipidemia, were observed in the study population.
Conclusion
The population-based ORISCAV-LUX survey revealed a high prevalence of potentially modifiable and treatable cardiovascular risk factors among apparently healthy subjects; significant gender and age-specific differences were seen not only for single but also for combined risk factors. From a public health perspective, these preliminary findings stress the urgent need for early routine health examinations, preventive interventions and lifestyle behavioural changes, even in young asymptomatic adults, to decrease cardiovascular morbidity and mortality in Luxembourg.
doi:10.1186/1471-2458-10-468
PMCID: PMC2925827  PMID: 20698957
18.  Prevalence and comorbidity of diabetes mellitus among non-institutionalized older adults in Germany - results of the national telephone health interview survey ‘German Health Update (GEDA)’ 2009 
BMC Public Health  2013;13:166.
Background
Despite the major public health impact of diabetes, recent population-based data regarding its prevalence and comorbidity are sparse.
Methods
The prevalence and comorbidity of diabetes mellitus were analyzed in a nationally representative sample (N = 9133) of the non-institutionalized German adult population aged 50 years and older. Information on physician-diagnosed diabetes and 20 other chronic health conditions was collected as part of the national telephone health interview survey ‘German Health Update (GEDA)’ 2009. Overall, 51.2% of contacted persons participated. Among persons with diabetes, diabetes severity was defined according to the type and number of diabetes-concordant conditions: no diabetes-concordant condition (grade 1); hypertension and/or hyperlipidemia only (grade 2); one comorbidity likely to represent diabetes-related micro- or macrovascular end-organ damage (grade 3); several such comorbidities (grade 4). Determinants of diabetes severity were analyzed by multivariable ordinal regression.
Results
The 12-month prevalence of diabetes was 13.6% with no significant difference between men and women. Persons with diabetes had a significantly higher prevalence and average number of diabetes-concordant as well as diabetes-discordant comorbidities than persons without diabetes. Among persons with diabetes, 10.2%, 46.8%, 35.6% and 7.4% were classified as having severity grade 1–4, respectively. Determinants of diabetes severity included age (cumulative odds ratio 1.05, 95% confidence interval 1.03-1.07, per year) and number of discordant comorbidities (1.40, 1.25-1.55). With respect to specific discordant comorbidities, diabetes severity was correlated to depression (2.15, 1.29-3.56), respiratory disease (2.75, 1.72-4.41), musculoskeletal disease (1.53, 1.06-2.21), and severe hearing impairment (3.00, 1.21-7.41).
Conclusions
Diabetes is highly prevalent in the non-institutionalized German adult population 50 years and older. Diabetes comorbidities including diabetes-concordant and diabetes-discordant conditions need to be considered in epidemiological studies, in order to monitor disease burden and quality of diabetes care. Definitional standards of diabetes severity need to be refined and consented.
doi:10.1186/1471-2458-13-166
PMCID: PMC3599814  PMID: 23433228
Diabetes; Prevalence; Comorbidity; Germany
19.  Caregiver- and Patient-Directed Interventions for Dementia 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:
Introduction
Caregiver-Directed Interventions for Dementia
Patient-Directed Interventions for Dementia
Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia
Caregiver-Directed Interventions for Dementia
Objective
To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.
Clinical Need: Target Population and Condition
Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.
Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.
Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.
It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.
Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.
Description of Interventions
The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.
Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.
Methods of Evidence-Based Analysis
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.
Questions
Section 2.1
Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Do respite care services impact on rates of institutionalization of these seniors?
Section 2.2
Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Which interventions reduce the risk for institutionalization of seniors with dementia?
Outcomes of Interest
any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;
rate of institutionalization; and
cost-effectiveness.
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.
Summary of Conclusions on Caregiver-Directed Interventions
There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.
There is considerable qualitative evidence of the perceived benefits of respite care.
Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.
Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)
There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.
There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.
RCT indicates randomized controlled trial.
Patient-Directed Interventions for Dementia
Objective
The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:
3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention
What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?
3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention
What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?
