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1.  Evidence of an Overweight/Obesity Transition among School-Aged Children and Youth in Sub-Saharan Africa: A Systematic Review 
PLoS ONE  2014;9(3):e92846.
Prevalence of childhood overweight/obesity has increased considerably in recent years. The transition to higher rates of overweight/obesity has been well documented in high income countries; however, consistent or representative data from lower income countries is scarce. It is therefore pertinent to assess if rates of overweight/obesity are also increasing in lower income countries, to inform public health efforts.
This systematic review aimed to investigate the evidence for an overweight/obesity transition occurring in school-aged children and youth in Sub Saharan Africa.
Studies were identified by searching the MEDLINE, Embase, Africa Index Medicus, Global Health, Geobase, and EPPI-Centre electronic databases. Studies that used subjective or objective metrics to assess body composition in apparently healthy or population-based samples of children and youth aged 5 to 17 years were included.
A total of 283 articles met the inclusion criteria, and of these, 68 were used for quantitative synthesis. The four regions (West, Central, East, and South) of Sub Saharan Africa were well represented, though only 11 (3.9%) studies were nationally representative. Quantitative synthesis revealed a trend towards increasing proportions of overweight/obesity over time in school-aged children in this region, as well as a persistent problem of underweight. Weighted averages of overweight/obesity and obesity for the entire time period captured were 10.6% and 2.5% respectively. Body composition measures were found to be higher in girls than boys, and higher in urban living and higher socioeconomic status children compared to rural populations or those of lower socioeconomic status.
This review provides evidence for an overweight/obesity transition in school-aged children in Sub Saharan Africa. The findings of this review serve to describe the region with respect to the growing concern of childhood overweight/obesity, highlight research gaps, and inform interventions.
PROSPERO Registration Number
PMCID: PMC3968060  PMID: 24676350
2.  Joint Associations of Physical Activity and Hypertension with the Development of Type 2 Diabetes among Urban Men and Women in Mainland China 
PLoS ONE  2014;9(2):e88719.
Physical activity (PA) and hypertension (HTN) are important influences on the development of type 2 diabetes (T2D). However, the joint impact of PA and HTN on T2D development is unknown.
Two community-based prospective cohort studies, with the same protocols, instruments and questionnaires, were conducted among adults in urban areas of Nanjing, China, during 2004–2007 and 2007–2010. T2D was defined using World Health Organization criteria based on physicians' diagnosis and fasting blood glucose concentration. PA level (sufficient/insufficient) and blood pressure status (hypertensive/normotensive) were assessed at baseline and the third year of follow-up. We pooled and analyzed data from these two studies.
Among 4550 participants aged 35 years or older, the three-year cumulative incidence of T2D was 5.1%. After adjusting for potential confounders, participants with sufficient PA were less likely to develop T2D than those with insufficient PA (OR = 0.43, 95%CI = 0.27, 0.68) and those who were normotensive were less likely to develop T2D than those who were hypertensive (OR = 0.39, 95%CI = 0.29, 0.51). Compared to participants with insufficient PA and who were hypertensive, those with sufficient PA and hypertension were at lower risk of developing T2D (OR = 0.36, 95%CI = 0.19, 0.69), as were those with insufficient PA who were normotensive (OR = 0.37, 95%CI = 0.28, 0.50) and those with sufficient PA who were normotensive (OR = 0.19, 95%CI = 0.10, 0.37).
Insufficient PA was found to be associated with the development of T2D among adults with and without hypertension. These findings support a role for promoting higher physical activity levels to lower T2D risk in both hypertensive and non-hypertensive individuals.
PMCID: PMC3923808  PMID: 24551143
3.  Spousal diabetes as a diabetes risk factor: A systematic review and meta-analysis 
BMC Medicine  2014;12:12.
Diabetes history in biologically-related individuals increases diabetes risk. We assessed diabetes concordance in spouses (that is, biologically unrelated family members) to gauge the importance of socioenvironmental factors.
We selected cross-sectional, case–control and cohort studies examining spousal association for diabetes and/or prediabetes (impaired fasting glucose or impaired glucose tolerance), indexed in Medline, Embase or Scopus (1 January 1997 to 28 February 2013). Effect estimates (that is, odds ratios, incidence rate ratios, and so on) with body mass index (BMI) adjustment were pooled separately from those without BMI adjustment (random effects models) to distinguish BMI-dependent and independent concordance.
Searches yielded 2,705 articles; six were retained (n = 75,498 couples) for systematic review and five for meta-analysis. Concordance was lowest in a study that relied on women’s reports of diabetes in themselves and their spouses (effect estimate 1.1, 95% CI 1.0 to 1.30) and highest in a study with systematic assessment of glucose tolerance (2.11, 95% CI 1.74 to 5.10). The random-effects pooled estimate adjusted for age and other covariates but not BMI was 1.26 (95% CI 1.08 to 1.45). The estimate with BMI adjustment was lower (1.18, 95% CI 0.97 to 1.40). Two studies assessing between-spouse associations of diabetes/prediabetes determined by glucose testing reported high concordance (OR 1.92, 95% CI 1.55 to 2.37 without BMI adjustment; 2.32, 95% CI 1.87 to 3.98 with BMI adjustment). Two studies did not distinguish type 1 and type 2 diabetes. However given that around 95% of adults is type 2, this is unlikely to have influenced the results.
Our pooled estimate suggests that a spousal history of diabetes is associated with a 26% diabetes risk increase. Recognizing shared risk between spouses may improve diabetes detection and motivate couples to increase collaborative efforts to optimize eating and physical activity habits.
