Continuous quality improvement and metabolic screening during pregnancy at primary health centres attended by Aboriginal and Torres Strait Islander women

Objective: To investigate associations between the provision of routine metabolic screening and follow-up in pregnancy and participation by primary health care centres in a large-scale continuous quality improvement (CQI) initiative.Design: Longitudinal analysis of 2592 audited maternal health records.Setting and participants: Seventy-six community-controlled or government-operated primary health care centres serving predominantly Aboriginal and Torres Strait Islander communities, in urban, regional or remote locations in five Australian states and territories.Intervention: Up to four CQI cycles supported by the Audit and Best Practice for Chronic Disease Research Partnership.Main outcomes measures:Screening and follow-up for body mass index (BMI), blood pressure and diabetes in pregnancy.Results: Overall, 87.9% of women attending the participating health centres were Aboriginal or Torres Strait Islander. Women attending a health centre after it had conducted one or more CQI cycles were more likely to receive BMI, blood pressure and diabetes screening. For example, the proportion of women receiving diabetes screening at baseline (before the first CQI cycle) was 56.1%; after cycle 1 it was 63.7% (odds ratio [OR], 1.3; 95% CI, 1.0–1.6), after cycle 2, 61.6% (OR, 1.2; 95% CI, 0.9–1.7), after cycle 3, 63.7% (OR, 1.7; 95% CI, 1.1–2.6), and after cycle 4, 75.5% (OR, 3.4; 95% CI, 1.9–5.9). Diabetes screening was associated with higher self-ratings of overall organisational systems (P = 0.03), self-management support (P = 0.04) and organisational influence and integration (P = 0.01).Conclusion: These findings support the value of CQI approaches that focus on systems-level issues in primary care to improve the provision of recommended pregnancy care at primary health care centres in predominantly Aboriginal and Torres Strait Islander communities

Diet quality in a weight gain prevention trial of reproductive aged women: a secondary analysis of a cluster randomized controlled trial

Reproductive-aged women are at high risk for obesity development. Limited research exploring weight gain prevention initiatives and associated modifiable risk factors, including diet quality exists. In a secondary analysis of a 12 month, cluster randomized controlled trial for weight gain prevention in reproductive-aged women, we evaluated change in diet quality, macronutrient and micronutrient intake, predictors of change and associations with weight change at follow-up. Forty-one rural towns in Victoria, Australia were randomized to a healthy lifestyle intervention (n = 21) or control (n = 20). Women aged 18⁻50, of any body mass index and without conditions known to affect weight, were recruited. Diet quality was assessed by the Dietary Guideline Index (DGI) and energy, macronutrient, and micronutrient intake as well as anthropometrics (weight; kg) were measured at baseline and 12 months. Results were adjusted for group (intervention/control), town cluster, and baseline values of interest. Of 409 women with matched data at baseline and follow-up, 220 women were included for final analysis after accounting for plausible energy intake. At 12 months, diet quality had improved by 6.2% following the intervention, compared to no change observed in the controls (p < 0.001). Significant association was found between a change in weight and a change in diet quality score over time β -0.66 (95%CI -1.2, -0.12) p = 0.02. The percentage of energy from protein (%) 0.009 (95%CI 0.002, 0.15) p = 0.01 and glycemic index -1.2 (95%CI -2.1, -0.24) p = 0.02 were also improved following the intervention, compared to the control group. Overall, a low-intensity lifestyle intervention effectively improves diet quality, with associated weight gain preventions, in women of reproductive age.Julie C. Martin, Lisa J. Moran, Helena J. Teede, Sanjeeva Ranasinha, Catherine B. Lombard and Cheryce L. Harriso

Expression of the plasminogen system in the physiological mouse ovary and in the pathological polycystic ovary syndrome (PCOS) state

