Individual, social and environmental correlates of active school travel among adolescents in India

Active School Travel (AST) is an important domain for physical activity among adolescents; however, few studies in India have explored barriers or correlates of AST. This was a cross-sectional study of 324 adolescents aged 12–17 years recruited via households and schools from diverse areas of Chennai, India. Adolescents reported their mode of travel to school, neighbourhood correlates, and the barriers for AST. Adolescents were considered to be using AST to/from school if they walked/cycled ≥once/week during an average week. Half the adolescents usually performed AST (≥1 trip/week). School being too far was associated with 75% lower odds and parents not allowing their child to walk or cycle was associated with 82% lower odds of the adolescent performing AST to or from school at least once/week. AST among adolescents should be encouraged and there is considerable scope for improvement. Parental restriction and distance to school were the two strongest barriers for AST

Mobile health technology (mDiab) for the prevention of type 2 diabetes: protocol for a randomized controlled trial

BACKGROUND: The prevalence of type 2 diabetes is increasing in epidemic proportions in low- and middle-income countries. There is an urgent need for novel methods to tackle the increasing incidence of diabetes. The ubiquity of mobile phone use and access to Internet makes mobile health (mHealth) technology a viable tool to prevent and manage diabetes. OBJECTIVE: The objective of this randomized controlled trial is to implement and evaluate the feasibility, cost-effectiveness, and sustainability of a reality television-based lifestyle intervention program. This intervention program is delivered via a mobile phone app (mDiab) to approximately 1500 Android smartphone users who are adults at a high risk for type 2 diabetes from three cities in India, namely, Chennai, Bengaluru, and New Delhi. METHODS: The mDiab intervention would be delivered via a mobile phone app along with weekly coach calls for 12 weeks. Each participant will go through a maintenance phase of 6 to 8 months post intervention. Overall, there would be 3 testing time points in the study: baseline, post intervention, and the end of follow-up. The app will enable individuals to track their weight, physical activity, and diet alongside weekly video lessons on type 2 diabetes prevention. RESULTS: The study outcomes are weight loss (primary measure of effectiveness); improvement in cardiometabolic risk factors (ie, waist circumference, blood pressure, glucose, insulin, and lipids); and improvement in physical activity, quality of life, and dietary habits. Sustainability will be assessed through focus group discussions. CONCLUSIONS: If successful, mDiab can be used as a model for translational and implementation research in the use of mHealth technology for diabetes prevention and may be further expanded for the prevention of other noncommunicable diseases such as hypertension and cardiovascular diseases. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2015/07/006011 http://ctri.nic.in/Clinicaltrials/pdf_generate.php? trialid=11841 (Archived by WebCite at http://www.webcitation.org/6urCS5kMB)

Physical activity patterns and gestational diabetes outcomes – The wings project

AbstractObjectiveTo compare physical activity (PA) patterns in pregnant woman with and without gestational diabetes (GDM) and to assess the effects of an exercise intervention on change in PA patterns, blood glucose levels and pregnancy outcomes in GDM women.MethodsFor the first objective, PA patterns were studied in 795 pregnant women with and without GDM. For the second objective, the Women in India with Gestational Diabetes Strategy-Model of Care (WINGS-MOC) intervention were evaluated in 151 women out of 189 with GDM. PA was assessed using a validated questionnaire and a pedometer. Changes in PA patterns, glycemic parameters and neonatal outcomes were evaluated.ResultsOverall, only 10% of pregnant women performed recommended levels of PA. Women with GDM were significantly more sedentary compared to those without GDM (86.2 vs. 61.2%, p<0.001). After the MOC was implemented in women with GDM, there was a significant improvement in PA and a decrease in sedentary behaviour amongst women (before MOC, moderate activity: 15.2%, sedentary: 84.8% vs. after MOC-moderate: 26.5%, sedentary: 73.5%; p<0.001), and an increase in their daily step count from 2206/day to 2476/day (p<0.001). Fasting 1 and 2-h postprandial glucose values significantly decreased (p<0.001 for all). Sedentary behaviour was associated with a fourfold higher risk (p=0.02), and recreational walking with 70% decreased risk, of adverse neonatal outcomes (p=0.04) after adjusting for potential confounders.ConclusionsPA levels are inadequate amongst this group of pregnant women studied i.e. those with and without GDM. However, a low-cost, culturally appropriate MOC can bring about significant improvements in PA in women with GDM. These changes are associated with improved glycemic control and reduction in adverse neonatal outcomes