PMCID: PMC3900990  PMID: 24460622
Diabetes mellitus; Prediabetes; Spouses concordance; Risk factor; Systematic review; Meta-analysis
4.  Step Monitoring to improve ARTERial health (SMARTER) through step count prescription in type 2 diabetes and hypertension: trial design and methods 
With increasing numbers of type 2 diabetes (DM2) and hypertension patients, there is a pressing need for effective, time-efficient and sustainable strategies to help physicians support their patients to achieve higher physical activity levels. SMARTER will determine whether physician-delivered step count prescriptions reduce arterial stiffness over a one-year period, compared with usual care, in sedentary overweight/obese adults with DM2/hypertension.
Randomized, allocation-concealed, assessor-blind, multisite clinical trial. The primary outcome is change in arterial stiffness over one year. The secondary outcomes include changes in physical activity, individual vascular risk factors, medication use, and anthropometric parameters. Assessments are at baseline and one year.
Participants are sedentary/low active adults with 25 ≤ BMI < 40 kg/m2 followed for DM2/hypertension by a collaborating physician. The active arm uses pedometers to track daily step counts and review logs with their physicians at 3 to 4-month intervals. A written step count prescription is provided at each visit, aiming to increase counts by ≥3,000 steps/day over one year, with an individualized rate increase. The control arm visits physicians at the same frequency and receives advice to engage in physical activity 30-60 minutes/day. SMARTER will enroll 364 individuals to detect a 10 ± 5% difference in arterial stiffness change between arms. Arterial stiffness is assessed noninvasively with carotid femoral pulse wave velocity using applanation tonometry.
The importance of SMARTER lies not simply in the use of pedometer-based monitoring but also on its integration into a prescription-based intervention delivered by the treating physician. Equally important is the measurement of impact of this approach on a summative indicator of arterial health, arterial stiffness. If effectiveness is demonstrated, this strategy has strong potential for widespread uptake and implementation, given that it is well-aligned with the structure of current clinical practice.
Trial registration (NCT01475201)
PMCID: PMC3893520  PMID: 24393423
5.  Association between Gestational Weight Gain and Postpartum Diabetes: Evidence from a Community Based Large Cohort Study 
PLoS ONE  2013;8(12):e75679.
We have investigated the prospective association between excess gestational weight gain (GWG) and development of diabetes by 21 years post-partum using a community-based large prospective cohort study in Brisbane, Australia. There were 3386 mothers for whom complete data were available on GWG, pre-pregnancy BMI and self-reported diabetes 21 years post-partum. We used The Institute of Medicine (IOM) definition to categorize GWG as inadequate, adequate and excessive. We found 839 (25.78%) mothers gained inadequate weight, 1,353 (39.96%) had adequate weight gain and 1,194 (35.26%) had gained excessive weight during pregnancy. At 21 years post-partum, 8.40% of mothers self-reported a diagnosis of diabetes made by their doctor. In the age adjusted model, we found mothers who gained excess weight during pregnancy were 1.47(1.11,1.94) times more likely to experience diabetes at 21 years post-partum compared to the mothers who gained adequate weight. This association was not explained by the potential confounders including maternal age, parity, education, race, smoking, TV watching and exercise. However, this association was mediated by the current BMI. There was no association for the women who had normal BMI before pregnancy and gained excess weight during pregnancy. The findings of this study suggest that women who gain excess weight during pregnancy are at greater risk of being diagnosed with diabetes in later life. This relationship is likely mediated through the pathway of post-partum weight-retention and obesity. This study adds evidence to the argument that excessive GWG during pregnancy for overweight mothers has long term maternal health implications.
PMCID: PMC3862846  PMID: 24348988
6.  The Prevalence and Determinants of Undiagnosed and Diagnosed Type 2 Diabetes in Middle-Aged Irish Adults 
PLoS ONE  2013;8(11):e80504.
The prevalence of type 2 diabetes within the Republic of Ireland is poorly defined, although a recent report suggested 135,000 cases in adults aged 45+, with approximately one-third of these undiagnosed. This study aims to assess the prevalence of undiagnosed and diagnosed diabetes in middle-aged adults, and compare features related to either condition, in order to investigate why certain individuals remain undetected.
This was a cross-sectional study involving a sample of 2,047 men and women, aged between 50–69 years, randomly selected from a large primary care centre. Univariate logistic regression was used to explore socio-economic, metabolic and other health related variable associations with undiagnosed or diagnosed diabetes. A final multivariate analysis was used to determine odds ratios and 95% confidence intervals for having undiagnosed compared to diagnosed diabetes, adjusted for gender, age and significant covariates determined from univariate models.
Principle Findings
The total prevalence of diabetes was 8.5% (95% CI: 7.4%–8.8%); 72 subjects (3.5%) had undiagnosed diabetes (95% CI: 2.8%–4.4%) and 102 subjects (5.0%) had diagnosed diabetes (95% CI: 4.1%–6.0%). Obesity, dyslipidaemia, and family history of diabetes were positively associated with both undiagnosed and diagnosed type 2 diabetes. Compared with diagnosed subjects, study participants with undiagnosed diabetes were significantly more likely to have low levels of physical activity and were less likely to be on treatment for diabetes-related conditions or to have private medical insurance.
The prevalence of diabetes within the Cork and Kerry Diabetes and Heart Disease Study is comparable to recent estimates from the Slán National Health and Lifestyle Survey, a study which was nationally representative of the general population. A considerable proportion of diabetes cases were undiagnosed (41%), emphasising the need for more effective detection strategies and equitable access to primary healthcare.
PMCID: PMC3840064  PMID: 24282548
7.  Nutritional Education Through Internet-Delivered Menu Plans Among Adults With Type 2 Diabetes Mellitus: Pilot Study 
JMIR Research Protocols  2013;2(2):e41.
A potential barrier to weight loss and vascular risk reduction is difficulty in operationalizing dietary education into a concrete plan. Although a variety of Internet-based software tools are now available to address this issue, there has been little formal evaluation of these tools.