3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention
Can exercise decrease the risk of subsequent cognitive decline/dementia?
3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention
Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?
Clinical Need: Target Population and Condition
Secondary Prevention2
Exercise
Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.
Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.
Nonpharmacologic and Nonexercise Interventions
Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.
Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.
Primary Prevention3
Exercise
Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).
Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.
Nonpharmacologic and Nonexercise Interventions
Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.
Description of Interventions
Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.
Questions
Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?
Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?
Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?
Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:
Summary of Findings
Table 2 summarizes the conclusions from Sections 3.1 through 3.4.
Summary of Conclusions on Patient-Directed Interventions*
Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.
A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.
Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).
Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).
Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).
Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.
Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.
1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.
Benefit/Risk Analysis
As per the GRADE Working Group, the overall recommendations consider 4 main factors:
the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;
the quality of the evidence;
translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and
uncertainty about the baseline risk for the population of interest.
The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).
Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*
Economic Analysis
Budget Impact Analysis of Effective Interventions for Dementia
Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.
Annual Budget Impact (2008 Canadian Dollars)
Assumed 7% prevalence of dementia aged 65+ in Ontario.
Assumed 8 weekly sessions plus 4 monthly phone calls.
Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).
Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.
Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.
PMCID: PMC3377513  PMID: 23074509
20.  The Effect of Rural-to-Urban Migration on Obesity and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2010;7(4):e1000268.
Shah Ebrahim and colleagues examine the distribution of obesity, diabetes, and other cardiovascular risk factors among urban migrant factory workers in India, together with their rural siblings. The investigators identify patterns of change of cardiovascular risk factors associated with urban migration.
Background
Migration from rural areas of India contributes to urbanisation and may increase the risk of obesity and diabetes. We tested the hypotheses that rural-to-urban migrants have a higher prevalence of obesity and diabetes than rural nonmigrants, that migrants would have an intermediate prevalence of obesity and diabetes compared with life-long urban and rural dwellers, and that longer time since migration would be associated with a higher prevalence of obesity and of diabetes.
Methods and Findings
The place of origin of people working in factories in north, central, and south India was identified. Migrants of rural origin, their rural dwelling sibs, and those of urban origin together with their urban dwelling sibs were assessed by interview, examination, and fasting blood samples. Obesity, diabetes, and other cardiovascular risk factors were compared. A total of 6,510 participants (42% women) were recruited. Among urban, migrant, and rural men the age- and factory-adjusted percentages classified as obese (body mass index [BMI] >25 kg/m2) were 41.9% (95% confidence interval [CI] 39.1–44.7), 37.8% (95% CI 35.0–40.6), and 19.0% (95% CI 17.0–21.0), respectively, and as diabetic were 13.5% (95% CI 11.6–15.4), 14.3% (95% CI 12.2–16.4), and 6.2% (95% CI 5.0–7.4), respectively. Findings for women showed similar patterns. Rural men had lower blood pressure, lipids, and fasting blood glucose than urban and migrant men, whereas no differences were seen in women. Among migrant men, but not women, there was weak evidence for a lower prevalence of both diabetes and obesity among more recent (≤10 y) migrants.
Conclusions
Migration into urban areas is associated with increases in obesity, which drive other risk factor changes. Migrants have adopted modes of life that put them at similar risk to the urban population. Gender differences in some risk factors by place of origin are unexpected and require further exploration.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
India, like the rest of the world, is experiencing an epidemic of diabetes, a chronic disease characterized by dangerous levels of sugar in the blood that cause cardiovascular and kidney disease, which lower life expectancy. The prevalence of diabetes (the proportion of the population with diabetes) has been increasing steadily in India over recent decades, particularly in urban areas. In 1984, only 5% of adults living in the towns and cities of India had diabetes, but by 2004, 15% of adults in urban areas were affected by diabetes. In rural areas of India, diabetes is less common than in urban areas but even here, the prevalence of diabetes is now 6%. Obesity—too much body fat—is a major risk factor for diabetes and, in parallel with the greater increase in diabetes in urban India compared to rural India, there has been a greater increase in obesity in urban areas than in rural areas.
