Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials

Aims/hypothesis: Individuals of South Asian origin have a high risk of type 2 diabetes and of dying from a diabetes-attributable cause. Lifestyle modification intervention trials to prevent type 2 diabetes in high-risk South Asian adults have suggested more modest effects than in European-origin populations. The strength of the evidence of individual studies is limited, however. We performed an individual participant data meta-analysis of available RCTs to assess the effectiveness of lifestyle modification in South Asian populations worldwide. Methods: We searched PubMed, EMBASE, Cochrane Library and Web of Science (to 24 September 2018) for RCTs on lifestyle modification interventions incorporating diet and/or physical activity in South Asian adults. Reviewers identified eligible studies and assessed the quality of the evidence. We obtained individual participant data on 1816 participants from all six eligible trials (four from Europe and two from India). We generated HR estimates for incident diabetes (primary outcome) and mean differences for fasting glucose, 2 h glucose, weight and waist circumference (secondary outcomes) using mixed-effect meta-analysis overall and by pre-specified subgroups. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence of the estimates. The study is registered with the International Prospective Register of Systematic Reviews ([PROSPERO] CRD42017078003). Results: Incident diabetes was observed in 12.6% of participants in the intervention groups and in 20.0% of participants in the control groups. The pooled HR for diabetes incidence was 0.65 (95% CI 0.51, 0.81; I2 = 0%) in intervention compared with control groups. The absolute risk reduction was 7.4% (95% CI 4.0, 10.2), with no interactions for the pre-specified subgroups (sex, BMI, age, study duration and region where studies were performed). The quality of evidence was rated as moderate. Mean difference for lifestyle modification vs control groups for 2 h glucose was −0.34 mmol/l (95% CI −0.62, −0.07; I2 = 50%); for weight −0.75 kg (95% CI −1.34, −0.17; I2 = 71%) and for waist −1.16 cm (95% CI −2.16, −0.16; I2 = 75%). No effect was found for fasting glucose. Findings were similar across subgroups, except for weight for European vs Indian studies (−1.10 kg vs −0.08 kg, p = 0.02 for interaction). Conclusions/interpretation: Despite modest changes for adiposity, lifestyle modification interventions in high-risk South Asian populations resulted in a clinically important 35% relative reduction in diabetes incidence, consistent across subgroups. If implemented on a large scale, lifestyle modification interventions in high-risk South Asian populations in Europe would reduce the incidence of diabetes in these populations

Study protocol of European Fans in Training (EuroFIT):a four-country randomised controlled trial of a lifestyle program for men delivered in elite football clubs

Background: Lifestyle interventions targeting physical activity, sedentary time and dietary behaviours have the potential to initiate and support behavioural change and result in public health gain. Although men have often been reluctant to engage in such lifestyle programs, many are at high risk of several chronic conditions. We have developed an evidence and theory-based, gender sensitised, health and lifestyle program (European Fans in Training (EuroFIT)), which is designed to attract men through the loyalty they feel to the football club they support. This paper describes the study protocol to evaluate the effectiveness and cost-effectiveness of the EuroFIT program in supporting men to improve their level of physical activity and reduce sedentary behaviour over 12 months. Methods: The EuroFIT study is a pragmatic, two-arm, randomised controlled trial conducted in 15 football clubs in the Netherlands, Norway, Portugal and the UK (England). One-thousand men, aged 30 to 65 years, with a self-reported Body Mass Index (BMI) ≥27 kg/m2 will be recruited and individually randomised. The primary outcomes are objectively-assessed changes in total physical activity (steps per day) and total sedentary time (minutes per day) at 12 months after baseline assessment. Secondary outcomes are weight, BMI, waist circumference, resting systolic and diastolic blood pressure, cardio-metabolic blood biomarkers, food intake, self-reported physical activity and sedentary time, wellbeing, self-esteem, vitality and quality of life. Cost-effectiveness will be assessed and a process evaluation conducted. The EuroFIT program will be delivered over 12 weekly, 90-minute sessions that combine classroom discussion with graded physical activity in the setting of the football club. Classroom sessions provide participants with a toolbox of behaviour change techniques to initiate and sustain long-term lifestyle changes. The coaches will receive two days of training to enable them to create a positive social environment that supports men in engaging in sustained behaviour change. Discussion: The EuroFIT trial will provide evidence on the effectiveness and cost-effectiveness of the EuroFIT program delivered by football clubs to their male fans, and will offer insight into factors associated with success in making sustained changes to physical activity, sedentary behaviour, and secondary outcomes, such as diet.Trial registration: ISRCTN: 81935608. Registered 16 June 2015.<br/

