High ultra-processed food consumption is associated with elevated psychological distress as an indicator of depression in adults from the Melbourne Collaborative Cohort Study

Background: Few studies have tested longitudinal associations between ultra-processed food consumption and depressive outcomes. As such, further investigation and replication are necessary. The aim of this study is to examine associations of ultra-processed food intake with elevated psychological distress as an indicator of depression after 15 years. Method: Data from the Melbourne Collaborative Cohort Study (MCCS) were analysed (n = 23,299). We applied the NOVA food classification system to a food frequency questionnaire (FFQ) to determine ultra-processed food intake at baseline. We categorised energy-adjusted ultra-processed food consumption into quartiles by using the distribution of the dataset. Psychological distress was measured by the ten-item Kessler Psychological Distress Scale (K10). We fitted unadjusted and adjusted logistic regression models to assess the association of ultra-processed food consumption (exposure) with elevated psychological distress (outcome and defined as K10 ≥ 20). We fitted additional logistic regression models to determine whether these associations were modified by sex, age and body mass index. Results: After adjusting for sociodemographic characteristics and lifestyle and health-related behaviours, participants with the highest relative intake of ultra-processed food were at increased odds of elevated psychological distress compared to participants with the lowest intake (aOR: 1.23; 95%CI: 1.10, 1.38, p for trend = 0.001). We found no evidence for an interaction of sex, age and body mass index with ultra-processed food intake. Conclusion: Higher ultra-processed food intake at baseline was associated with subsequent elevated psychological distress as an indicator of depression at follow-up. Further prospective and intervention studies are necessary to identify possible underlying pathways, specify the precise attributes of ultra-processed food that confer harm, and optimise nutrition-related and public health strategies for common mental disorders

Health literacy, dementia knowledge and perceived utility of digital health modalities among future health professionals

Objectives: Studies of dementia knowledge (including dementia risk reduction) in health-care trainees highlight varying levels of understanding across countries and disciplines. This draws attention to the need for a well-trained health workforce with the knowledge to champion and implement such strategies. This study (a) assessed dementia knowledge and health literacy among a sample of Australian health-care students, (b) identified modality preferences of digital health interventions addressing dementia prevention and (c) examined potential relationships among health literacy, dementia knowledge, dementia prevention knowledge and a student's preferences for different digital health modalities. Methods: A cross-sectional survey assessed dementia knowledge and health literacy in 727 health students across 16 Australian universities representing both metropolitan and regional cohorts. The All Aspects of Health Literacy Scale and the Dementia Knowledge Assessment Scale were administered. Questions about the perceived effectiveness of strategies and preferred digital health modalities for dementia prevention/risk reduction were asked. Results: The students had relatively high health literacy scores. However, dementia knowledge and evidence-based dementia prevention knowledge were average. Only 7% claimed knowledge of available dementia-related digital health interventions. Associations among health literacy, dementia knowledge and dementia prevention, with recommendations for different digital modalities, are presented. Conclusions: Health-related degrees need to increase dementia knowledge, health literacy and knowledge of effective dementia-related digital health interventions. It is imperative to equip the future health workforce amid an ageing population with increased dementia rates and where evidence-based digital health interventions will increasingly be a source of support

A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program.

BACKGROUND: The major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score. METHODS AND FINDINGS: The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30-60 years) were those with an Indian Diabetes Risk Score (IDRS) ≥60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66-1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: -1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (≥5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate. CONCLUSIONS: A low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909

Prevalence of normal weight obesity and its associated cardio-metabolic risk factors - Results from the baseline data of the Kerala Diabetes Prevention Program (KDPP)