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH

Erratum: Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Interpretation: By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk-outcome associations. METHODS: We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Stanaway JD, Afshin A, Gakidou E, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923-1994.Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk outcome pairs, and new data on risk exposure levels and risk outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings In 2017,34.1 million (95% uncertainty interval [UI] 33.3-35.0) deaths and 121 billion (144-1.28) DALYs were attributable to GBD risk factors. Globally, 61.0% (59.6-62.4) of deaths and 48.3% (46.3-50.2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10.4 million (9.39-11.5) deaths and 218 million (198-237) DALYs, followed by smoking (7.10 million [6.83-7.37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6.53 million [5.23-8.23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4.72 million [2.99-6.70] deaths and 148 million [98.6-202] DALYs), and short gestation for birthweight (1.43 million [1.36-1.51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4.9% (3.3-6.5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23.5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18.6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning. Copyright (C) 2018 The Author(s). Published by Elsevier Ltd

Technology in the management of diabetes mellitus

The explosive increase in the prevalence of diabetes mellitus in resource-strapped regions of the world demands innovative solutions in healthcare. Advances in information technology, diagnostics and food technology have the potential to make diagnosis and treatment of diabetes simpler, cost-effective and patient-friendly. Newer methods of glucose testing such as the ambulatory glucose profile promise to make clinical decision-making easier and more robust. More advanced modes of insulin delivery are likely to help larger proportions of patients achieve their glycaemic goals with minimal risk of hypoglycaemia. Use of telemedicine and electronic medical records represents a significant advance in improving delivery of diabetes care and monitoring its outcomes. Efforts are also on to harness the wide penetrance of mobile phones in spreading awareness about diabetes and its prevention as well as in screening for retinopathy. Advances in technology also promise to favourably alter the food habits of the population, with the advent of the novel high-fibre white rice being a case in point. This narrative review aims to discuss some of the ways in which emerging technologies are making diabetes monitoring and treatment easier, more effective and pleasant for the patient

Obesity Reduction and Awareness and Screening of Noncommunicable Diseases through Group Education in Children and Adolescents (ORANGE): Methodology Paper (ORANGE-1)

Aim: Our goal is to estimate the prevalence of obesity, glucose intolerance, hypertension, dyslipidemia, and metabolic syndrome among urban children and adolescents aged 6-19 years and to raise awareness about noncommunicable diseases (NCDs) among school children in Chennai, South India. Methods: The Obesity Reduction and Awareness and Screening of Noncommunicable Diseases through Group Education project plans to reach out to children and adolescents using two approaches: the school and the community approach. The school approach aims to reach out to a representative sample of approximately 20,000 urban school children and adolescents, aged 6-19 years, covering 50 schools from all parts of Chennai. Anthropometric measures will include height, weight, waist, body fat, and blood pressure. Data on demographics, family profile, behavioral aspects, physical activity, and food pattern will be obtained by using a validated questionnaire. Awareness about metabolic NCDs like obesity and diabetes will be increased by educating the children and adolescents about healthy lifestyles. Through the community approach, 2000 children and adolescents from randomly selected residential colonies in Chennai will be screened for obesity, glucose intolerance, hypertension, dyslipidemia, and metabolic syndrome. Expected Outcomes: Awareness about NCDs will be increased among children and their parents in Chennai. This study will also provide valuable epidemiological data on obesity, glucose intolerance, dyslipidemia, hypertension and metabolic syndrome in children and adolescents in urban India

Mobile health technology in the prevention and management of Type 2 diabetes

Essential steps in diabetes prevention and management include translating research into the real world, improving access to health care, empowering the community, collaborative efforts involving physicians, diabetes educators, nurses, and public health scientists, and access to diabetes prevention and management efforts. Mobile phone technology has shown wide acceptance across various ages and socioeconomic groups and offers several opportunities in health care including self-management as well as prevention of Type 2 diabetes mellitus (T2DM). The future seems to lie in mobile health (mHealth) applications that can use embedded technology to showcase advanced uses of a smartphone to help with prevention and management of chronic disorders such as T2DM. This article presents a narrative review of the mHealth technologies used for the prevention and management of T2DM. Majority (48%) of the studies used short message service (SMS) technology as their intervention while some studies (29%) incorporated applications for medication reminders and insulin optimization for T2DM management. Few studies (23%) showed that, along with mHealth technology, health-care professionals\u27 support resulted in added positive outcomes for the patients. This review highlights the fact that an mHealth intervention need not be restricted to SMS alone