BACKGROUND:The fibrinolytic system and its inhibitors play a number of roles, apart from their function in blood haemostasis and thrombosis, namely in ovarian folliculogenesis and in ovulation. Plasminogen is converted to active plasmin at the time of follicular rupture through a decrease in plasminogen activator inhibitor-1 (PAI-1) and an increase in plasminogen activators. Oligo-/anovulation and follicle arrest are key characteristics of PCOS, but studies evaluating fibrinolytic/proteolytic markers within human or animal PCOS ovaries are lacking. We aimed to investigate and compare the expression and distribution of the plasminogen system markers in PCOS and control ovaries. METHODS:A hyperandrogenised PCOS mouse model was used that mimics the ovarian, endocrine and metabolic features of the human condition. Immunohistochemistry and digital image analysis were used to investigate and compare fibrinolytic/proteolytic markers plasminogen, plasminogen/plasmin, tissue plasminogen activator, urokinase plasminogen activator and inhibitor PAI-1 in PCOS and control ovaries. Student's t-test was used to compare data sets for normally distributed data and Wilcoxon-Mann Whitney test for non-normally distributed data. RESULTS:We noted differences in the ovarian distribution of PAI-1 that was expressed throughout the PCOS ovary, unlike the peripheral distribution observed in control ovaries. Plasminogen was present in small follicles only in PCOS ovaries but not in small follicles of control ovaries. When we assessed and compared PAI-1 expression within follicles of different developmental stages we also noted significant differences for both the PCOS and control ovaries. While we noted differences in distribution and expression within specific ovarian structures, no differences were noted in the overall ovarian expression of markers assessed between acyclical PCOS mice and control mice at the diestrus stage of the estrous cycle. CONCLUSIONS:Our novel study, that comprehensively assessed the fibrinolytic/proteolytic system in the mouse ovary, showed the expression, differential localisation and a potential role for the plasminogen system in the physiological mouse ovary and in PCOS. Androgens may be involved in regulating expression of the ovarian plasminogen system. Further studies evaluating these markers at different time-points of ovulation may help to further clarify both physiological and potential pathological actions these markers play in ovulatory processes distorted in PCOS.Genia F. Burchall, Dodie S. Pouniotis, Helena J. Teede, Sanjeeva Ranasinha, Kirsty A. Walters and Terrence J. Piv

Comprehensive assessment of the hemostatic system in polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) affects 12 to 19% of women and has reproductive and metabolicfeatures (endothelial dysfunction, increased diabetes, and cardiovascular risk factors). It also appears to have altered coagulation and fibrinolysis with a prothrombotic state with epidemiological evidence of increased venous thromboembolism. We aimed to comprehensively assess hemostasis in women with PCOS versus control women. In an established case-control cohort of lean, overweight, and obese women with (n = 1 07) and without PCOS (n = 67), with existing measures of plasminogen activator inhibitor 1 (PAI-1 ), asymmetric dimethylarginine (ADMA), hormonal, and metabolic markers, we also assessed prothrombin fragments 1 and 2 (PF1 &amp; 2), plasminogen, tissue plasminogen activator (tPA), and thrombin generation (TG). Higher levels of ADMA (0.70 vs. 0.39 mumol/L, p &lt; 0.01 ), PAI-1 (4.80 vs. 3.66 U/ml, p &lt; 0.01 ), and plasminogen (118.39 vs. 108.46%, p &lt; 0.01) were seen in PCOS versus controls, and persisted after adjustment for age and body mass index (BMI). PF1 &amp; 2 was marginally lower (180.0 vs. 236.0 pmolfl, p 0.05), whereas tPA and TG were not different between groups, after adjustment for age and BMI. Significant relationships were observed between hormonal and metabolic factors with ADMA and PAI-1. We demonstrate impaired fibrinolysis in PCOS. In the context of abnormal endothelial function and known hormonal and metabolic abnormalities, this finding may underpin an increased risk of cardiovascular disease and venous thrombosis in PCOS

Gaps and barriers in health-care provision for co-morbid diabetes and chronic kidney disease: a cross-sectional study

Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers.This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed.308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c ≥ 8%, and 39.3% had a measured blood pressure ≥ 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05).Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required.C. Lo, H. Teede, G. Fulcher, M. Gallagher, P. G. Kerr, S. Ranasinha, G. Russell, R. Walker and S. Zounga

Effect of dietary advanced glycation end products on inflammation and cardiovascular risks in healthy overweight adults: A randomised crossover trial