Five-year cost-effectiveness analysis of the European Fans in Training (EuroFIT) physical activity intervention for men versus no intervention

OBJECTIVES: Increasing physical activity reduces the risk of chronic illness including Type 2 diabetes, cardiovascular disease and certain types of cancer. Lifestyle interventions can increase physical activity but few successfully engage men. This study aims to investigate the 5 year cost-effectiveness of EuroFIT, a program to improve physical activity tailored specifically for male football (soccer) fans compared to a no intervention comparison group. METHODS: We developed a Markov cohort model in which the impact of improving physical activity on five chronic health conditions (colorectal cancer, Type 2 diabetes, coronary heart disease, stroke and depression) and mortality was modelled. We estimated costs from a societal perspective and expressed benefits as quality adjusted life years (QALYs). We obtained data from a 4-country (England, Netherlands, Portugal and Norway) pragmatic randomised controlled trial evaluating EuroFIT, epidemiological and cohort studies, and meta-analyses. We performed deterministic and probabilistic sensitivity analyses to assess the impact of uncertainty in the model's parameter values on the cost-effectiveness results. We used Monte Carlo simulations to estimate uncertainty and presented this using cost-effectiveness acceptability curves (CEACs). We tested the robustness of the base case analysis using five scenario analyses. RESULTS: Average costs over 5 years per person receiving EuroFIT were €14,663 and per person receiving no intervention €14,598. Mean QALYs over 5 years were 4.05 per person for EuroFIT and 4.04 for no intervention. Thus, the average incremental cost per person receiving EuroFIT was €65 compared to no intervention, while the average QALY gain was 0.01. This resulted in an ICER of €5206 per QALY gained. CEACs show that the probability of EuroFIT being cost-effective compared to no intervention is 0.53, 0.56 and 0.58 at thresholds of €10,000, €22,000 and €34,000 per QALY gained, respectively. When using a time horizon of 10 years, the results suggest that EuroFIT is more effective and less expensive compared to (i.e. dominant over) no intervention with a probability of cost-effectiveness of 0.63 at a threshold of €22,000 per QALY gained. CONCLUSIONS: We conclude the EuroFIT intervention is not cost-effective compared to no intervention over a period of 5 years from a societal perspective, but is more effective and less expensive (i.e. dominant) after 10 years. We thus suggest that EuroFIT can potentially improve public health in a cost-effective manner in the long term

What can we learn from the SARS-COV-2 pandemic about the value of specific radiological examinations?

Background The SARS-COV-2 pandemic provides a natural intervention to assess practical priority setting and internal evaluation of specific health services, such as radiological services. Norway makes an excellent case as it had a very low infection rate and very few cases of COVID-19. Accordingly, the objective of this study is to use the changes in performed outpatient radiological examinations during the first stages of the SARS-COV-2 pandemic to assess the practical evaluation of specific radiological examinations in Norway. Methods Data was collected retrospectively from the Norwegian Health Economics Administration (HELFO) in the years 2015–2020. Data included the number of performed outpatient imaging examinations at public hospitals and private imaging centers in Norway and was divided in to three periods based on the level of restrictions on elective health services. Results were analyzed with descriptive statistics. Results In the first period there was a 45% reduction in outpatient radiology compared to the same time period in 2015–2019 while in period 2 and 3 there was a 25 and 6% reduction respectively. The study identified a list of specific potential low-value radiological examinations. While some of these are covered by the Choosing Wisely campaign, others are not. Conclusion By studying the priority setting practice during the initial phases of the pandemic this study identifies a set of potential low value radiological examinations during the initial phases of the SARS-COV-2 pandemic. These examinations are candidates for closer assessments for health services quality improvement

Reducing low-value radiological services in Norway –a qualitative multi-professional study on measures and facilitators for change

Background Overuse, underuse, and significant variation in the utilisation of radiological services are well documented in the literature. Several radiological examinations are identified as low-value examinations as they do not lead to a change in diagnosis or course of treatment. Even so, such examinations are frequently performed. Many measures for reducing low-value imaging have been carried out with variable outcomes. While there is little evidence as to why some measures work and others do not, adjusting to the context seems important for success. The objective of this study was to investigate which measures stakeholders consider appropriate for reducing the use of low-value imaging and what it takes to make them work. Methods Semi-structured interviews were conducted among radiographers, radiologists, radiological department managers, hospital clinicians, general practitioners, and health government/authorities’ representatives. The interview guide covered two broad areas: Experience with low-value services, and possible future measures deemed appropriate for reducing low-value services. Data were analysed in line with a qualitative framework analysis. Results The analysis included information from 27 participants. All participants acknowledged that low-value imaging was a problem, but few had very specific suggestions on reducing this in practice. Suggested measures were to stop referrals from being sent, provide support in assessing referrals, or change the healthcare system. Identified facilitators were categorised as management and resources, evidence, and experienced value. In general, appropriate measures should be practical, well-founded, and valuable. Conclusions This study provides insight into various stakeholders’ perceptions of suitable interventions to reduce low-value imaging. While many measures for reducing low-value imaging are available, contextual sensitivity is crucial to make them work