The aim of this single-arm pilot study is to determine the effect of a 24-week Internet-based menu-planning program, by examining pre- to postintervention changes in the body weight, blood pressure, and glycemia, specifically among overweight adults with type 2 diabetes mellitus (DM2), a clinical population at high risk for vascular diseases.
A total of 33 adults with DM2 were recruited by collaborating registered dietitians to a 24-week Internet-based menu-planning program. Individualized dietary prescriptions were operationalized into weekly Internet-delivered menu plans through an adapted version of a commercially available service. Adherence was defined as logging into the program at least once per week for a minimum of 18 of the 24 weeks. Multiple imputations were used for missing data. Using baseline and postintervention assessments, we calculated the weight changes (mean, 95% CI) and investigated the corresponding effects (linear regression models) on blood pressure (systolic, diastolic) and hemoglobin A1C (ie, glycemia).
The mean age was 58 (SD 7) years and the mean baseline body mass index was 34.4 (SD 4.6) kg/m2. The results of this study showed that ≥5% weight reduction was achieved by 6/33 participants (18%) and by 5/18 adherent participants (28%). A mean weight change of −2.0% (95% CI −2.6 to −1.4) was observed, with changes occurring in the adherent (−3.6%, 95% CI −4.5 to −2.8) but not in the nonadherent (0%, 95% CI −0.6 to 0.7). It was found that each 1% reduction in body weight was associated with a −2.4 mmHg change in systolic (95% CI −3.5 to −1.2) and a −0.8 mmHg change in diastolic blood pressure (95% CI −1.4 to −0.2). Percent weight change was not found to be related to changes in A1C.
In adults with DM2, an Internet-based menu-planning program has the potential to lead to clinically important weight reductions in more than one quarter of those who adhere, with corresponding improvements in blood pressure.
PMCID: PMC3806354  PMID: 24185033
weight loss; obesity; hemoglobin A1C; blood pressure; Internet; Web; type 2 diabetes mellitus; diet; menu
8.  Systematic Review and Meta-Analysis of Validation Studies on a Diabetes Case Definition from Health Administrative Records 
PLoS ONE  2013;8(10):e75256.
Health administrative data are frequently used for diabetes surveillance. We aimed to determine the sensitivity and specificity of a commonly-used diabetes case definition (two physician claims or one hospital discharge abstract record within a two-year period) and their potential effect on prevalence estimation.
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched Medline (from 1950) and Embase (from 1980) databases for validation studies through August 2012 (keywords: “diabetes mellitus”; “administrative databases”; “validation studies”). Reviewers abstracted data with standardized forms and assessed quality using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. A generalized linear model approach to random-effects bivariate regression meta-analysis was used to pool sensitivity and specificity estimates. We applied correction factors derived from pooled sensitivity and specificity estimates to prevalence estimates from national surveillance reports and projected prevalence estimates over 10 years (to 2018).
The search strategy identified 1423 abstracts among which 11 studies were deemed relevant and reviewed; 6 of these reported sensitivity and specificity allowing pooling in a meta-analysis. Compared to surveys or medical records, sensitivity was 82.3% (95%CI 75.8, 87.4) and specificity was 97.9% (95%CI 96.5, 98.8). The diabetes case definition underestimated prevalence when it was ≤10.6% and overestimated prevalence otherwise.
The diabetes case definition examined misses up to one fifth of diabetes cases and wrongly identifies diabetes in approximately 2% of the population. This may be sufficiently sensitive and specific for surveillance purposes, in particular monitoring prevalence trends. Applying correction factors to adjust prevalence estimates from this definition may be helpful to increase accuracy of estimates.
PMCID: PMC3793995  PMID: 24130696
9.  Intensive Lifestyle Intervention in General Practice to Prevent Type 2 Diabetes among 18 to 60-Year-Old South Asians: 1-Year Effects on the Weight Status and Metabolic Profile of Participants in a Randomized Controlled Trial 
PLoS ONE  2013;8(7):e68605.
To study 1-year effectiveness of an intensive, culturally targeted lifestyle intervention in general practice for weight status and metabolic profile of South-Asians at risk of type 2 diabetes.
536 South-Asians at risk of type 2 diabetes were randomized to an intervention (n = 283) or control (n = 253) group. The intervention, which was targeted culturally to the South-Asian population, consisted of individual lifestyle counselling, a family session, cooking classes, and supervised physical activity programme. All components of the intervention were carried out by professionals as part of their daily clinical practice. The control group received generic lifestyle advice. Change in weight status and metabolic profile were assessed after 1 year.
After 1 year, 201 participants were lost to follow-up. Remaining participants in intervention (n = 177) and control (n = 158) group had similar baseline characteristics. Weight loss in the intervention group was 0.2±3.3 kg, weight gain in the control group was 0.4±3.1 kg (p = 0.08). Changes in other weight-related measurements did not differ significantly between groups. Furthermore, there were no differences between groups in changes of metabolic profile. All results remained similar after repeating analyses in a multiple imputed dataset.
An intensive, culturally targeted, lifestyle intervention of 1 year did not improve weight status and metabolic profile of South-Asians at risk of type 2 diabetes. The laborious recruitment, high drop-out, and lack of effectiveness emphasise the difficulty of realising health benefits in practice and suggest that this strategy might not be the optimal approach for this population.
Trial Registration
Nederlands Trial Register NTR1499
PMCID: PMC3718785  PMID: 23894322
10.  Strategies to Optimize Participation in Diabetes Prevention Programs following Gestational Diabetes: A Focus Group Study 
PLoS ONE  2013;8(7):e67878.
We performed a qualitative study among women within 5 years of Gestational Diabetes (GDM) diagnosis. Our aim was to identify the key elements that would enhance participation in a type 2 diabetes (DM2) prevention program.
Research Design and Methods
Potential participants received up to three invitation letters from their GDM physician. Four focus groups were held. Discussants were invited to comment on potential facilitators/barriers to participation and were probed on attitudes towards meal replacement and Internet/social media tools. Recurring themes were identified through qualitative content analysis of discussion transcripts.
