Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

Background Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories. Methods We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5–19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For schoolaged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median). Findings From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness. Interpretation The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesit

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Global variations in diabetes mellitus based on fasting glucose and haemogloblin A1c

Fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c) are both used to diagnose diabetes, but may identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening had elevated FPG, HbA1c, or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardised proportion of diabetes that was previously undiagnosed, and detected in survey screening, ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the agestandardised proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global gap in diabetes diagnosis and surveillance.peer-reviewe

Quantification of atmospheric lead emissions from 70 years of leaded petrol consumption in Australia

Lead is a persistent pollutant and the subject of many environmental studies, yet, in Australia, the extent of atmospheric lead emissions from the use of leaded petrol is unquantified. This paper details the first comprehensive account of leaded petrol sales and its lead concentrations over the 70 years of use in Australia. The resulting atmospheric lead emissions are calculated to provide the most complete understanding of the volume of lead released to the Australian continent from the consumption of leaded petrol. Atmospheric emissions of lead to the entire Australian continent from leaded petrol are calculated to total 240,510 tonnes over seven decades of use, peaking at 7869 tonnes in 1974. Total emissions for individual states and territories range from 1745 to 67,893 tonnes, with New South Wales responsible for the largest emissions. The effect of regulations on allowable concentrations of tetraethyl-lead additives are observed in the reduction of lead emissions in New South Wales and Victoria. The consequences to human health and the environment of leaded petrol consumption in Australia's populous cities are examined against historical air quality data and blood lead levels.7 page(s

Identification and measurement of contemporary sources and exposure risks from lead emissions and depositions in Australia

Thesis by publication.Bibliography: pages 175-184.Chapter 1. Introduction -- Chapter 2. Quantification and identification of sources of lead emissions -- Chap[ter 3. Measurement of lead emissions and exposures -- Chapter 4. Impacts and consequences of lead emissions -- Chapter 5. Synthesis of research.Lead emissions in Australia have been occurring for almost two centuries. In that time, environmental quality and human health have been greatly affected. As a result, lead contaminated soils are widespread in Australian urban and industrial locations and lead emissions are ongoing in lead industrial locations. The removal of primary sources, leaded petrol and paint, as well as the decline in blood lead levels in mining and smelting communities has led to complacency that much of the problem has been resolved. However, elevated childhood blood lead levels are still being measured in lead towns.Despite the global abundance of studies on environmental lead sources, emissions and human health consequences, relatively little research has been undertaken in Australia following the removal of lead from petrol in 2002. In light of this knowledge gap, this thesis includes twelve papers that present research into the current state of lead emissions in Australia. The papers address multiple and interconnecting aspects of lead emissions: identification of major sources emitting large volumes; measurement of lead in the environment and ongoing exposures; the impacts on the environment and consequences to human health. Additionally, this thesis examines the role of regulations and guidelines in protecting children from the harmful effects relating to the toxicity of lead.The outcome of the studies in this thesis demonstrate that environmental lead emissions, depositions and exposures remain a cause for serious public health concern in Australia. Current lead emissions from mining and smelting operations continue to expose children to dangerous levels of toxic metals that result in blood lead levels above current guideline values. Quantification of lead emitted from petrol, at a quarter million tonnes, has revealed the enormity of this legacy source, even in relation to mining and smelting emissions. Although petrol emissions form an historical source, the findings in this thesis reveal its impact prevails in the environment. By providing a contemporary analysis on the issue of lead emissions, this thesis demonstrates that reliance on outdated regulations and guidelines are ineffective at reducing exposure to both historic and ongoing lead emissions in Australia. Therefore, in light of the globally accepted paradigm that there is no safe level of lead exposure, this thesis highlights the urgent need to revise existing strategies and regulations to limit preventable exposures.Mode of access: World wide web1 online resource (xii, 185, [68] pages) illustrations (some colour), maps (some colour

Tracing changes in atmospheric sources of lead contamination using lead isotopic compositions in Australian red wine