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

Background It is estimated that 20–50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. Methods An electronic database search was completed in Medline – Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. Results The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. Conclusions Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts

Executive Function, Behavioral Self-Regulation, and School Related Well-Being Did Not Mediate the Effect of School-Based Physical Activity on Academic Performance in Numeracy in 10-Year-Old Children : The Active Smarter Kids (ASK) Study

Inconsistent findings exist for the effect of school-based physical activity interventions on academic performance. The Active Smarter Kids (ASK) study revealed a favorable intervention effect of school-based physical activity on academic performance in numeracy in a subsample of 10-year-old elementary schoolchildren performing poorer at baseline in numeracy. Aiming to explain this finding, we investigated the mediating effects of executive function, behavioral self-regulation, and school related well-being in the relation between the physical activity intervention and child’s performance in numeracy. An ANCOVA model with latent variable structural equation modeling was estimated using data from 360 children (the lower third in academic performance in numeracy at baseline). The model consisted of the three latent factors as mediators; executive function, behavioral self-regulation, and school related well-being. We found no mediating effects of executive function, behavioral self-regulation or school related well-being in the relationship between the ASK intervention and academic performance in numeracy (p ≥ 0.256). Our results suggest that the effect of the intervention on performance in numeracy in the present sample is not explained by change in executive function, behavioral self-regulation, or school related well-being. We suggest this finding mainly could be explained by the lack of effect of the intervention on the mediators, which might be due to an insufficient dose of physical activity

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

Background Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. Methods A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. Results A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. Conclusions A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. Systematic review registration: PROSPERO: CRD42020208072

Active Smarter Kids (ASK): Rationale and design of a cluster-randomized controlled trial investigating the effects of daily physical activity on children’s academic performance and risk factors for non-communicable diseases

Background: Evidence is emerging from school-based studies that physical activity might favorably affect children’s academic performance. However, there is a need for high-quality studies to support this. Therefore, the main objective of the Active Smarter Kids (ASK) study is to investigate the effect of daily physical activity on children’s academic performance. Because of the complexity of the relation between physical activity and academic performance it is important to identify mediating and moderating variables such as cognitive function, fitness, adiposity, motor skills and quality of life (QoL). Further, there are global concerns regarding the high prevalence of lifestyle-related non-communicable diseases (NCDs). The best means to address this challenge could be through primary prevention. Physical activity is known to play a key role in preventing a host of NCDs. Therefore, we investigated as a secondary objective the effect of the intervention on risk factors related to NCDs. The purpose of this paper is to describe the design of the ASK study, the ASK intervention as well as the scope and details of the methods we adopted to evaluate the effect of the ASK intervention on 5th grade children. Methods & design: The ASK study is a cluster randomized controlled trial that includes 1145 fifth graders (aged 10 years) from 57 schools (28 intervention schools; 29 control schools) in Sogn and Fjordane County, Norway. This represents 95.3 % of total possible recruitment. Children in all 57 participating schools took part in a curriculum-prescribed physical activity intervention (90 min/week of physical education (PE) and 45 min/week physical activity, in total; 135 min/week). In addition, children from intervention schools also participated in the ASK intervention model (165 min/week), i.e. a total of 300 min/week of physical activity/PE. The ASK study was implemented over 7 months, from November 2014 to June 2015. We assessed academic performance in reading, numeracy and English using Norwegian National tests delivered by The Norwegian Directorate for Education and Training. We assessed physical activity objectively at baseline, midpoint and at the end of the intervention. All other variables were measured at baseline and post-intervention. In addition, we used qualitative methodologies to obtain an in-depth understanding of children’s embodied experiences and pedagogical processes taking place during the intervention. Discussion: If successful, ASK could provide strong evidence of a relation between physical activity and academic performance that could potentially inform the process of learning in elementary schools. Schools might also be identified as effective settings for large scale public health initiatives for the prevention of NCDs. Trial registration: Clinicaltrials.gov ID nr: NCT02132494 . Date of registration, 6th of May, 2014.Family Practice, Department ofMedicine, Faculty ofNon UBCReviewedFacult