Diet and epidemiology of non-communicable chronic diseases: focusing on dietary and nutrient patterns and bone fragility in adults

Existing evidence supports the increasing consumption of unhealthy diet and associated growing impact on the current burden of non-communicable diseases (NCDs) globally. However, evidence on the extent of diet-related NCD burden remains limited. Firstly, this thesis assesses the trends in diet-related NCDs in Australia from 1990 to 2015 and compares the results with other countries of the Organization for Economic Co-operation and Development (OECD). Fourteen dietary risk factors (eight food groups, five nutrients and fibre intake) were included in Global Burden of Disease (GBD) 2015. Body mass index, total serum cholesterol, fasting plasma glucose and systolic blood pressure were considered to mediate the relationship between dietary factors and NCDs. The results demonstrated that over the past 25 years, the burden of diet-related NCDs in Australia has declined. However, despite this and improvements in Australia’s comparative global standing, the relative contribution of dietary risk factors to NCD burden is still high in Australia. In 2015, nearly one-fifth (19.7%) of NCD deaths in Australia were attributable to dietary risk factors. Young (25–49 years) and middle-age (50–69 years) males had a higher population attributable fraction of diet-related NCD deaths and disability-adjusted life years (DALYs) than their female counterparts. Overall, more than three-quarters (80.5%) of diet-related NCD deaths were caused by cardiovascular disease (CVD) and 42.3% of all CVD deaths were attributable to dietary risks. Diets low in fruits, vegetables (FV), nuts and seeds, and whole grains, and high in sodium were the major contributors to both NCD deaths and DALYs. The findings above form the basis for the remaining studies presented in this thesis. The above study did not look at the impact of diet on musculoskeletal diseases, specifically on osteoporosis and fractures. In the subsequent studies, I hypothesize that diet is an important risk factor for osteoporosis and fractures. Previous studies on the association between dietary patterns and bone mineral density (BMD) have reported inconsistent findings. Data from the North West Adelaide Health Study (NWAHS), a population-based cohort study undertaken in Australia, are used to assess this association among adults aged 50 years and above. Overall, 1182 adults (545 males, 45.9%) had dietary data collected using a food frequency questionnaire (FFQ) and also had BMD measurements taken using Dual-energy X-ray absorptiometry (DXA). Factor analysis using the principal component analysis (PCA) method was applied to ascertain dietary patterns. Two distinct dietary patterns were identified. Pattern 1 (‘prudent’ pattern) was characterised by high intake of FV, sugar, nut-based milk, fish, legumes and high-fibre bread. In contrast, pattern 2 (‘Western’ pattern) was characterised by high levels of processed and red meat, snacks, takeaway foods, jam, beer, soft drinks, white bread, poultry, potato with fat, high-fat dairy products and eggs. Compared with the study participants with lowest consumption (first tertile) of the ‘prudent’ pattern, participants in the third tertile had a lower prevalence of low BMD (prevalence ratio (PR) = 0.52; 95% confidence interval (CI): 0.33, 0.83) after adjusting for sociodemographic, lifestyle and behavioural characteristics, chronic conditions and energy intake. Participants in the third tertile of the ‘Western’ pattern had a higher prevalence of low BMD (PR = 1.68; 95% CI: 1.02, 2.77) compared with those in tertile 1. In contrast to the ‘Western’ diet, a dietary pattern characterised by high intake of FV and dairy products is positively associated with BMD. In addition to dietary patterns, exploring the association between nutrient patterns and BMD provides further insight into the physiological mechanisms of how dietary patterns impact BMD. There is limited evidence of the link between the overall nutrients intake from diet and BMD. I assess the association between nutrient patterns and BMD among an older Australian population. Participants (n = 1135; males, 45.8%; median age, 62.0 years) with dietary and BMD data in the NWAHS were included. Dietary intake was assessed using a FFQ. BMD was measured using DXA. Nutrient patterns were identified by factor analysis. Linear regression analyses were conducted to assess the association between nutrient patterns and BMD. Multiple imputation and sensitivity analyses were conducted to investigate the effect of missing data on the estimates. Three nutrient patterns (animal-sourced [cholesterol, protein, Vitamin B12 and fat], plant-sourced [fibre, carotene, vitamin C and Lutein] and mixed-source—a combination of both animal- and plant-sourced [potassium, calcium, fibre, retinol and Vitamin B12]) were identified. After adjusting for sociodemographic, lifestyle and behavioural characteristics, chronic conditions