Why Was This Study Done?
Experts think that the increasing prevalence of obesity and diabetes in India (and in other developing countries) is caused in part by increased consumption of saturated fats and sugars and by reduced physical activity, and that these changes are related to urbanization—urban expansion into the countryside and migration from rural to urban areas. If living in an urban setting is a major determinant of obesity and diabetes risk, then people migrating into urban areas should acquire the high risk of the urban population for these two conditions. In this cross-sectional study (a study in which participants are studied at a single time point), the researchers investigate whether rural to urban migrants in India have a higher prevalence of obesity and diabetes than rural nonmigrants. They also ask whether migrants have a prevalence of obesity and diabetes intermediate between that of life-long urban and rural dwellers and whether a longer time since migration is associated with a higher prevalence of obesity and diabetes.
What Did the Researchers Do and Find?
The researchers recruited rural-urban migrants working in four Indian factories in north, central, and south regions and their spouses (if they were living in the same town) into their study. Each migrant worker and spouse asked one nonmigrant brother or sister (sibling) still living in their place of origin to join the study. The researchers also enrolled nonmigrant factory workers and their urban siblings into the study. All the participants (more than 6,500 in total) answered questions about their diet and physical activity and had their fasting blood sugar and their body mass index (BMI; weight in kg divided by height in meters squared) measured; participants with a fasting blood sugar of more than 7.0 nmol/l or a BMI of more than 25 kg/m2 were classified as diabetic or obese, respectively. 41.9% and 37.8% of the urban and migrant men, respectively, but only 19.0% of the rural men were obese. Similarly, 13.5% and 14.3% of the urban and migrant men, respectively, but only 6.2% of the rural men had diabetes. Patterns of obesity and diabetes among the women participants were similar. Finally, although the prevalence of diabetes and obesity was lower in the most recent male migrants than in those who had moved more than 10 years previously, this difference was small and not seen in women migrants.
What Do These Findings Mean?
These findings show that rural-urban migration in India is associated with rapid increases in obesity and in diabetes. They also show that the migrants have adopted modes of life (for example, reduced physical activity) that put them at a similar risk for obesity and diabetes as the urban population. The findings do not show, however, that migrants have an intermediate prevalence of obesity and diabetes compared to urban and rural dwellers and provide only weak support for the idea that a longer time since migration is associated with a higher risk of obesity and diabetes. Although the study's cross-sectional design means that the researchers could not investigate how risk factors for diabetes evolve over time, these findings suggest that urbanization is helping to drive the diabetes epidemic in India. Thus, targeting migrants and their families for health promotion activities and for treatment of risk factors for obesity and diabetes might help to slow the progress of the epidemic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000268.
The International Diabetes Federation provides information about all aspects of diabetes, including information on diabetes in Southeast Asia (in English, French, and Spanish)
DiabetesIndia.com provides information on the Indian Task Forces on diabetes care in India
Diabetes Foundation (India) has an international collaborative research focus and provides information about health promotion for diabetes; it has also produced consensus guidelines on dietary change for prevention of diabetes in India
The US National Diabetes Information Clearinghouse provides detailed information about diabetes for patients, health care professionals, and the general public (in English and Spanish)
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
doi:10.1371/journal.pmed.1000268
PMCID: PMC2860494  PMID: 20436961
21.  Metabolic syndrome in Iranian elderly 
ARYA Atherosclerosis  2012;7(4):157-161.
BACKGROUND:
This study aimed to compare Iranian elderly with the middle-aged population in terms of the prevalence of metabolic syndrome and its components.
METHODS:
This cross-sectional study was conducted using the data from the third phase of the Isfahan Healthy Heart Program. Male and female residents of Isfahan over 19 years of age were selected by multistage cluster random sampling. A questionnaire including demographic characteristics, health status, medical history, medications used, as well as waist circumference, weight, height, and systolic and diastolic blood pressures was completed for all participants. Fasting blood samples were obtained from all subjects and examined for fasting blood sugar and lipid profile. T-test and Mann-Whitney test were used for quantitative data and chi-square test was performed for qualitative data.
