Quantifying urbanisation as a risk factor for non-communicable disease

Aim of this study was to investigate the poorly understood relationship between the process of urbanization and non-communicable diseases (NCDs) in Sri Lanka using a multi-component, quantitative measure of urbanicity.

NCD prevalence data were taken from the Sri Lankan Diabetes and Cardiovascular Study comprising a representative sample of people from seven of the nine provinces in Sri Lanka (n=4,485/5,000; response rate=89.7%). We constructed a measure of the urban environment for seven areas using a seven-item scale based on data from study clusters to develop an ―urbanicity” scale. The items were population size, population density, and access to markets, transportation, communications/media, economic factors, environment/sanitation, health, education, and housing quality. Linear and logistic regression models were constructed to examine the relationship between urbanicity and chronic disease risk factors.

Among men, urbanicity was positively associated with physical inactivity (OR: 3.22; 2.27 – 4.57), high body mass index (OR: 2.45; 95% CI: 1.88 – 3.20) and diabetes mellitus (OR: 2.44; 95% CI: 1.66 – 3.57). Among women, too, urbanicity was positively associated with physical inactivity (OR: 2.29; 95% CI: 1.64 – 3.21), high body mass index (OR: 2.92;95% CI: 2.41 – 3.55) and diabetes mellitus (OR: 2.10; 95% CI: 1.58 – 2.80).

There is a clear relationship between urbanicity and common modifiable risk factors for chronic disease in a representative sample of Sri Lankan adults.

The societal benefits of reducing six behavioural risk factors : an economic modelling study from Australia

Background
A large proportion of disease burden is attributed to behavioural risk factors. However, funding for public health programs in Australia remains limited. Government and non-government organisations are interested in the productivity effects on society from reducing chronic diseases. We aimed to estimate the potential health status and economic benefits to society following a feasible reduction in the prevalence of six behavioural risk factors: tobacco smoking; inadequate fruit and vegetable consumption; high risk alcohol consumption; high body mass index; physical inactivity; and intimate partner violence.
Methods
Simulation models were developed for the 2008 Australian population. A realistic reduction in current risk factor prevalence using best available evidence with expert consensus was determined. Avoidable disease, deaths, Disability Adjusted Life Years (DALYs) and health sector costs were estimated. Productivity gains included workforce (friction cost method), household production and leisure time. Multivariable uncertainty analyses and correction for the joint effects of risk factors on health status were undertaken. Consistent methods and data sources were used.
Results
Over the lifetime of the 2008 Australian adult population, total opportunity cost savings of AUD2,334 million (95% Uncertainty Interval AUD1,395 to AUD3,347; 64% in the health sector) were found if feasible reductions in the risk factors were achieved. There would be 95,000 fewer DALYs (a reduction of about 3.6% in total DALYs for Australia); 161,000 less new cases of disease; 6,000 fewer deaths; a reduction of 5 million days in workforce absenteeism; and 529,000 increased days of leisure time.
Conclusions
Reductions in common behavioural risk factors may provide substantial benefits to society. For example, the total potential annual cost savings in the health sector represent approximately 2% of total annual health expenditure in Australia. Our findings contribute important new knowledge about productivity effects, including the potential for increased household and leisure activities, associated with chronic disease prevention. The selection of targets for risk factor prevalence reduction is an important policy decision and a useful approach for future analyses. Similar approaches could be applied in other countries if the data are available.

Low-frequency volatility of yen interest rate swap market in relation to macroeconomic risk

Using ‘low-frequency’ volatility extracted from aggregate volatility shocks in interest rate swap (hereafter, IRS) market, this paper investigates whether Japanese yen IRS volatility can be explained by macroeconomic risks. The analysis suggests that this low-frequency yen IRS volatility has strong and positive association with most of the macroeconomic risk proxies (e.g., volatility of consumer price index, industrial production volatility, foreign exchange volatility, slope of the term structure and money supply) with the exception of the unemployment rate, which is negatively related to IRS volatility. This finding is fairly consistent with the argument that the greater the macroeconomic risk the greater is the use of derivative instruments to hedge or speculate. The relationship between the macroeconomic risks and IRS volatility varies slightly across the different swap maturities but is robust to alternative volatility specifications. This linkage between swap market and macroeconomy has practical implications since market makers and hedgers use the swap rate as benchmark for pricing long-term interest rates, corporate bonds and various other securities.