Among the 1,201 contacted and 79 eligible/interested, 29 women attended a focus group discussion. More than half of discussants were overweight/obese, and less than half were physically active. For DM2 prevention, a strong need for social support to achieve changes in dietary and physical activity habits was expressed. In this regard, face-to-face interactions with peers and professionals were preferred, with adjunctive roles for Internet/social media. Further, direct participation of partners/spouses in a DM2 prevention program was viewed as important to enhance support for behavioural change at home. Discussants highlighted work and child-related responsibilities as potential barriers to participation, and emphasized the importance of childcare support to allow attendance. Meal replacements were viewed with little interest, with concerns that their use would provide a poor example of eating behaviour to children.
Among women within 5 years of a GDM diagnosis who participated in a focus group discussion, participation in a DM2 prevention program would be enhanced by face-to-face interactions with professionals and peers, provision of childcare support, and inclusion of spouses/partners.
PMCID: PMC3701629  PMID: 23861824
11.  Quality Control Methods in Accelerometer Data Processing: Defining Minimum Wear Time 
PLoS ONE  2013;8(6):e67206.
When using accelerometers to measure physical activity, researchers need to determine whether subjects have worn their device for a sufficient period to be included in analyses. We propose a minimum wear criterion using population-based accelerometer data, and explore the influence of gender and the purposeful inclusion of children with weekend data on reliability.
Accelerometer data obtained during the age seven sweep of the UK Millennium Cohort Study were analysed. Children were asked to wear an ActiGraph GT1M accelerometer for seven days. Reliability coefficients(r) of mean daily counts/minute were calculated using the Spearman-Brown formula based on the intraclass correlation coefficient. An r of 1.0 indicates that all the variation is between- rather than within-children and that measurement is 100% reliable. An r of 0.8 is often regarded as acceptable reliability. Analyses were repeated on data from children who met different minimum daily wear times (one to 10 hours) and wear days (one to seven days). Analyses were conducted for all children, separately for boys and girls, and separately for children with and without weekend data.
At least one hour of wear time data was obtained from 7,704 singletons. Reliability increased as the minimum number of days and the daily wear time increased. A high reliability (r = 0.86) and sample size (n = 6,528) was achieved when children with ≥ two days lasting ≥10 hours/day were included in analyses. Reliability coefficients were similar for both genders. Purposeful sampling of children with weekend data resulted in comparable reliabilities to those calculated independent of weekend wear.
Quality control procedures should be undertaken before analysing accelerometer data in large-scale studies. Using data from children with ≥ two days lasting ≥10 hours/day should provide reliable estimates of physical activity. It’s unnecessary to include only children with accelerometer data collected during weekends in analyses.
PMCID: PMC3691227  PMID: 23826236
12.  Mastication and Risk for Diabetes in a Japanese Population: A Cross-Sectional Study 
PLoS ONE  2013;8(6):e64113.
Associations between mastication and insufficient nutrient intake, obesity, and glucose metabolism have been shown in previous studies. However, the association between mastication and diabetes has not been clarified. Our objective was to examine the association between mastication, namely masticatory performance or rate of eating, and diabetes in a population-based cohort.
We conducted a cross-sectional study of the association between mastication and diabetes in the Nagahama Prospective Cohort Study, an ongoing study which recruits citizens of Nagahama City in Shiga Prefecture, central Japan. 2,283 male and 4,544 female residents aged 40–74 years were enrolled from July 2009 to November 2010. Masticatory performance was evaluated by spectrophotometric measurement of color changes after masticating color-changeable chewing gum. Categorical rate of eating (fast, intermediate or slow) was self-assessed using a questionnaire.
177 males (7.7%) and 112 (2.4%) females were diagnosed with diabetes. We divided participants into four groups by quartile of masticatory performance, namely Q1 (lowest), 2, and 3 and 4 (highest). Compared to the lowest performance group, the multivariable adjusted odds ratio (OR) of diabetes was 0.91 (95% confidence interval (CI), 0.58–1.4) in Q2, 0.77 (95% CI, 0.48–1.2) in Q3, and 0.53 (95% CI, 0.31–0.90) in the highest group in males, and 1.2 (95% CI, 0.73–2.0), 0.95 (95% CI, 0.54–1.6) and 0.56 (95% CI, 0.30–1.0) in females. We also estimated ORs of diabetes by rate of eating. Compared to the fast eating group, ORs in males were 0.87 (95% CI, 0.61–1.2) in the intermediate group and 0.38 (95% CI, 0.16–0.91) in the slow group, and ORs in females were 0.92 (95% CI, 0.59–1.4) and 1.5 (95% CI, 0.73–3.0).
These findings support the hypothesis that higher masticatory performance and slow eating prevent the occurrence of diabetes.
PMCID: PMC3674007  PMID: 23755114
13.  Sedentary Behaviour, Visceral Fat Accumulation and Cardiometabolic Risk in Adults: A 6-Year Longitudinal Study from the Quebec Family Study 
PLoS ONE  2013;8(1):e54225.
Sedentary behaviour has recently emerged as a unique risk factor for chronic disease morbidity and mortality. One factor that may explain this relationship is visceral adiposity, which is prospectively associated with increased cardiometabolic risk and mortality. The objective of the present study was to determine whether sedentary behaviour was associated with increased accumulation of visceral fat or other deleterious changes in cardiometabolic risk over a 6-year follow-up period among adult participants in the Quebec Family Study.
The current study included 123 men and 153 women between the ages of 18 and 65. Total sedentary time and physical activity were assessed by self-report questionnaire. Cross-sectional areas of visceral and subcutaneous abdominal adipose tissue were assessed using computed tomography. Cardiometabolic biomarkers including fasting insulin, glucose, blood lipids, HOMA-Insulin Resistance, and oral glucose tolerance were also measured. All variables of interest were collected at both baseline and follow-up.