and energy intake, animal (β = −4.07; 95% CI: −11.89, 3.76) and plant-sourced (β = −0.99; 95% CI: −7.43, 5.45) patterns were not associated with BMD. However, I found that the mixed-source pattern was positively associated with BMD (β = 10.86; 95% CI: 1.91, 19.80). There were no interactions between the pattern, other covariates and BMD. The multiple imputation and sensitivity analyses including missing data identified similar patterns of association between nutrient patterns and BMD. Whereas animal- and plant-sourced nutrient patterns are not associated with BMD, a mixed-source pattern may prevent a reduction in BMD. In addition to investigating the association of dietary and nutrient patterns with BMD, the relationship between long-term dietary and nutrient patterns and the ultimate consequence of low BMD (i.e. fracture risk) is pivotal. However, studies on long-term exposure to foods/nutrients and the associations with fracture risk are scarce. Using data from the China Health and Nutrition Survey, I determine the prospective association of dietary and nutrient patterns with fractures. Data from 15,572 adults aged ≥18 years were analysed. Fracture occurrence was self-reported and dietary intake data were collected using a 24-hour (24-h) recall method for three consecutive days, for each individual across nine waves (1989–2011). I used cumulative and overall mean, recent and baseline dietary and nutrient exposures. Hazard ratios (HR) were used to determine the associations. Two dietary (traditional and modern) and two nutrient (plant- and animal-sourced) patterns were identified. After adjusting for potential confounders, study participants within the highest intake (third tertiles) of the modern dietary and animal-sourced nutrient patterns’ cumulative scores had a 34% (HR = 1.34; 95% CI: 1.06–1.71) and 37% (HR = 1.37; 95% CI: 1.08–1.72) increase in fracture risks compared to those in the first tertiles, respectively. While the overall mean factor scores of dietary and nutrient patterns had a similar (or stronger) pattern of association as the cumulative scores, no association between recent and baseline scores and fracture was found. Greater adherence to a modern dietary and/or an animal-sourced nutrient pattern is associated with a higher total fracture risk. This suggests that a modern animal-based diet is related to bone fragility. A repeated three-day 24-h recall dietary assessment provides a stronger association with fracture compared to a recent or baseline exposure. In the above studies, I used factor analysis with PCA method. However, in addition to this method, there are other common data reduction methods. The relative advantages of these methods, particularly in identifying dietary patterns associated with bone mass, have not been investigated. I evaluated three methods: PCA, partial least-squares (PLS) and reduced-rank regressions (RRR) in determining dietary patterns associated with bone mass. Dietary patterns were constructed using PCA, PLS and RRR and compared based on the performance to identify plausible patterns associated with BMD and bone mineral content (BMC). PCA, PLS and RRR identified two, four and four dietary patterns, respectively. All methods identified similar patterns for the first two factors (factor 1, ‘prudent’ and factor 2, ‘Western’ patterns). Three, one and none of the patterns derived by RRR, PLS and PCA were significantly associated with bone mass, respectively. The ‘prudent’ and dairy (factor 3) patterns determined by RRR were positively and significantly associated with BMD and BMC. Vegetables and fruit pattern (factor 4) of PLS and RRR was negatively and significantly associated with BMD and BMC, respectively. RRR was found to be more appropriate in identifying more (plausible) dietary patterns that are associated with bone mass than PCA and PLS. Nevertheless, the advantage of RRR over the other two methods (PCA and PLS) should be confirmed in future studies. The findings from these studies indicate that diet is a leading risk factor for the current burden of disease in Australia and has a significant impact on bone health among adults in Australia and China. In identifying dietary patterns that are associated with bone health, dietary data collection and analysis methods are important factors that potentially bias findings. These analyses have not previously been undertaken and indicate the potential implications of diet on long-term bone health. The findings have significant implications in public health interventions and clinical practices. Future studies should focus on the potential mechanisms and pathways of the associations of diet with osteoporosis and fracture risks. Identification of mediating factors and investigating their roles in the pathways should be the focus of future studies. Further evaluation of statistical methods in the analysis of dietary patterns associated with bone health and other disease outcome is warranted.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 201

Sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students, northern Ethiopia: a cross-sectional study

Sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students, northern Ethiopia: a cross-sectional study. Health, 14: 252 http://dx.doi. org/10.1186/1471-2458-14-252 Access to the published version may require subscription. N.B. When citing this work, cite the original published paper. BMC Public Permanent link to this version: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-87988 R E S E A R C H A R T I C L E Open Access Sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students, northern Ethiopia: a cross-sectional study Abstract Background: Adolescent girls continue to fall victim to unintended pregnancy and its consequences, with particular problems arising in low income countries. Awareness about methods of contraception is an important step towards gaining access and using suitable contraceptive methods. However, studies assessing the relationship between sexual and reproductive health communication and awareness of contraceptive methods among secondary school female students are lacking. Methods: A cross sectional study was conducted among 807 female students in six secondary schools in Mekelle town, Ethiopia. Study participants were selected with a stratified cluster sampling technique. Data collection was carried out using a structured, self-administered questionnaire, and data entry was done using EPI Info Version 3.3.2 software. The data were then cleaned and analyzed using SPSS version 20. Bivariate and multivariate logistic regressions were used to determine factors associated with awareness of female students on methods of contraception. Result: Of all the students, 127(15.8%) reported ever having had sex, of whom 109(85.8%) had ever used contraceptives. Twenty (16%) of the sexually active students reported having been pregnant, of whom 18(90%) terminated their pregnancies with induced abortion. Discussion on sexual and reproductive health matters with their parent/s and peer/s in the six months prior to the study was reported by 351(43.5%) and 493(61.1%) of the students respectively. 716(88%) students were aware of different methods of contraception. Discussing sexual and reproductive health issues with parents (AOR =2.56(95% CI: 1.45, 4.50)) and peers (AOR = 2.46(95% CI: 1.50, 4.03)) were found to be independent predictors for contraceptive awareness among students. Conclusions: Discussion on sexual and reproductive health issues with family and peers has a positive effect on contraceptive awareness of students. Therefore, strategies to improve open parent-child communication, and appropriate peer-to-peer communication in schools on sexual and reproductive health should be established and strengthened

Association Between Dietary Inflammatory Index, Dietary Patterns, Plant-Based Dietary Index and the Risk of Obesity

Evidence on the association between various dietary constructs and obesity risk is limited. This study aims to investigate the longitudinal relationship between different diet indices and dietary patterns with the risk of obesity. Non-obese participants (n = 787) in the North West Adelaide Health Study were followed from 2010 to 2015. The dietary inflammatory index (DII®), plant-based dietary index (PDI) and factor-derived dietary pattern scores were computed based on food frequency questionnaire data. We found the incidence of obesity was 7.62% at the 5-year follow up. In the adjusted model, results from multivariable log-binomial logistic regression showed that a prudent dietary pattern (RRQ5 vs. Q1 = 0.38; 95% CI: 0.15–0.96), healthy PDI (RR = 0.31; 95% CI: 0.12–0.77) and overall PDI (RR = 0.56; 95% CI: 0.23–1.33) were inversely associated with obesity risk. Conversely, the DII (RR = 1.59; 95% CI: 0.72–3.50), a Western dietary pattern (RR = 2.16; 95% CI: 0.76–6.08) and unhealthy PDI (RR = 1.94; 95% CI: 0.81–4.66) were associated with increased risk of obesity. Based on the cubic spline analysis, the association between an unhealthy PDI or diet quality with the risk of obesity was non-linear. In conclusion, an anti-inflammatory diet, healthy diet or consumption of healthy plant-based foods were all associated with a lower risk of developing obesity

Trends and causes of maternal mortality in Ethiopia during 1990-2013:Findings from the Global Burden of Diseases study 2013

Background: Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. Methods: We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. Results: In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20-29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was-1.6 (95% UI:-2.8 to-0.3). Conclusion: The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period