Does an increase in body mass index over 10 years affect knee structure in a population-based cohort study of adult women?

Introduction : Although obesity is a modifiable risk factor for knee osteoarthritis (OA), the effect of weight gain on knee structure in young and healthy adults has not been examined. The aim of this study was to examine the relationship between body mass index (BMI), and change in BMI over the preceding 10-year period, and knee structure (cartilage defects, cartilage volume and bone marrow lesions (BMLs)) in a population-based sample of young to middle-aged females.

Methods : One hundred and forty-two healthy, asymptomatic females (range 30 to 49 years) in the Barwon region of Australia, underwent magnetic resonance imaging (MRI) during 2006 to 2008. BMI measured 10 years prior (1994 to 1997), current BMI and change in BMI (accounting for baseline BMI) over this period, was assessed for an association with cartilage defects and volume, and BMLs.

Results : After adjusting for age and tibial plateau area, the risk of BMLs was associated with every increase in one-unit of baseline BMI (OR 1.14 (95% CI 1.03 to 1.26) P = 0.009), current BMI (OR 1.13 (95% CI 1.04 to 1.23) P = 0.005), and per one unit increase in BMI (OR 1.14 (95% CI 1.03 to 1.26) P = 0.01). There was a trend for a one-unit increase in current BMI to be associated with increased risk of cartilage defects (OR 1.06 (95% CI 1.00 to 1.13) P = 0.05), and a suggestion that a one-unit increase in BMI over 10 years may be associated with reduced cartilage volume (-17.8 ml (95% CI -39.4 to 3.9] P = 0.10). Results remained similar after excluding those with osteophytes.

Conclusions : This study provides longitudinal evidence for the importance of avoiding weight gain in women during early to middle adulthood as this is associated with increased risk of BMLs, and trend toward increased tibiofemoral cartilage defects. These changes have been shown to precede increased cartilage loss. Longitudinal studies will show whether avoiding weight gain in early adulthood may play an important role in diminishing the risk of knee OA.

The number of years lived with obesity and the risk of all-cause and cause-specific mortality

Background The role of the duration of obesity as an independent risk factor for mortality has not been investigated. The aim of this study was to analyse the association between the duration of obesity and the risk of mortality.

Methods A total of 5036 participants (aged 28–62 years) of the Framingham Cohort Study were followed up every 2 years from 1948 for up to 48 years. The association between obesity duration and all-cause and cause-specific mortality was analysed using time-dependent Cox models adjusted for body mass index. The role of biological intermediates and chronic diseases was also explored.

Results The adjusted hazard ratio (HR) for mortality increased as the number of years lived with obesity increased. For those who were obese for 1–4.9, 5–14.9, 15–24.9 and ≥25 years of the study follow-up period, adjusted HRs for all-cause mortality were 1.51 [95% confidence interval (CI) 1.27–1.79], 1.94 (95% CI 1.71–2.20), 2.25 (95% CI 1.89–2.67) and 2.52 (95% CI 2.08–3.06), respectively, compared with those who were never obese. A dose–response relation between years of duration of obesity was also clear for all-cause, cardiovascular, cancer and other-cause mortality. For every additional 2 years of obesity, the HRs for all-cause, cardiovascular disease, cancer and other-cause mortality were 1.06 (95% CI 1.05–1.07), 1.07 (95% CI 1.05–1.08), 1.03 (95% CI 1.01–1.05) and 1.07 (95% CI 1.05–1.11), respectively.

Conclusions The number of years lived with obesity is directly associated with the risk of mortality. This needs to be taken into account when estimating its burden on mortality.

