A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS)

Background: Annual foot risk assessment of people with diabetes is recommended in national and international clinical guidelines. At present, these are consensus based and use only a proportion of the available evidence. Objectives: We undertook a systematic review of individual patient data (IPD) to identify the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes. Data sources: Studies were identified from searches of MEDLINE and EMBASE. Review methods: The electronic search strategies for MEDLINE and EMBASE databases created during an aggregate systematic review of predictive factors for foot ulceration in diabetes were updated and rerun to January 2013. One reviewer applied the IPD review eligibility criteria to the full-text articles of the studies identified in our literature search and also to all studies excluded from our aggregate systematic review to ensure that we did not miss eligible IPD. A second reviewer applied the eligibility criteria to a 10% random sample of the abstract search yield to check that no relevant material was missed. This review includes exposure variables (risk factors) only from individuals who were free of foot ulceration at the time of study entry and who had a diagnosis of diabetes mellitus (either type 1 or type 2). The outcome variable was incident ulceration. Results: Our search identified 16 cohort studies and we obtained anonymised IPD for 10. These data were collected from more than 16,000 people with diabetes worldwide and reanalysed by us. One data set was kept for independent validation. The data sets contributing IPD covered a range of temporal, geographical and clinical settings. We therefore selected random-effects meta-analysis, which assumes not that all the estimates from each study are estimates of the same underlying true value, but rather that the estimates belong to the same distribution. We selected candidate variables for meta-analysis using specific criteria. After univariate meta-analyses, the most clinically important predictors were identified by an international steering committee for inclusion in the primary, multivariable meta-analysis. Age, sex, duration of diabetes, monofilaments and pulses were considered most prognostically important. Meta-analyses based on data from the entire IPD population found that an inability to feel a 10-g monofilament [odds ratio (OR) 3.184, 95% confidence interval (CI) 2.654 to 3.82], at least one absent pedal pulse (OR 1.968, 95% CI 1.624 to 2.386), a longer duration of a diagnosis of diabetes (OR 1.024, 95% CI 1.011 to 1.036) and a previous history of ulceration (OR 6.589, 95% CI 2.488 to 17.45) were all predictive of risk. Female sex was protective (OR 0.743, 95% CI 0.598 to 0.922). Limitations: It was not possible to perform a meta-analysis using a one-step approach because we were unable to procure copies of one of the data sets and instead accessed data via Safe Haven. Conclusions: The findings from this review identify risk assessment procedures that can reliably inform national and international diabetes clinical guideline foot risk assessment procedures. The evidence from a large sample of patients in worldwide settings show that the use of a 10-g monofilament or one absent pedal pulse will identify those at moderate or intermediate risk of foot ulceration, and a history of foot ulcers or lower-extremity amputation is sufficient to identify those at high risk. We propose the development of a clinical prediction rule (CPR) from our existing model using the following predictor variables: insensitivity to a 10-g monofilament, absent pedal pulses and a history of ulceration or lower-extremities amputations. This CPR could replace the many tests, signs and symptoms that patients currently have measured using equipment that is either costly or difficult to use. Study registration: This study is registered as PROSPERO CRD42011001841. Funding: The National Institute for Health Research Health Technology Assessment programme

Vigilância de fatores de risco para doenças não transmissíveis entre adolescentes: a experiência da cidade do Rio de Janeiro, Brasil Surveillance of risk factors for non-communicable diseases among adolescents: the experience in Rio de Janeiro, Brazil

Este trabalho apresenta métodos e resultados da implantação de sistema de vigilância de fatores de risco para doenças não transmissíveis entre adolescentes. Uma amostra (n = 1.699) probabilística de alunos de oitava série do ensino fundamental da rede pública municipal de ensino do Rio de Janeiro, Brasil, respondeu a questionário autopreenchido anônimo sobre consumo alimentar, atividade física, atividades sedentárias de lazer e consumo de cigarro. Estimativas de prevalência dos fatores de risco foram calculadas para o total da amostra e segundo sexo. Taxas de não resposta variaram de 0,2% a 13,4%. Foram observados: baixo consumo de frutas (45,8%) e hortaliças (20% e 16,5% para saladas e legumes cozidos), consumo freqüente de refrigerantes (36,7%), balas e doces (46,7%), grande quantidade de horas alocadas em frente à TV, computador ou videogame (71,7% alocam pelo menos 4h/dia nestas atividades), baixa freqüência de prática regular de atividade física (40%) e prevalência de 6,4% de fumantes. Meninas apresentaram menores índices de atividade física e maiores de consumo de cigarro. O sistema testado mostrou-se factível e indicou prevalências relevantes de fatores de risco para doenças não transmissíveis.<br>This paper presents the methodology and results of the implementation of a Surveillance System for Non-Communicable Disease Risk Factors in Adolescents. A random sample of 8th-grade students (n = 1,684) enrolled in municipal schools in Rio de Janeiro, Brazil, was studied. Students were asked to complete a confidential questionnaire on food consumption, physical activity, sedentary leisure-time activities, and tobacco consumption. Prevalence estimates of risk factors were calculated for the entire sample and by gender. Non-response rates ranged from 1.1 to 8.9%. The findings included low consumption of fruits (45.8%) and vegetables (20.0% and 16.5% for salads and cooked vegetables, respectively), regular consumption of soft drinks (36.7%) and candies (46.7%), extensive time on TV, computer, and videogames (71.7% spend at least 4h/day at these activities), low frequency of regular physical activity (40%), and 6.4% prevalence of smoking. Girls showed less physical activity and more smoking. The system appeared to be feasible and indicated high prevalence of risk factors for non-communicable diseases