After adjustment for age, sex, baseline BMI, physical activity, energy intake, smoking, education, income and menopausal status, baseline sedentary behaviour was not associated with changes in visceral adiposity or any other marker of cardiometabolic risk. In the longitudinal model which adjusted for all studied covariates, every 15-minute increase in sedentary behaviour from baseline to follow-up was associated with a 0.13 cm increase in waist circumference (95% CI = 0.02, 0.25). However, there was no association between changes in sedentary behaviour and changes in visceral adiposity or other markers of cardiometabolic risk.
These results suggest that neither baseline sedentary behaviour nor changes in sedentary behaviour are associated with longitudinal changes in visceral adiposity in adult men and women. With the exception of waist circumference, the present study did not find evidence of a relationship between sedentary behaviour and any marker of cardiometabolic risk in this population.
PMCID: PMC3541147  PMID: 23326600
14.  Self-Reported Screen Time and Cardiometabolic Risk in Obese Dutch Adolescents 
PLoS ONE  2012;7(12):e53333.
It is not clear whether the association between sedentary time and cardiometabolic risk exists among obese adolescents. We examined the association between screen time (TV and computer time) and cardiometabolic risk in obese Dutch adolescents.
Methods and Findings
For the current cross-sectional study, baseline data of 125 Dutch overweight and obese adolescents (12–18 years) participating in the Go4it study were included. Self-reported screen time (Activity Questionnaire for Adolescents and Adults) and clustered and individual cardiometabolic risk (i.e. body composition, systolic and diastolic blood pressure, low-density (LDL-C), high-density (HDL-C) and total cholesterol (TC), triglycerides, glucose and insulin) were assessed in all participants. Multiple linear regression analyses were used to assess the association between screen time and cardiometabolic risk, adjusting for age, gender, pubertal stage, ethnicity and moderate-to-vigorous physical activity. We found no significant relationship between self-reported total screen time and clustered cardiometabolic risk or individual risk factors in overweight and obese adolescents. Unexpectedly, self-reported computer time, but not TV time, was slightly but significantly inversely associated with TC (B = −0.002; CI = [−0.003;−0.000]) and LDL-C (B = −0.002; CI = [−0.001;0.000]).
In obese adolescents we could not confirm the hypothesised positive association between screen time and cardiometabolic risk. Future studies should consider computer use as a separate class of screen behaviour, thereby also discriminating between active video gaming and other computer activities.
PMCID: PMC3532349  PMID: 23285284
15.  Statistical and Biological Gene-Lifestyle Interactions of MC4R and FTO with Diet and Physical Activity on Obesity: New Effects on Alcohol Consumption 
PLoS ONE  2012;7(12):e52344.
Fat mass and obesity (FTO) and melanocortin-4 receptor (MC4R) and are relevant genes associated with obesity. This could be through food intake, but results are contradictory. Modulation by diet or other lifestyle factors is also not well understood.
To investigate whether MC4R and FTO associations with body-weight are modulated by diet and physical activity (PA), and to study their association with alcohol and food intake.
Adherence to Mediterranean diet (AdMedDiet) and physical activity (PA) were assessed by validated questionnaires in 7,052 high cardiovascular risk subjects. MC4R rs17782313 and FTO rs9939609 were determined. Independent and joint associations (aggregate genetic score) as well as statistical and biological gene-lifestyle interactions were analyzed.
FTO rs9939609 was associated with higher body mass index (BMI), waist circumference (WC) and obesity (P<0.05 for all). A similar, but not significant trend was found for MC4R rs17782313. Their additive effects (aggregate score) were significant and we observed a 7% per-allele increase of being obese (OR = 1.07; 95%CI 1.01–1.13). We found relevant statistical interactions (P<0.05) with PA. So, in active individuals, the associations with higher BMI, WC or obesity were not detected. A biological (non-statistical) interaction between AdMedDiet and rs9939609 and the aggregate score was found. Greater AdMedDiet in individuals carrying 4 or 3-risk alleles counterbalanced their genetic predisposition, exhibiting similar BMI (P = 0.502) than individuals with no risk alleles and lower AdMedDiet. They also had lower BMI (P = 0.021) than their counterparts with low AdMedDiet. We did not find any consistent association with energy or macronutrients, but found a novel association between these polymorphisms and lower alcohol consumption in variant-allele carriers (B+/−SE: −0.57+/−0.16 g/d per-score-allele; P = 0.001).
Statistical and biological interactions with PA and diet modulate the effects of FTO and MC4R polymorphisms on obesity. The novel association with alcohol consumption seems independent of their effects on BMI.
PMCID: PMC3528751  PMID: 23284998
16.  Effects of meal preparation training on body weight, glycemia, and blood pressure: results of a phase 2 trial in type 2 diabetes 
Modest reductions in weight and small increases in step- related activity (e.g., walking) can improve glycemic and blood pressure control in type 2 diabetes mellitus (DM2). We examined changes in these parameters following training in time- efficient preparation of balanced, low- energy meals combined with pedometer- based step count monitoring.
Seventy- two adults with DM2 were enrolled in a 24- week program (i.e., 15 three- hour group sessions). They prepared meals under a chef’s supervision, and discussed eating behaviours/nutrition with a registered dietitian. They maintained a record of pedometer- assessed step counts. We evaluated changes from baseline to 24 weeks in terms of weight, step counts, hemoglobin A1c (HbA1c, glycemic control), blood pressure, and eating control ability (Weight Efficacy Lifestyle WEL Questionnaire). 53 participants (73.6%) completed assessments.