The duration of obesity and the risk of type-2 diabetes

Objective The evidence for the association between obesity and the risk of type 2 diabetes has been derived mainly from the analysis of the degree of obesity. The role of the duration of obesity as an independent risk has not been fully explored. The objective of the present study was to investigate the association between the duration of obesity and the risk of type 2 diabetes.

Design Prospective cohort study.

Setting The Framingham Heart Study (FHS), follow-up from 1948 to 1998.

Subjects A total of 1256 FHS participants who were free from type 2 diabetes at baseline, but were obese on at least two consecutive of the study’s twenty-four biennial examinations, were included. Type 2 diabetes status was collected throughout the 48 years of follow-up of the study. The relationship between duration of obesity and type 2 diabetes was analysed using time-dependent Cox models, adjusting for a number of covariates.

Results The unadjusted hazard ratio (HR) for the risk of type 2 diabetes for men was 1·13 (95 % CI 1·09, 1·17) and for women was 1·12 (95 % CI 1·08, 1·16) per additional 2-year increase in the duration of obesity. Adjustment for sociodemographic variables, family history of diabetes, health behaviour and physical activity made little difference to these HR. For women the evidence of a dose–response relationship was less clear than for men, particularly for women with an older age at obesity onset.

Conclusions The duration of obesity is a relevant risk factor for type 2 diabetes, independent of the degree of BMI.

Risk of falls and motor vehicle collisions in glaucoma

PURPOSE. To investigate the risk of falls and motor vehicle collisions (MVCs) in patients with glaucoma.

METHODS. The sample comprised 48 patients with glaucoma (mean visual field mean deviation [MD] in the better eye = −3.9 dB; 5.1 dB SD) and 47 age-matched normal control subjects, who were recruited from a university-based hospital eye care clinic and are enrolled in an ongoing prospective study of risk factors for falls, risk factors for MVCs, and on-road driving performance in glaucoma. Main outcome measures at baseline were previous self-reported falls and MVCs, and police-reported MVCs. Demographic and medical data were obtained. In addition, functional independence in daily living, physical activity level and balance were assessed. Clinical vision measures included visual acuity, contrast sensitivity, standard automated perimetry, useful field of view (UFOV), and stereopsis. Analyses of falls and MVCs were adjusted to account for the possible confounding effects of demographic characteristics, medications, and visual field impairment. MVC analyses were also adjusted for kilometers driven per week.

RESULTS. There were no significant differences between patients with glaucoma and control subjects with respect to number of systemic medical conditions, body mass index, functional independence, and physical activity level (P > 0.10). At baseline, 40 (83%) patients with glaucoma and 44 (94%) control subjects were driving. Compared with control subjects, patients with glaucoma were over three times more likely to have fallen in the previous year (odds ratio [OR]adjusted = 3.71; 95% CI, 1.14–12.05), over six times more likely to have been involved in one or more MVCs in the previous 5 years (ORadjusted = 6.62; 95% CI, 1.40–31.23), and more likely to have been at fault (ORadjusted = 12.44; 95% CI, 1.08–143.99). The strongest risk factor for MVCs in patients with glaucoma was impaired UFOV selective attention (ORadjusted = 10.29; 95% CI, 1.10–96.62; for selective attention >350 ms compared with ≤350 ms).

CONCLUSIONS. There is an increased risk of falls and MVCs in patients with glaucoma.

A mystery to the medical world : Florence Nightingale, Rosendo Salvado and the risk of civilisation

In 1860 Florence Nightingale conducted a study on the mortality rates of indigenous children attending native colonial schools across the British Empire. Her study was driven by the question: ‘Can we civilise the natives without killing them?’ One colonial school that participated in the survey was New Norcia Benedictine mission in Western Australia. When Rosendo Salvado, the mission’s superintendent, responded, he drew on his daily encounters with the Yuat people, his statistics on the mission residents and his Benedictine philosophy of civilisation and conversion of colonised peoples. The correspondence between Salvado and Nightingale took place in the climate of intense debates about Aboriginal health, colonisation and extinction in Britain and the colonies. While many settlers and colonial observers understood Aboriginal depopulation to be the result of either the vices and diseases of unprincipled Europeans or an unstoppable destiny, whether Divine Providence or natural selection, Nightingale and Salvado shared a belief in practical solutions to what they understood to be a practical problem. Their collaboration is an example of the humanitarian opposition to the racial pessimism of Social Darwinism. They both sought to use the recently influential intellectual discipline of social statistics to support their conviction that Aborigines, if patiently and carefully handled, would survive the admittedly risky process of civilisation.