RESULTS:
The prevalence of metabolic syndrome in individuals aged over 60 years was significantly higher than those under 60 (49.5% vs. 17.5%, respectively; P < 0.001). Metabolic syndrome was also more prevalent among elderly females than in males (59.2% vs. 39.8%, respectively; P < 0.005). Some anthropometric measures such as height, body mass index, abdominal circumference, waist-hip ratio, and waist-to-height ratio were significantly different in men and women below 60 years in comparison with those over 60 years (P < 0.05). Moreover, there were significant differences in most studied parameters between the elderly and non-elderly women (P < 0.001).
CONCLUSION:
This study showed that metabolic syndrome has a relatively high prevalence in Iranian elderly people, especially in elderly women. Therefore, early diagnosis and management of the complication are recommended among this high-risk group to avoid the subsequent complications.
PMCID: PMC3413084  PMID: 23205049
Metabolic Syndrome; Elderly; Iran
22.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Background
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
Conclusions
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001320.
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
doi:10.1371/journal.pmed.1001320
PMCID: PMC3462761  PMID: 23055833
23.  Bariatric Surgery for People with Diabetes and Morbid Obesity 
Executive Summary
In June 2008, the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project, an evidence-based review of the literature surrounding strategies for successful management and treatment of diabetes. This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry’s newly released Diabetes Strategy.
After an initial review of the strategy and consultation with experts, the secretariat identified five key areas in which evidence was needed. Evidence-based analyses have been prepared for each of these five areas: insulin pumps, behavioural interventions, bariatric surgery, home telemonitoring, and community based care. For each area, an economic analysis was completed where appropriate and is described in a separate report.
To review these titles within the Diabetes Strategy Evidence series, please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/masabout.html,
Diabetes Strategy Evidence Platform: Summary of Evidence-Based Analyses
Continuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics: An Evidence-Based Analysis
Behavioural Interventions for Type 2 Diabetes: An Evidence-Based Analysis
Bariatric Surgery for People with Diabetes and Morbid Obesity: An Evidence-Based Summary
Community-Based Care for the Management of Type 2 Diabetes: An Evidence-Based Analysis
Home Telemonitoring for Type 2 Diabetes: An Evidence-Based Analysis
Application of the Ontario Diabetes Economic Model (ODEM) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario
Objective
The purpose of this evidence-based analysis was to examine the effectiveness and cost-effectiveness of bariatric surgery for the management of diabetes in morbidly obese people.
This report summarized evidence specific to bariatric surgery and the improvement of diabetes from the full evidence-based analysis of bariatric surgery for the treatment of morbid obesity completed by the Medical Advisory Secretariat (MAS) in January 2005. To view the full report, please visit the MAS website at: http://www.health.gov.on.ca/english/providers/program/mas/tech/techmn.html.
Clinical Need: Condition and Target Population
Obesity is defined as an excessive accumulation of body fat as measured by the body mass index (BMI) and calculated as body weight in kilograms (kg) divided by height in metres squared (m2). People with a BMI over 30 kg/m2 are considered obese in most countries. The condition is associated with the development of several diseases, including hypertension, diabetes mellitus (type 2 diabetes), hyperlipidemia, coronary artery disease, obstructive sleep apnea, depression, and cancers of the breast, uterus, prostate, and colon. Clinically severe, or morbid obesity, is commonly defined by a BMI of at least 40 kg/m2, or a BMI of at least 35 kg/m2 if there are comorbid conditions such as diabetes, cardiovascular disease, or arthritis.
The prevalence of morbid obesity among people with type 2 diabetes has been examined and of 2,460 patients with type 2 diabetes, 52% (n = 1,279) were obese (BMI ≥ 30 kg/m2) and 23% (n = 561) had a BMI ≥ 35 kg/m2.