There were improvements in eating control (11.2 point WEL score change, 95% CI 4.7 to 17.8), step counts (mean change 869 steps/day, 95% CI 198 to 1,540), weight (mean change −2.2%; 95% CI −3.6 to −0.8), and HbA1c (mean change −0.3% HbA1c, 95% CI −0.6 to −0.1), as well as suggestion of systolic blood pressure reduction (mean change −3.5 mm Hg, 95% CI −7.8 to 0.9). Findings were not attributable to medication changes. In linear regression models (adjusted for age, sex, ethnicity, insulin use, season), a −2.5% weight change was associated with a −0.3% HbA1c change (95% CI −0.4 to −0.2) and a −3.5% systolic blood pressure change (95% CI −5.5 to −1.4).
In this ‘proof of concept’ study, persistence with the program led to improvements in eating and physical activity habits, glycemia reductions, and suggestion of blood pressure lowering effects. The strategy thus merits further study and development to expand the range of options for vascular risk reduction in DM2.
PMCID: PMC3543247  PMID: 23075398
Body weight; Physical activity; Patient education; Risk factors; Type 2 diabetes
17.  Socioeconomic and Environmental Risk Factors among Rheumatic Heart Disease Patients in Uganda 
PLoS ONE  2012;7(8):e43917.
Although low socioeconomic status, and environmental factors are known risk factors for rheumatic heart disease in other societies, risk factors for rheumatic heart disease remain less well described in Uganda.
Aims and Objective
The objective of this study was to investigate the role of socio-economic and environmental factors in the pathogenesis of rheumatic heart disease in Ugandan patients.
This was a case control study in which rheumatic heart disease cases and normal controls aged 5–60 years were recruited and investigated for socioeconomic and environmental risk factors such as income status, employment status, distance from the nearest health centre, number of people per house and space area per person.
486 participants (243 cases and 243 controls) took part in the study. Average age was 32.37+/−14.6 years for cases and 35.75+/−12.6 years for controls. At univariate level, Cases tended to be more overcrowded than controls; 8.0+/−3.0 versus 6.0+/−3.0 persons per house. Controls were better spaced at 25.2 square feet versus 16.9 for cases. More controls than cases were employed; 45.3% versus 21.1%. Controls lived closer to health centers than the cases; 4.8+/−3.8 versus 3.3+/−12.9 kilometers. At multivariate level, the odds of rheumatic heart disease was 1.7 times higher for unemployment status (OR = 1.7, 95% CI = 1.05–8.19) and 1.3 times higher for overcrowding (OR = 1.35, 95% CI = 1.1–1.56). There was interaction between overcrowding and longer distance from the nearest health centre (OR = 1.20, 95% CI = 1.05–1.42).
The major findings of this study were that there was a trend towards increased risk of rheumatic heart disease in association with overcrowding and unemployment. There was interaction between overcrowding and distance from the nearest health center, suggesting that the effect of overcrowding on the risk of acquiring rheumatic heart disease increases with every kilometer increase from the nearest health center.
PMCID: PMC3428272  PMID: 22952810
18.  Effectiveness of Standardized Nursing Care Plans in Health Outcomes in Patients with Type 2 Diabetes Mellitus: A Two-Year Prospective Follow-Up Study 
PLoS ONE  2012;7(8):e43870.
Implementation of a standardized language in Nursing Care Plans (SNCP) allows for increased efficiency in nursing data management. However, the potential relationship with patientś health outcomes remains uncertain. The aim of this study was to evaluate the effectiveness of SNCP implementation, based on North American Nursing Diagnosis Association (NANDA) and Nursing Interventions Classification (NIC), in the improvement of metabolic, weight, and blood pressure control of Type 2 Diabetes Mellitus (T2DM) patients.
A two-year prospective follow-up study, in routine clinical practice conditions. 31 primary health care centers (Spain) participated with 24,124 T2DM outpatients. Data was collected from Computerized Clinical Records; SNCP were identified using NANDA and NIC taxonomies. Descriptive and ANCOVA analyses were conducted.
18,320 patients were identified in the Usual Nursing Care (UNC) group and 5,168 in the SNCP group. At the two-year follow-up, the SNCP group improved all parameters except LDL cholesterol and diastolic blood pressure. We analyzed data adjustming by the baseline value for these variables and variables with statistically significant differences between groups at baseline visit. Results indicated a lowering of all parameters except HbA1c, but a statistically significant reduction was only observed with diastolic blood pressure results. However, the adjusted reduction of diastolic blood pressure is of little clinical relevance. Greater differences of control values for diastolic blood pressure, HbA1c, LDL-cholesterol and Body Mass Index were found in the SNCP group, but only reached statistical significance for HbA1c. A greater proportion of patients with baseline HbA1c ≥7 decreased to <7% at the two-year follow-up in the SNCP group than in the UNC group (16.9% vs. 15%; respectively; p = 0.01).
Utilization of SNCP was helpful in achieving glycemic control targets in poorly controlled patients with T2DM (HbA1c ≥7%). Diastolic blood pressure results were slightly improved in the SNCP group compared to the UNC group.
Trial Registration NCT01482481
PMCID: PMC3428286  PMID: 22952794
19.  Long-Term Health Outcomes in Children Born to Mothers with Diabetes: A Population-Based Cohort Study 
PLoS ONE  2012;7(5):e36727.
To examine whether prenatal exposure to parental type 1 diabetes, type 2 diabetes, or gestational diabetes is associated with an increased risk of malignant neoplasm or diseases of the circulatory system in the offspring.
Methods/Principal Findings
We conducted a population-based cohort study of 1,781,576 singletons born in Denmark from 1977 to 2008. Children were followed for up to 30 years from the day of birth until the onset of the outcomes under study, death, emigration, or December 31, 2009, whichever came first. We used Cox proportional hazards model to estimate hazard ratios (HR) with 95% confidence intervals (95% CI) for the outcomes under study while adjusting for potential confounders. An increased risk of malignant neoplasm was found in children prenatally exposed to maternal type 2 diabetes (HR = 2.2, 95%CI: 1.5–3.2). An increased risk of diseases of the circulatory system was found in children exposed to maternal type 1 diabetes (HR = 2.2, 95%CI: 1.6–3.0), type 2 diabetes (HR = 1.4, 95%CI: 1.1–1.7), and gestational diabetes (HR = 1.3, 95%CI: 1.1–1.6), but results were attenuated after excluding children with congenital malformations. An increased risk of diseases of the circulatory system was also found in children exposed to paternal type 2 diabetes (HR = 1.5, 95%CI: 1.1–2.2) and the elevated risk remained after excluding children with congenital malformations.