Multilevel analysis of the Be Active Eat Well intervention : environmental and behavioural influences on reductions in child obesity risk

Background: The Be Active Eat Well (BAEW) community-based child obesity prevention intervention was successful in modestly reducing unhealthy weight gain in primary school children using a multi-strategy and multi-setting approach.

Objective: To (1) examine the relationship between changes in obesity-related individual, household and school factors and changes in standardised child body mass index (zBMI), and (2) determine if the BAEW intervention moderated these effects.

Methods: The longitudinal relationships between changes in individual, household and school variables and changes in zBMI were explored using multilevel modelling, with measurement time (baseline and follow-up) at level 1, individual (behaviours, n=1812) at level 2 and households (n=1318) and schools (n=18) as higher levels (environments). The effect of the intervention was tested while controlling for child age, gender and maternal education level.

Results: This study confirmed that the BAEW intervention lowered child zBMI compared with the comparison group (−0.085 units, P=0.03). The variation between household environments was found to be a large contributor to the percentage of unexplained change in child zBMI (59%), compared with contributions from the individual (23%) and school levels (1%). Across both groups, screen time (P=0.03), sweet drink consumption (P=0.03) and lack of household rules for television (TV) viewing (P=0.05) were associated with increased zBMI, whereas there was a non-significant association with the frequency the TV was on during evening meals (P=0.07). The moderating effect of the intervention was only evident for the relationship between the frequency of TV on during meals and zBMI, however, this effect was modest (P=0.04).

Conclusions: The development of childhood obesity involves multi-factorial and multi-level influences, some of which are amenable to change. Obesity prevention strategies should not only target individual behaviours but also the household environment and family practices. Although zBMI changes were modest, these findings are encouraging as small reductions can have population level impacts on childhood obesity levels.

Reducing risk in coronary artery disease. Are Australian patients in general practice achieving targets? The coronary artery disease in general practice study (CADENCE)

Background The benefits of secondary preventive measures for stable coronary artery disease are well established and risk factor treatment targets are defined.

Aim The aim of this study was to examine Australian general practitioners' (GP) perception and management of risk factors in chronic stable angina patients in primary care.

Methods Using a cluster-stratified design, 2031 consecutive stable angina patients were recruited between October 2006 and March 2007 by 207 GP who documented their risk factors and reported if they were optimally controlled.

Results Among the patients, 93% had objective evidence of coronary artery disease and 63% were male, and mean age was 71 ± 11 years. Based upon national guidelines, recommended targets were achieved in: 60% for blood pressure, 24% for body mass index, 23% for waist circumference, 17% for lipid profiles (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides) and 54% of diabetics for haemoglobin A1c. However, GP perceived risk factors to be ‘optimally controlled’ in: 86% for blood pressure (kappa statistic (κ) = 0.37), 44% for weight (κ = 0.3), 70% for lipids (κ = 0.20) and 60% for haemoglobin A1c (κ = 0.74).

Conclusions In this representative cohort of chronic stable angina patients attending GP, cardiovascular risk factor control was frequently suboptimal despite being perceived as satisfactory by the clinicians. New strategies that raise awareness and address this treatment gap need to be implemented.

Risk factors for incident delirium in acute medical in-patients. A systematic review

Review question/objective
What risk factors are associated with incident delirium in adult patients during an acute medical hospitalisation?
More specifically, the objectives are to:
Identify and synthesise the best available evidence on the factors which are associated with delirium in adult patients admitted to acute medical facilities.