BACKGROUND: Cardiometabolic disorders are frequently observed among those who have obesity as measured by body mass index (BMI). However, there is limited data available on the cardiometabolic profile of those who are non-obese by BMI but with a high body fat percentage (BFP), a phenotype frequently observed in the Indian population. We examined the prevalence of individuals with normal weight obesity (NWO) and the cardiometabolic profile of NWO individuals at high risk for type 2 diabetes(T2D) in a south Asian population. MATERIAL AND METHODS: In the Kerala Diabetes Prevention Program, individuals aged between 30 to 60 years were screened using the Indian Diabetes Risk Score(IDRS) in 60 rural communities in the Indian state of Kerala. We used data from the baseline survey of this trial for this analysis which included 1147 eligible high diabetes risk individuals(IDRS >60). NWO was defined as BMI within the normal range and a high BFP (as per Asia-pacific ethnicity based cut-off); Non-obese (NO) as normal BMI and BFP and overtly obese (OB) as BMI ≥25 kg/m2 irrespective of the BFP. Data on demographic, clinical and biochemical characteristics were collected using standardized questionnaires and protocols. Body fat percentage was assessed using TANITA body composition analyser (model SC330), based on bioelectrical impedance. RESULTS: The mean age of participants was 47.3 ± 7.5 years and 46% were women. The proportion with NWO was 32% (n = 364; 95% CI: 29.1 to 34.5%), NO was 17% (n = 200) and OB was 51% (n = 583). Among those with NWO, 19.7% had T2D, compared to 18.7% of those who were OB (p value = 0.45) and 8% with NO (p value = 0.003). Among those with NWO, mean systolic and diastolic blood pressure were 129 ± 20; 78 ± 12 mmHg, compared to 127 ± 17; 78±11 mmHg among those with OB (p value = 0.12;0.94) and 120 ± 16; 71±10 mmHg among with NO (p value<0.001; 0.001), respectively. A similar pattern of association was observed for LDL cholesterol and triglycerides. After adjusting for other risk factors, the odds of having diabetes (OR:2.72[95% CI:1.46-5.08]) and dyslipidemia (2.37[1.55-3.64]) was significantly more in individuals with NWO as compared to non-obese individuals. CONCLUSIONS: Almost one-third of this South Asian population, at high risk for T2D, had normal weight obesity. The significantly higher cardiometabolic risk associated with increased adiposity even in lower BMI individuals has important implications for recognition in clinical practice

Effectiveness of lifestyle intervention programs in the prevention of type 2 diabetes and reduction of cardiovascular diseases risk in resource-constrained settings

© 2019 Mojtaba Lotfaliany Abrand AbadiBackground The number of people with type 2 diabetes is increasing rapidly, particularly in low- and middle-income countries (LMICs). High and increasing prevalence of type 2 diabetes contributes to increased morbidity and mortality due to its complications, most importantly, cardiovascular diseases (CVD). Therefore, preventing type 2 diabetes is a high priority. This thesis focuses on the effectiveness of two types of lifestyle interventions that aim to prevent type 2 diabetes and reduce CVD risk by reducing underlying modifiable lifestyle risk factors. The interventions include 1) community-wide lifestyle interventions that target the whole population living in a particular geographic area and 2) structured lifestyle interventions among individuals at high risk of developing type 2 diabetes based on a screening tool. Aims The overarching aim of the current thesis is to assess the effectiveness of lifestyle intervention programs in the prevention of type 2 diabetes and the reduction of cardiovascular diseases risk in resource-constrained settings. This thesis has three main objectives to address its overarching aim: i) To evaluate the effectiveness of a community-wide lifestyle intervention on the prevention of type 2 diabetes in a trial conducted in Iran (Chapter 4), ii) To evaluate the performance of different screening methods in identifying those at high risk of type 2 diabetes (Chapters 5 and 6), iii) To evaluate the effects of a structured lifestyle intervention on the reduction of CVD risk among individuals at high risk of developing type 2 diabetes in a cluster-randomized trial conducted in India (Chapter 7). Methods To meet the study objectives, I conducted a secondary analysis to datasets of two lifestyle intervention trails entitled “Tehran Lipid and Glucose Study (TLGS)” and “Kerala Diabetes Prevention Program (KDPP)”: In TLGS, three areas in District 13 of Tehran, the capital city of Iran, were selected for the study. People living in one area received a multi-component community-wide intervention including an educational session in a medical health centre, newsletters and health education materials four times a year and public education in community gatherings from 1999 until 2015. People in the other two areas were assigned to the control status. People in all three areas were followed up every three years, from 1999 until 2015 (Wave 1 to Wave 5). In KDPP, 60 randomly-selected polling areas in the Kerala state (India) were screened by a non-invasive risk score entitled “Indian Diabetes Risk Score (IDRS)”. Those with IDRS score of >=60 were recruited in the KDPP study if they did not have type 2 diabetes in an oral glucose tolerance test. Identified high-risk individuals in 30 randomly-selected polling areas were assigned to the lifestyle intervention and their counterparts in the other 30 polling areas were assigned to the control. People in the intervention group received 15 group sessions delivered over 12 months. High-risk individuals in both intervention and control groups were followed at baseline, 12 months, and 24 months. I used generalized estimating equations (GEEs) to evaluate the effectiveness of lifestyle intervention programs in the prevention of type 2 diabetes in TLGS. I also used the Framingham risk prediction model for CVD to compare the change in predicted 10-year CVD risk between intervention and control groups of KDPP study, using mixed-effect models. Moreover, I validated several non-invasive and step-wise screening methods in the control group of TLGS, and then I assessed their performance for identifying those at high risk of type 2 diabetes. Results I found that lifestyle intervention in TLGS was associated with a 28% reduction in the incidence of type 2 diabetes in short-time (i.e., 3.4 years after starting the intervention). However, there was no statistically significant and clinically meaningful reduction in the incidence of type 2 diabetes in the following waves (Chapter 4). I also showed that favourable effects of the lifestyle intervention on the reduction of smoking prevalence and improvement of diet quality maintained even in the latest follow-up wave (Chapter 4). In addition, I found that non-invasive risk prediction models have limited utility in identifying those at high risk of developing type 2 diabetes and cannot be used as the only measurement for screening in Iran (Chapter 5). However, stepwise screening methods that combine a non-invasive measurement (e.g., anthropometrics) with a lab-based measurement (e.g., fasting plasma glucose level) have acceptable performance in identifying those at high risk of type 2 diabetes. Moreover, I found that the KDPP lifestyle intervention was associated with a one percentage point reduction in the 10-year CVD risk based on the Framingham risk prediction model after 24 months. My further investigations showed that favourable effects of the intervention on CVD risk are mainly due to a reduction in the incidence of type 2 diabetes and the reduction of smoking prevalence in the intervention group as compared to the control group. Conclusions This thesis provides much-needed evidence on the effects of lifestyle intervention programs on type 2 diabetes prevention and CVD risk reduction in LMICs. Findings from this thesis also highlight the importance of selecting a valid, reliable, and accurate screening method for identifying those at high risk of type 2 diabetes in designing lifestyle intervention programs with a high-risk strategy