AbstractDiets high in advanced glycation end products (AGEs) are thought to be detrimental to cardiovascular health. However, there remains uncertainty about the beneficial effect of a low AGE diet on cardiovascular risk factors and inflammatory markers in overweight individuals. We thus performed a randomised, double blind, crossover trial to determine whether consumption of low AGE diets reduce inflammation and cardiovascular risks in overweight and obese otherwise healthy adults. All participants (n = 20) consumed low and high AGE diets alternately for two weeks and separated by a four week washout period. Low AGE diets did not change systolic (p = 0.2) and diastolic blood pressure (p = 0.3), mean arterial pressure (p = 0.8) and pulse pressure (p = 0.2) compared to high AGE diets. Change in total cholesterol (p = 0.3), low-density lipoprotein (p = 0.7), high-density lipoprotein (p = 0.2), and triglycerides (p = 0.4) also did not differ and there was no difference in inflammatory markers: interleukin-6 (p = 0.6), monocyte chemoattractant protein-1 (p = 0.9), tumour necrosis factor α (p = 0.2), C-reactive protein (p = 0.6) and nuclear factor kappa beta (p = 0.2). These findings indicate that consumption of low AGE diets for two weeks did not improve the inflammatory and cardiovascular profiles of overweight and obese adults.</jats:p

Higher glomerular filtration rate is related to insulin resistance but not to obesity in a predominantly obese non-diabetic cohort

Correction to this article published https://doi.org/10.1038/srep4696

Patient reported barriers are associated with low physical and mental well-being in patients with co-morbid diabetes and chronic kidney disease

BACKGROUND:Little is known about how patient reported barriers to health care impact the quality of life (HRQoL) of patients with comorbid disease. We investigated patient reported barriers to health care and low physical and mental well-being among people with diabetes and chronic kidney disease (CKD). METHODS:Adults with diabetes and CKD (estimated Glomerular Filtration Rate < 60 ml/min/1.73m2) were recruited and completed a questionnaire on barriers to health care, the 12-Item HRQoL Short Form Survey and clinical assessment. Low physical and mental health status were defined as mean scores < 50. Logistic regression models were used. RESULTS:Three hundred eight participants (mean age 66.9 ± 11 years) were studied. Patient reported 'impact of the disease on family and friends' (OR 2.07; 95% CI 1.14 to 3.78), 'feeling unwell' (OR 4.23; 95% CI 1.45 to 12.3) and 'having other life stressors that make self-care a low priority' (OR 2.59; 95% CI 1.20 to 5.61), were all associated with higher odds of low physical health status. Patient reported 'feeling unwell' (OR 2.92; 95% CI 1.07 to 8.01), 'low mood' (OR 2.82; 95% CI 1.64 to 4.87) and 'unavailability of home help' (OR 1.91; 95% CI 1.57 to 2.33) were all associated with higher odds of low mental health status. The greater the number of patient reported barriers the higher the odds of low mental health but not physical health status. CONCLUSIONS:Patient reported barriers to health care were associated with lower physical and mental well-being. Interventions addressing these barriers may improve HRQoL among people with comorbid diabetes and CKD.Edward Zimbudzi, Clement Lo, Sanjeeva Ranasinha, Gregory Fulcher, Martin Gallagher, Stephen Jan, Peter G. Kerr, Helena J. Teede, Kevan R. Polkinghorne, Grant Russell, Rowan G. Walker, and Sophia Zounga

The association between patient activation and self-care practices: a cross-sectional study of an Australian population with comorbid diabetes and chronic kidney disease

Objective: This study aimed to examine the association between performance of self‐care activities and patient or disease factors as well as patient activation levels in patients with diabetes and chronic kidney disease (CKD) in Australia. Methods: A cross‐sectional study was conducted among adults with diabetes and CKD (eGFR <60 mL/min/1.73m2) who were recruited from renal and diabetes clinics of four tertiary hospitals in Australia. Demographic and clinical data were collected, as well as responses to the Patient Activation Measure (PAM) and the Summary of Diabetes Self‐Care Activities (SDSCA) scale. Regression analyses were performed to determine the relationship between activation and performance of self‐care activities. Results: A total of 317 patients (70% men) with a mean age of 66.9 (SD=11.0) years participated. The mean (SD) PAM and composite SDSCA scores were 57.6 (15.5) % (range 0‐100) and 37.3 (11.2) (range 0‐70), respectively. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self‐care components. Patient activation was positively associated with the composite SDSCA score, and in particular the domains of general diet and blood sugar checking (P<.05), but not specific diet, exercising and foot checking. Conclusion: In people with diabetes and CKD, a high level of patient activation was positively associated with a higher overall level of self‐care. Our results identify subgroups of people who may benefit from tailored interventions to further improve their health outcomes. Further prospective studies are warranted to confirm present findings.Edward Zimbudzi, Clement Lo, Sanjeeva Ranasinha, Peter G Kerr, Kevan R Polkinghorne, Helena Teede ... et al