What principles should guide interactions between population health researchers and the food industry? Systematic scoping review of peer-reviewed and grey literature.

There is no explicit consensus amongst population health researchers regarding what constitutes acceptable or effective interactions with the food industry. This has led to confusion and disagreements over conflicts of interest, which can undermine the integrity of science. To clarify this issue, we aimed to systematically identify the key principles developed by population health researchers to prevent or minimize conflicts of interest when interacting with the food industry. Databases of peer-reviewed literature were searched. In addition, an advanced Google search, a request to experts seeking related documents, and hand searching of references were undertaken. Thematic analysis of the extracted data was undertaken. We examined 54 eligible documents describing guidelines for population health researchers when interacting with the food industry. Fifty-six principles were identified and synthesized in five themes. There were high levels of agreement in themes relating to research governance, transparency, and publication but less agreement and guidance on how principles should be applied in relation to funding and risk assessment. There is agreement on some of the general principles for preventing and minimizing conflicts of interests for population health researchers when interacting with the food industry. However, for issues such as assessing the appropriateness of an industry partner, greater clarity and consensus are required.MW, JA, NF, OF and KC are funded by core grants to Medical Research Council (MRC) Epidemiology Unit, University of Cambridge and the Centre for Diet and Activity Research (CEDAR). CEDAR is a UKCRC public health research centre of excellence with funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, MRC, National Institute of Health Research and the Wellcome Trust. NGF acknowledges MRC funding (MC_UU_12015/5). The views expressed in this paper do not necessarily represent those of any of the above named funders

Prevalência e fatores associados ao sobrepeso e à obesidade em adolescentes, estudantes de escolas de Ensino Médio de Pernambuco, Brasil Prevalence of overweight and obesity and associated factors among public high school students in Pernambuco State, Brazil

O objetivo deste estudo foi analisar a associação entre fatores demográficos, sócio-econômicos, escolares e comportamentais e a prevalência de sobrepeso e obesidade em adolescentes. A amostra foi constituída por 4.210 estudantes (14-19 anos) da rede pública estadual em Pernambuco, Brasil, selecionados mediante amostragem por conglomerados em dois estágios. Além das medidas antropométricas, dados pessoais e comportamentais foram coletadas usando o Global School-Based Health Survey. Pontos de corte utilizados para classificação dos casos de sobrepeso e obesidade foram os propostos pelo International Obesity Task Force. A prevalência de sobrepeso e obesidade foi 11,5% (IC95%: 10,7-12,8) e 2,4% (IC95%: 1,9-2,9), respectivamente. Verificou-se maior risco de sobrepeso e obesidade entre rapazes que residiam em áreas urbanas e que não participavam das aulas de educação física. Entre as moças, assistir à televisão três horas ou mais foi fator associado à ocorrência de obesidade. Redução do tempo de televisão e participação nas aulas de educação física podem ser ações efetivas no enfrentamento da epidemia da obesidade.<br>This study aims to analyze the association between demographic, socioeconomic, school-related, and behavioral factors and overweight and obesity in adolescents. The sample included 4,210 public high school students (14-19 years old) in Pernambuco State, Brazil, selected by two-stage cluster sampling. Obesity and overweight were assessed using anthropometric measurements, and the Global School-Based Health Survey was used to collect personal and behavioral data. The cutoff points for defining overweight and obesity were those recommended by the International Obesity Task Force. Prevalence rates for overweight and obesity were 11.5% (95%CI: 10.7-12.8) and 2.4% (95%CI: 1.9-2.9), respectively. Overweight and obesity were more common in males who reported residing in urban areas and were not enrolled in physical education classes. Watching television 3+ hours/day was associated with obesity in females. Reducing TV time and encouraging enrollment in physical education could be effective measures to counteract the growing obesity trends