Optimal cut-points of different anthropometric indices and their joint effect in prediction of type 2 diabetes: results of a cohort study

Abstract Background To determine the anthropometric indices that would predict type 2 diabetes (T2D) and delineate their optimal cut-points. Methods In a cohort study, 7017 Iranian adults, aged 20–60 years, free of T2D at baseline were investigated. Using Cox proportional hazard models, hazard ratios (HRs) for incident T2D per 1 SD change in body mass index (BMI), waist circumference (WC), waist to height ratio (WHtR), waist to hip ratio (WHR), and hip circumference (HC) were calculated. The area under the receiver operating characteristics (ROC) curves (AUC) was calculated to compare the discriminative power of anthropometric variables for incident T2D. Cut-points of each index were estimated by the maximum value of Youden’s index and fixing the sensitivity at 75%. Using the derived cut-points, joint effects of BMI and other obesity indices on T2D hazard were assessed. Results During a median follow-up of 12 years, 354 men, and 490 women developed T2D. In both sexes, 1 SD increase in anthropometric variables showed significant association with incident T2D, except for HC in multivariate adjusted model in men. In both sexes, WHtR had the highest discriminatory power while HC had the lowest. The derived cut-points for BMI, WC, WHtR, WHR, and HC were 25.56 kg/m2, 89 cm, 0.52, 0.91, and 96 cm in men and 27.12 kg/m2, 87 cm, 0.56, 0.83, and 103 cm in women, respectively. Assessing joint effects of BMI and each of the obesity measures in the prediction of incident T2D showed that among both sexes, combined high values of obesity indices increase the specificity for the price of reduced sensitivity and positive predictive value. Conclusions Our derived cut-points differ between both sexes and are different from other ethnicities

Impact Of Hypertension versus Diabetes on Cardiovascular and All-cause Mortality in Iranian Older Adults: Results of 14 Years of Follow-up

Abstract To evaluate the joint effect of hypertension (HTN) and diabetes (DM) on coronary heart disease (CHD), and stroke event, all-cause, and cardiovascular disease (CVD) mortality in Middle Eastern older adults, 2747 people (1436 women) aged ≥ 50 years, free of CVD at baseline, were categorized into four groups (HTN−/DM−, HTN+/DM−, HTN−/DM+, HTN+/DM+). Multivariate Cox proportional hazard models were run for different outcomes. To compare the impact of HTN versus DM, HTN+/DM− was considered as reference. In a median of 13.9 years, incidence rate of CHD, and stroke event, all-cause and CVD mortality in total population were 19.0, 4.7, 13.5, and 6.4 per 1000 person-years, respectively. The multivariate sex-adjusted hazard ratios (HRs) of HTN−/DM+ for CHD, stroke, all-cause mortality and CVD mortality were 1.19 (confidence interval (CI): 0.9–1.57), 1.07 (CI: 0.63–1.82), 1.62 (CI: 1.2–2.18), and 1.28 (CI: 0.83–1.97); the corresponding HRs for HTN+/DM+ were 1.96 (CI: 1.57–2.46), 1.66 (CI: 1.1–2.52), 2.32 (CI: 1.8–2.98), and 2.6 (CI: 1.85–3.65) respectively. The associations between HTN/DM status with stroke incidence and all-cause mortality were stronger among men than in women (P for interaction <0.05). Compared to HTN+/DM−, HTN−/DM+ increases all-cause mortality by 62%, however, they are not considerably different regarding CHD, stroke incidence and CVD mortality