Air quality data detailing changes to atmospheric composition from Australia's leaded petrol consumption is spatially and temporally limited. In order to address this data gap, wine was investigated as a potential proxy for atmospheric lead conditions. Wine spanning sixty years was collected from two wine regions proximal to the South Australian capital city, Adelaide, and analysed for lead concentration and lead and strontium isotopic composition for source apportionment. Maximum wine lead concentrations (328 μg/L) occur prior to the lead-in-air monitoring in South Australia in the later 1970s. Wine lead concentrations mirror available lead-in-air measurements and show a declining trend reflecting parallel reductions in leaded petrol emissions. Lead from petrol dominated the lead in wine (²⁰⁶Pb/²⁰⁷Pb: 1.086; ²⁰⁸Pb/²⁰⁷Pb: 2.360) until the introduction of unleaded petrol, which resulted in a shift in the wine lead isotopic composition closer to vineyard soil (²⁰⁶Pb/²⁰⁷Pb: 1.137; ²⁰⁸Pb/²⁰⁷Pb: 2.421). Current mining activities or vinification processes appear to have no impact with recent wine samples containing less than 4 μg/L of lead. This study demonstrates wine can be used to chronicle changes in environmental lead emissions and is an effective proxy for atmospherically sourced depositions of lead in the absence of air quality data.8 page(s

Environmental contamination in an Australian mining community and potential influences on early childhood health and behavioural outcomes

Arsenic, cadmium and lead in aerosols, dusts and surface soils from Australia's oldest continuous lead mining town of Broken Hill were compared to standardised national childhood developmental (year 1) and education performance measures (years 3,5,7,9). Contaminants close to mining operations were elevated with maximum lead levels in soil: 8900 mg/kg; dust wipe: 86,061 μg/m²; dust deposition: 2950 μg/m²/day; aerosols: 0.707 μg/m³. The proportion of children from Broken Hill central, the area with the highest environmental contamination, presented with vulnerabilities in two or more developmental areas at 2.6 times the national average. Compared with other school catchments of Broken Hill, children in years 3 and 5 from the most contaminated school catchment returned consistently the lowest educational scores. By contrast, children living and attending schools associated with lower environmental contamination levels recorded higher school scores and lower developmental vulnerabilities. Similar results were identified in Australia's two other major lead mining and smelting cities of Port Pirie and Mount Isa.12 page(s

Environmental arsenic, cadmium and lead dust emissions from metal mine operations : implications for environmental management, monitoring and human health

Although blood lead values in children are predominantly falling globally, there are locations where lead exposure remains a persistent problem. One such location is Broken Hill, Australia, where the percentage of blood lead values >10μg/dL in children aged 1-4 years has risen from 12.6% (2010), to 13% (2011) to 21% (2012). The purpose of this study was to determine the extent of metal contamination in places accessible to children. This study examines contemporary exposure risks from arsenic, cadmium, lead, silver and zinc in surface soil and dust, and in pre- and post-play hand wipes at six playgrounds across Broken Hill over a 5-day period in September 2013. Soil lead (mean 2,450mg/kg) and zinc (mean 3,710mg/kg) were the most elevated metals in playgrounds. Surface dust lead concentrations were consistently elevated (mean 27,500μg/m2) with the highest lead in surface dust (59,900μg/m2) and post-play hand wipes (60,900μg/m2) recorded close to existing mining operations. Surface and post-play hand wipe dust values exceeded national guidelines for lead and international benchmarks for arsenic, cadmium and lead. Lead isotopic compositions (²⁰⁶Pb/²⁰⁷Pb, ²⁰⁸Pb/²⁰⁷Pb) of surface dust wipes from the playgrounds revealed the source of lead contamination to be indistinct from the local Broken Hill ore body. The data suggest frequent, cumulative and ongoing mine-derived dust metal contamination poses a serious risk of harm to children.8 page(s

Environmental lead exposure risks associated with children's outdoor playgrounds

This study examines exposure risks associated with lead smelter emissions at children's public playgrounds in Port Pirie, South Australia. Lead and other metal values were measured in air, soil, surface dust and on pre- and post-play hand wipes. Playgrounds closest to the smelter were significantly more lead contaminated compared to those further away (t(27.545) = 3.76; p =.001). Port Pirie post-play hand wipes contained significantly higher lead loadings (maximum hand lead value of 49,432 μg/m²) than pre-play hand wipes (t(27) = 3.57, p =.001). A 1% increase in air lead (μg/m³) was related to a 0.713% increase in lead dust on play surfaces (95% CI, 0.253-1.174), and a 0.612% increase in post-play wipe lead (95% CI, 0.257-0.970). Contaminated dust from smelter emissions is determined as the source and cause of childhood lead poisoning at a rate of approximately one child every third day.8 page(s