This study suggests that susceptibility to malignant neoplasm is modified partly by fetal programming. Diseases of the circulatory system may be modified by genetic factors, other time-stable family factors, or fetal programming.
PMCID: PMC3359312  PMID: 22649497
20.  Objective vs. Self-Reported Physical Activity and Sedentary Time: Effects of Measurement Method on Relationships with Risk Biomarkers 
PLoS ONE  2012;7(5):e36345.
Imprecise measurement of physical activity variables might attenuate estimates of the beneficial effects of activity on health-related outcomes. We aimed to compare the cardiometabolic risk factor dose-response relationships for physical activity and sedentary behaviour between accelerometer- and questionnaire-based activity measures.
Physical activity and sedentary behaviour were assessed in 317 adults by 7-day accelerometry and International Physical Activity Questionnaire (IPAQ). Fasting blood was taken to determine insulin, glucose, triglyceride and total, LDL and HDL cholesterol concentrations and homeostasis model-estimated insulin resistance (HOMAIR). Waist circumference, BMI, body fat percentage and blood pressure were also measured.
For both accelerometer-derived sedentary time (<100 counts.min−1) and IPAQ-reported sitting time significant positive (negative for HDL cholesterol) relationships were observed with all measured risk factors – i.e. increased sedentary behaviour was associated with increased risk (all p≤0.01). However, for HOMAIR and insulin the regression coefficients were >50% lower for the IPAQ-reported compared to the accelerometer-derived measure (p<0.0001 for both interactions). The relationships for moderate-to-vigorous physical activity (MVPA) and risk factors were less strong than those observed for sedentary behaviours, but significant negative relationships were observed for both accelerometer and IPAQ MVPA measures with glucose, and insulin and HOMAIR values (all p<0.05). For accelerometer-derived MVPA only, additional negative relationships were seen with triglyceride, total cholesterol and LDL cholesterol concentrations, BMI, waist circumference and percentage body fat, and a positive relationship was evident with HDL cholesterol (p = 0.0002). Regression coefficients for HOMAIR, insulin and triglyceride were 43–50% lower for the IPAQ-reported compared to the accelerometer-derived MVPA measure (all p≤0.01).
Using the IPAQ to determine sitting time and MVPA reveals some, but not all, relationships between these activity measures and metabolic and vascular disease risk factors. Using this self-report method to quantify activity can therefore underestimate the strength of some relationships with risk factors.
PMCID: PMC3348936  PMID: 22590532
21.  Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction 
Patients prescribed antiplatelet treatment to prevent recurrent acute myocardial infarction are often also given a selective serotonin reuptake inhibitor (SSRI) to treat coexisting depression. Use of either treatment may increase the risk of bleeding. We assessed the risk of bleeding among patients taking both medications following acute myocardial infarction.
We conducted a retrospective cohort study using hospital discharge abstracts, physician billing information, medication reimbursement claims and demographic data from provincial health services administrative databases. We included patients 50 years of age or older who were discharged from hospital with antiplatelet therapy following acute myocardial infarction between January 1998 and March 2007. Patients were followed until admission to hospital due to a bleeding episode, admission to hospital due to recurrent acute myocardial infarction, death or the end of the study period.
The 27 058 patients in the cohort received the following medications at discharge: acetylsalicylic acid (ASA) (n = 14 426); clopidogrel (n = 2467), ASA and clopidogrel (n = 9475); ASA and an SSRI (n = 406); ASA, clopidogrel and an SSRI (n = 239); or clopidogrel and an SSRI (n = 45). Compared with ASA use alone, the combined use of an SSRI with antiplatelet therapy was associated with an increased risk of bleeding (ASA and SSRI: hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.08–1.87; ASA, clopidogrel and SSRI: HR 2.35, 95% CI 1.61–3.42). Compared with dual antiplatelet therapy alone (ASA and clopidogrel), combined use of an SSRI and dual antiplatelet therapy was associated with an increased risk of bleeding (HR 1.57, 95% CI 1.07–2.32).
Patients taking an SSRI together with ASA or dual antiplatelet therapy following acute myocardial infarction were at increased risk of bleeding.
PMCID: PMC3216455  PMID: 21948719
22.  Daily steps are low year-round and dip lower in fall/winter: findings from a longitudinal diabetes cohort 
Higher walking levels lead to lower mortality in type 2 diabetes, but inclement weather may reduce walking. In this patient population, we conducted a longitudinal cohort study to objectively quantify seasonal variations both in walking and in two vascular risk factors associated with activity levels, hemoglobin A1C and blood pressure.
Between June 2006 and July 2009, volunteer type 2 diabetes patients in Montreal, Quebec, Canada underwent two weeks of pedometer measurement up to four times over a one year follow-up period (i.e. once/season). Pedometer viewing windows were concealed (snap-on cover and tamper proof seal). A1C, blood pressure, and anthropometric parameters were also assessed. Given similarities in measures for spring/summer and fall/winter, and because not all participants completed four assessments, spring and summer values were collapsed as were fall and winter values. Mean within-individual differences (95% confidence intervals) were computed for daily steps, A1C, and systolic and diastolic blood pressure, by subtracting spring/summer values from fall/winter values.