Bariatric Surgery
Men and women with morbid obesity may be eligible for surgical intervention. There are numerous surgical options available, all of which can be divided into two general types, both of which can be performed either as open surgery or laparoscopically:
malabsorptive - bypassing parts of the gastrointestinal tract to limit the absorption of food, and
restrictive - decreasing the size of the stomach in order for the patient to feel satiated with a smaller amount food
Surgery for morbid obesity is usually considered a last resort for people who have attempted first-line medical management (e.g. diet, behaviour modification, increased physical activity, and drugs) but who have not lost weight permanently. Surgery is restricted to people with morbid obesity (BMI ≥ 40 kg/m2) or those with a BMI of at least 35 kg/m2 and serious comorbid conditions.
Evidence-Based Analysis Methods
Details of the full literature search can be found in the 2005 evidence-based analysis of bariatric surgery (http://www.health.gov.on.ca/english/providers/program/mas/tech/techmn.html). Briefly, a literature search was conducted examining published works from January 1996 to December 2004, including OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment/Centre for Review and Dissemination.
Inclusion Criteria
Data on the effectiveness or cost-effectiveness of bariatric surgery for the improvement of diabetes
Systematic reviews, randomized controlled trials (RCTs), and observational controlled prospective studies that had >100 patients
Randomized controlled trials (RCTs), systematic reviews and meta-analyses
Exclusion Criteria
Duplicate publications (superseded by another publication by the same investigator group, with the same objective and data)
Non-English-language articles
Non-systematic reviews, letters, and editorials
Animal and in-vitro studies
Case reports, case series
Studies that did not examine the outcomes of interest
Outcomes of Interest
Improvement or resolution of diabetes
The quality of the studies was examined according to the GRADE Working Group criteria for grading quality of evidence.
Summary of Findings
There is evidence that bariatric surgery is effective for improvement and resolution of diabetes in patients who are morbidly obese (BMI≥35 kg/m2). The quality of evidence for the use of bariatric surgery for the resolution or improvement of diabetes in morbidly obese people, according to the GRADE quality-of-evidence criteria, was found to be moderate (see ES Table 1).
Comparison of various bariatric techniques:
No prospective, long-term direct comparison is available between malabsorptive and restrictive techniques.
Retrospective subgroup analyses from a large observational study showed greater improvement and resolution of diabetes using malabsorptive techniques rather than purely restrictive methods.
There is evidence from a meta-analysis that malabsorptive techniques are better than other banding techniques in terms of improvement and resolution of diabetes.
Keywords
Bariatric surgery, morbid obesity, comorbidity, diabetes
GRADE Quality of Evidence for Bariatric Surgery for the Resolution or Improvement of Diabetes
Downgraded due to study design (not randomized controlled trial)
Unlikely to be an important uncertainty. Inclusion criteria for the SOS study not specific to conventional definition of “morbidly obese” patients (BMI ≥ 40 or ≥ 35 kg/m2 with comorbid conditions)
Unlikely to be an important uncertainty. Control group not standardized, however, this lends to the pragmatic nature of the study.
PMCID: PMC3377514  PMID: 23074527
24.  Trends in adult cardiovascular disease risk factors and their socio-economic patterning in the Scottish population 1995–2008: cross-sectional surveys 
BMJ Open  2011;1(1):e000176.
Objectives
To examine secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population. This could contribute to a better understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with a widening of socio-economic inequalities.
Design
Four Scottish Health Surveys 1995, 1998, 2003 and 2008 (6190, 6656, 5497 and 4202 respondents, respectively, aged 25–64 years) were used to examine gender-stratified, age-standardised prevalences of smoking, alcohol consumption, physical activity, fruit and vegetable consumption, discretionary salt use and self-reported diabetes or hypertension. Prevalences were determined according to education and social class. Inequalities were assessed using the slope index of inequality, and time trends were determined using linear regression.