Association of antenatal diet and physical activity-based interventions with gestational weight gain and pregnancy outcomes: a systematic review and meta-analysis

Published online December 20, 2021.Importance: Excessive gestational weight gain (GWG) is common and associated with adverse pregnancy outcomes. Antenatal lifestyle interventions limit GWG; yet benefits of different intervention types and specific maternal and neonatal outcomes are unclear. Objective: To evaluate the association of different types of diet and physical activity–based antenatal lifestyle interventions with GWG and maternal and neonatal outcomes. Data Sources: A 2-stage systematic literature search of MEDLINE, Embase, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Health Technology Assessment Database was conducted from February 1, 2017, to May 31, 2020. Search results from the present study were integrated with those from a previous systematic review from 1990 to February 2017. Study Selection: Randomized trials reporting GWG and maternal and neonatal outcomes. Data Extraction and Synthesis: Data were extracted for random-effects meta-analyses to calculate the summary effect estimates and 95% CIs. Main Outcomes and Measures: Outcomes were clinically prioritized, with mean GWG as the primary outcome. Secondary outcomes included gestational diabetes, hypertensive disorders of pregnancy, cesarean section, preterm delivery, large or small for gestational age neonates, neonatal intensive care unit admission, or fetal death. Results: A total of 117 randomized clinical trials of antenatal lifestyle interventions (involving 34 546 women) were included. Overall lifestyle intervention was associated with reduced GWG (−1.15 kg; 95% CI, −1.40 to −0.91), risk of gestational diabetes (odds ratio [OR], 0.79; 95% CI, 0.70-0.89), and total adverse maternal outcomes (OR, 0.89; 95% CI, 0.84-0.94) vs routine care. Compared with routine care, diet was associated with less GWG (−2.63 kg; 95% CI, −3.87 to −1.40) than physical activity (−1.04 kg; 95% CI, −1.33 to −0.74) or mixed interventions (eg, unstructured lifestyle support, written information with weight monitoring, or behavioral support alone) (−0.74 kg; 95% CI, −1.06 to −0.43). Diet was associated with reduced risk of gestational diabetes (OR, 0.61; 95% CI, 0.45-0.82), preterm delivery (OR, 0.43; 95% CI, 0.22-0.84), large for gestational age neonate (OR, 0.19; 95% CI, 0.08-0.47), neonatal intensive care admission (OR, 0.68; 95% CI, 0.48-0.95), and total adverse maternal (OR, 0.75; 95% CI, 0.61-0.92) and neonatal outcomes (OR, 0.44; 95% CI, 0.26-0.72). Physical activity was associated with reduced GWG and reduced risk of gestational diabetes (OR, 0.60; 95% CI, 0.47-0.75), hypertensive disorders (OR, 0.66; 95% CI, 0.48-0.90), cesarean section (OR, 0.85; 95% CI, 0.75-0.95), and total adverse maternal outcomes (OR, 0.78; 95% CI, 0.71-0.86). Diet with physical activity was associated with reduced GWG (−1.35 kg; 95% CI, −1.95 to −0.75) and reduced risk of gestational diabetes (OR, 0.72; 95% CI, 0.54-0.96) and total adverse maternal outcomes (OR, 0.81; 95% CI, 0.69-0.95). Mixed interventions were associated with reduced GWG only. Conclusions and Relevance: This systematic review and meta-analysis found level 1 evidence that antenatal structured diet and physical activity–based lifestyle interventions were associated with reduced GWG and lower risk of adverse maternal and neonatal outcomes. The findings support the implementation of such interventions in routine antenatal care and policy around the world.Helena J. Teede, Cate Bailey, Lisa J. Moran, Mahnaz Bahri Khomami, Joanne Enticott, Sanjeeva Ranasinha, Ewelina Rogozińska, Helen Skouteris, Jacqueline A. Boyle, Shakila Thangaratinam, Cheryce L. Harrison