Among 201 participants, 166 (82.6%) underwent at least one fall/winter and one spring/summer evaluation. Approximately half were women, the mean age was 62.4 years (SD 10.8), and the mean BMI was 30.1 kg/m2 (SD 5.7). Step counts averaged at a sedentary level in fall/winter (mean 4,901 steps/day, SD 2,464) and at a low active level in spring/summer (mean 5,659 steps/day, SD 2,611). There was a -758 (95% CI: -1,037 to -479) mean fall/winter to spring/summer within-individual difference. There were no significant differences in A1C or in anthropometric parameters. Systolic blood pressure was higher in fall/winter (mean 137 mm Hg, SD 16) than spring/summer (133 mm Hg, SD 14) with a mean difference of 4.0 mm Hg (95% CI: 2.3 to 5.7).
Daily step counts in type 2 diabetes patients are low, dipping lower during fall/winter. In this medication-treated cohort, A1C was stable year-round but a fall/winter systolic blood pressure increase was detected. Our findings signal a need to develop strategies to help patients increase step counts year-round and prevent both reductions in step counts and increases in blood pressure during the fall and winter.
PMCID: PMC3004821  PMID: 21118567
23.  Sex Differences in Step Count-Blood Pressure Association: A Preliminary Study in Type 2 Diabetes 
PLoS ONE  2010;5(11):e14086.
Walking and cardiovascular mortality are inversely associated in type 2 diabetes, but few studies have objectively measured associations of walking with individual cardiovascular risk factors. Such information would be useful for “dosing” daily steps in clinical practice. This study aimed to quantify decrements in blood pressure and glycated hemoglobin (A1C) per 1,000 daily step increments.
Methodology/Principal Findings
Two hundred and one subjects with type 2 diabetes underwent assessments of step counts (pedometer-measured), blood pressure, A1C and anthropometric parameters. Due to missing data, the final analysis was conducted on 83 women and 102 men, with a mean age of 60 years. Associations of daily steps with blood pressure and A1C were evaluated using sex-specific multivariate linear regression models (adjusted for age, ethnicity, and BMI). Potential sex differences were confirmed in a combined model (women and men) with interaction terms. Mean values for daily steps, blood pressure, A1C and BMI were 5,357 steps/day; 137/80 mm Hg; 7.7% and 30.4 kg/m2 respectively. A 1,000 daily step increment among women was associated with a −2.6 (95% CI: −4.1 to −1.1) mm Hg change in systolic and a −1.4 (95% CI: −2.2 to −0.6) mm Hg change in diastolic blood pressure. Among men, corresponding changes were −0.7 (95% CI: −2.1 to 0.7) and −0.6 (95% CI: −1.4 to 0.3) mm Hg, respectively. Sex differences were confirmed in combined models. Step counts and A1C did not demonstrate clinically important associations.
A 1,000 steps/day increment is associated with important blood pressure decrements among women with type 2 diabetes but the data were inconclusive among men. Targeted “dose increments” of 1,000 steps/day in women may lead to measurable blood pressure reductions. This information may be of potential use in the titration or “dosing” of daily steps. No associations were found between step count increments and A1C.
PMCID: PMC2989914  PMID: 21124929
24.  Short-term mortality associated with failure to receive home care after hemiarthroplasty 
Hemiarthroplasty is often the treatment of choice after hip fracture, particularly in frail elderly patients. Such patients may benefit from home care after discharge. We assessed factors associated with the receipt of home care and evaluated the risk of death within three months after discharge.
We obtained administrative data for patients 65 years or older in the province of Quebec who were discharged alive from hospital after hemiarthroplasty during the period 1997–2004. We evaluated destination after discharge and mortality within three months after discharge.
Of 11 326 study patients, 5.6% were discharged home with home care, 29.9% home without home care, 2.0% to a rehabilitation centre, 24.2% to a nursing home and 38.3% to another hospital. Among patients who were discharged home, those who were older, had osteoarthritis, had an emergent admission and were admitted to a high-volume hospital were less likely to receive home care. Discharge with home care was most likely among patients admitted to teaching hospitals, those in hospital for more than seven days, those with atrial fibrillation and those with acute renal failure. Patients who received home care were at lower risk of death than those discharged home without care (hazard ratio 0.57, 95% confidence interval 0.39–0.85).
Less than 16% of the patients discharged home after hemiarthroplasty received home care. Those who received such care had a lower risk of death within three months after discharge.
PMCID: PMC2942914  PMID: 20713576
25.  Outcomes in a diabetic population of south Asians and whites following hospitalization for acute myocardial infarction: a retrospective cohort study 
The aim of this study was to determine whether South Asian patients with diabetes have a worse prognosis following hospitalization for acute myocardial infarction (AMI) compared with their White counterparts. We measured the risk of developing a composite cardiovascular outcome of recurrent AMI, congestive heart failure (CHF) requiring hospitalization, or death, in these two groups.
Using hospital administrative data, we performed a retrospective cohort study of 41,615 patients with an incident AMI in British Columbia and the Calgary Health Region between April 1, 1995, and March 31, 2002. South Asian ethnicity was determined using validated surname analysis. Baseline demographic characteristics and co-morbidities were included in Cox proportional hazard models to compare time to reaching the composite outcome and its individual components.
Among the AMI cohort, 29.7% of South Asian patients and 17.6% of White patients were identified as having diabetes (n = 7416). There was no significant difference in risk of developing the composite cardiovascular outcome (Hazard Ratio = 0.90, 95% CI = 0.80-1.01). However, South Asian patients had significantly lower mortality at long term follow-up (HR = 0.62, 95% CI = 0.51-0.74) compared to their White counterparts.
Following hospitalization for AMI, South Asian patients with diabetes do not have a significantly different long term risk of a composite cardiovascular outcome compared to White patients with diabetes. While previous research has suggested worse cardiovascular outcomes in the South Asian population, we found lower long-term mortality among South Asians with diabetes following AMI.
PMCID: PMC2816974  PMID: 20096107

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