Results
There were moderate secular declines in the prevalence of smoking, excess alcohol consumption and physical inactivity. Smoking prevalence declined between 1995 and 2008 from 33.4% (95% CI 31.8% to 35.0%) to 29.9% (27.9% to 31.8%) for men and from 36.1% (34.5% to 37.8%) to 27.4% (25.5% to 29.3%) for women. Adverse trends in prevalence were noted for self-reported diabetes and hypertension. Over the four surveys, the diabetes prevalence increased from 1.9% (1.4% to 2.4%) to 3.6% (2.8% to 4.4%) for men and from 1.7% (1.2% to 2.1%) to 3.0% (2.3% to 3.7%) for women. Socio-economic inequalities were evident for almost all risk factors, irrespective of the measure used. These social gradients appeared to be maintained over the four surveys. An exception was self-reported diabetes where, although inequalities were small, the gradient increased over time. Alcohol consumption was unique in consistently showing an inverse gradient, especially for women.
Conclusions
There has been only a moderate decline in behavioural cardiovascular risk factor prevalences since 1995, with increases in self-reported diabetes and hypertension. Adverse socio-economic gradients have remained unchanged. These findings could help explain the recent stagnation in coronary heart disease mortalities and persistence of related inequalities.
Article summary
Article focus
In Scotland, as in other developed countries, coronary heart disease mortality has declined substantially over time.
This decline may now be slowing among younger groups, and there are still large inequalities in mortality between socio-economic groups.
This study examined secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population.
Key messages
In Scotland, over a 13-year period since 1995 there have been at best only moderate declines in the prevalence of behavioural risk factors and no change in their socio-economic patterning, notably for smoking and poor diet.
There has, however, been an increase in self-reported conditions predisposing to cardiovascular disease.
This threatens to maintain inequalities in coronary heart disease mortalities and stifle further declines in mortality.
Strengths and limitations of this study
This study utilised data from nationally representative surveys conducted over a 13-year period.
The declining response levels to these surveys are of concern, possibly introducing bias. However, differential non-response by the socio-economically disadvantaged may lead to an underestimation of the magnitude of inequalities.
doi:10.1136/bmjopen-2011-000176
PMCID: PMC3191578  PMID: 22021783
Cardiovascular diseases; risk factors; socio-economic factors; cross-sectional studies; Scotland; epidemiology; public health; social medicine; coronary heart disease; multilevel modelling; inequalities; modelling; prevention; health services research; mortality; routine data; statistics
25.  Socio-Economic Inequalities in the Prevalence of Multi-Morbidity among the Rural Elderly in Bargarh District of Odisha (India) 
PLoS ONE  2014;9(6):e97832.
Background
Multi-morbidity among elderly is increasingly recognized as a major public health challenge in most of the developing countries. However, information on the size of population suffering from multi-morbidity and socio-economic differentials of multi-morbidity is scarce. The objectives of this paper are twofold; first, to assess the prevalence of various chronic conditions and morbidity among rural elderly and second, to examine the socio-economic and demographic factors that have a significant effect on the morbidity.
Methods
A cross-sectional survey has been done using multi-stage random sampling procedure that was conducted among elderly (60+ years) in Bargarh District of Odisha during October 2011-February 2012. The survey was conducted among 310 respondents including 153 males and 157 females. Descriptive analyses were performed to assess the pattern of multi-morbidity. Logistic regression analyses were used to see the adjusted effect of various socio-economic and demographic covariates of multi-morbidity.
Results
The overall prevalence of multi-morbidity is 57% among rural elderly in Bargarh District of Odisha. The most common diseases in rural areas are: Arthritis, Chronic Obstructive Pulmonary Disease (COPD), High Blood Pressure and Cataract. Results from the logistic regression analyses show that age, state of economic independence and life style indicators are the most important measured predictors of multi-morbidity. Unlike earlier studies, wealth index and education have a marginal impact on multi-morbidity rate. Moreover, the occurrence of multi-morbidity is higher for elderly males compared to their female counterparts, though the difference is not significant.
Conclusion
The high prevalence of morbidity observed in the present study suggests that there is an urgent need to develop geriatric health care services in a developing country like India. Any effort to reorganize primary care for elderly people should also consider the high prevalence of multi-morbidity among rural elderly in India.
doi:10.1371/journal.pone.0097832
PMCID: PMC4046974  PMID: 24902041

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