High-quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk

Study Objectives: Most studies on diet and sleep apnea focus on calorie restriction. Here we investigate potential associations between dietary quality (Healthy Eating Index [HEI], Dietary Inflammatory Index [DII]) and overall healthy lifestyle with sleep apnea risk. Methods: National Health and Nutrition Examination Survey data (waves 2005-2008 and 2015-2018; n = 14,210) were used to determine HEI, DII, and their quintiles, with the fifth quintile indicating highest adherence to each dietary construct. A healthy lifestyle score was determined using diet, smoking, alcohol intake, and physical activity level. The STOP-BANG questionnaire was used to define sleep apnea risk. Generalized linear regression models with binomial family and logit link were used to investigate potential associations. The models were adjusted for socioeconomic status, lifestyle factors, and chronic conditions. Results: The prevalence of high sleep apnea risk was 25.1%. Higher DII was positively associated with sleep apnea (odds ratioQuintile 5 vs Quintile 1 = 1.55; 95% confidence interval, 1.24-1.94; P for trend < .001), whereas higher HEI was associated with reduced sleep apnea risk (odds ratioQuintile 5 vs Quintile 1 = 0.72; 95% confidence interval, 0.59-0.88; P for trend = .007). Higher healthy lifestyle score was also associated with decreased odds of sleep apnea (P for trend < .001). There was a significant interaction between healthy lifestyle and sex with sleep apnea risk (P for interaction = .049) whereby females with higher healthy lifestyle scores had a lower risk of sleep apnea compared to males. Conclusions: Higher-quality and anti-inflammatory diets and a healthier overall lifestyle are associated with lower sleep apnea risk. These findings underline the importance of strategies to improve overall diet quality and promote healthy behavior, not just calorie restriction, to reduce sleep apnea risk

The burden of HIV/AIDS in Ethiopia from 1990 to 2016: evidence from the Global Burden of Diseases 2016 Study

BACKGROUND: The burden of HIV/AIDS in Ethiopia has not been comprehensively assessed over the last two decades. In this study, we used the 2016 Global Burden of Diseases, Injuries and Risk factors (GBD) data to analyze the incidence, prevalence, mortality and Disability-adjusted Life Years Lost (DALY) rates of Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome (HIV/AIDS) in Ethiopia over the last 26 years. METHODS: The GBD 2016 used a wide range of data source for Ethiopia such as verbal autopsy (VA), surveys, reports of the Federal Ministry of Health and the United Nations (UN) and published scientific articles. The modified United Nations Programme on HIV/AIDS (UNAIDS) Spectrum model was used to estimate the incidence and mortality rates for HIV/AIDS. RESULTS: In 2016, an estimated 36,990 new HIV infections (95% uncertainty interval [UI]: 8775-80262), 670,906 prevalent HIV cases (95% UI: 568,268-798,970) and 19,999 HIV deaths (95% UI: 16426-24412) occurred in Ethiopia. The HIV/AIDS incidence rate peaked in 1995 and declined by 6.3% annually for both sexes with a total reduction of 77% between 1990 and 2016. The annualized HIV/AIDS mortality rate reduction during 1990 to 2016 for both sexes was 0.4%

The need to promote sleep health in public health agendas across the globe.

Healthy sleep is essential for physical and mental health, and social wellbeing; however, across the globe, and particularly in developing countries, national public health agendas rarely consider sleep health. Sleep should be promoted as an essential pillar of health, equivalent to nutrition and physical activity. To improve sleep health across the globe, a focus on education and awareness, research, and targeted public health policies are needed. We recommend developing sleep health educational programmes and awareness campaigns; increasing, standardising, and centralising data on sleep quantity and quality in every country across the globe; and developing and implementing sleep health policies across sectors of society. Efforts are needed to ensure equity and inclusivity for all people, particularly those who are most socially and economically vulnerable, and historically excluded

Population structure and transmission of Mycobacterium bovis in Ethiopia

Bovine tuberculosis (bTB) is endemic in cattle in Ethiopia, a country that hosts the largest national cattle herd in Africa. The intensive dairy sector, most of which is peri-urban, has the highest prevalence of disease. Previous studies in Ethiopia have demonstrated that the main cause is Mycobacterium bovis , which has been investigated using conventional molecular tools including deletion typing, spoligotyping and Mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR). Here we use whole-genome sequencing to examine the population structure of M. bovis in Ethiopia. A total of 134 M . bovis isolates were sequenced including 128 genomes from 85 mainly dairy cattle and six genomes isolated from humans, originating from 12 study sites across Ethiopia. These genomes provided a good representation of the previously described population structure of M. bovis , based on spoligotyping and demonstrated that the population is dominated by the clonal complexes African 2 (Af2) and European 3 (Eu3). A range of within-host diversity was observed amongst the isolates and evidence was found for both short- and long-distance transmission. Detailed analysis of available genomes from the Eu3 clonal complex combined with previously published genomes revealed two distinct introductions of this clonal complex into Ethiopia between 1950 and 1987, likely from Europe. This work is important to help better understand bTB transmission in cattle in Ethiopia and can potentially inform national strategies for bTB control in Ethiopia and beyond

National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015

Background: Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk factors 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years. Methods: GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015. Results: CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015. Conclusions: Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country’s performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country