Types of participants
This review will consider studies that include adults (defined as 18 years and above) who were admitted to an acute medical setting (e.g. general medical units, stroke units, short stay units and neuromedical units) who were not delirious on admission (in order to differentiate incident delirium) but who developed incident delirium during hospitalisation

The review will exclude patients who were:
- critically ill and admitted to specialist unit e.g. ICU or CCU
- admitted for any type of surgery
- admitted for alcohol related reasons
- admitted to psychiatric facility
These patients will be excluded in order to determine factors that may be exclusive to the medical in patient setting.

Types of intervention(s)/phenomena of interest
This review will consider studies that evaluate any risk factors that may contribute to the development of delirium during in-patient hospitalisation. The review will look at factors present on admission (predisposing) and also factors that may occur during hospitalisation (precipitating) that contribute to incident delirium.

Types of outcomes
This review will consider studies that include the following outcome measures: the incidence of delirium as related to individual risk factors.

Assessing risk post intervention for an acute coronary syndrome: a review of the risk assessment tools and their development

Considerable variability in survival rate after an acute myocardial infarction exists and accurate risk stratification is of significant importance. The American College of Cardiology and the American Heart Association has recommended early risk stratification using several clinical risk scoring instruments to identify high risk patients. The aim of this paper is to identify secondary cardiovascular risk scoring instruments that could be utilized at the time of intervention for acute coronary syndromes and compare their psychometric properties as they were developed. A search using Medline, Cumulative Index to Nursing and Allied Health Literature and the Psychology and Behavioral Sciences Collection data-bases identified studies published between January 1990 and January 2010 used to measure risk after intervention for acute coronary syndrome. Four validated secondary risk prediction scoring instruments were identified for comparison.Secondary risk prediction scoring instruments for the acute coronary syndrome patient population are evidence based, valid and reliable. Use of the instruments by cardiac focused clinicians will aid in the determination of treatment strategies, and estimation of short and long term events and mortality.

Risk factors for incident delirium in acute medical in-patients: a systematic review

Delirium is a serious problem that can occur in many older people admitted to hospital. Delirium has the potential to dramatically complicate the hospitalisation of a patient, and often results in functional decline, an increased likelihood of complications associated with longer hospital stays, increasing the risk of admission to a care facility post discharge, a greater incidence of falls and is associated with high mortality and morbidity rates. Understanding the factors that contribute to delirium can provide insights into the mechanisms that underlie the syndrome.

A comparison of Australian rural and metropolitan cardiovascular risk and mortality: the Greater Green Triangle and North West Adelaide population surveys

Objectives:
Cardiovascular (CVD) mortality disparities between rural/regional and urban-dwelling residents of Australia are persistent. Unavailability of biomedical CVD risk factor data has, until now, limited efforts to understand the causes of the disparity. This study aimed to further investigate such disparities.

Associations between child temperament, maternal feeding practices and child body mass index during the preschool years: a systematic review of the literature

It is a research priority to identify modifiable risk factors to improve the effec- tiveness of childhood obesity prevention strategies. Research, however, has largely overlooked the role of child temperament and personality implicated in obesogenic risk factors such as maternal feeding and body mass index (BMI) of preschoolers. A systematic review of relevant literature was conducted to inves- tigate the associations between child temperament, child personality, maternal feeding and BMI and/or weight gain in infants and preschoolers; 18 papers were included in the review. The findings revealed an association between the temperament traits of poor self-regulation, distress to limitations, low and high soothability, low negative affectivity and higher BMI in infants and preschool- aged children. Temperament traits difficult, distress to limitations, surgency/ extraversion and emotionality were significantly associated with weight gain rates in infants. The results also suggested that child temperament was associated with maternal feeding behaviours that have been shown to influence childhood over- weight and obesity, such as using restrictive feeding practices with children per- ceived as having poor self-regulation and feeding potentially obesogenic food and drinks to infants who are more externalizing. Interestingly, no studies to date have evaluated the association between child personality and BMI/weight gain in infants and preschoolers. There is a clear need for further research into the association of child temperament and obesogenic risk factors in preschool-aged children.