Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies

Increased consumption of fruit and vegetables has been shown to be associated with a reduced risk of coronary heart disease (CHD) in many epidemiological studies, however, the extent of the association is uncertain. We quantitatively assessed the relation between fruit and vegetable intake and incidence of CHD by carrying out a meta-analysis of cohort studies. Studies were included if they reported relative risks (RRs) and corresponding 95% confidence interval (CI) of CHD with respect to frequency of fruit and vegetable intake. Twelve studies, consisting of 13 independent cohorts, met the inclusion criteria. There were 278 459 individuals (9143 CHD events) with a median follow-up of 11 years. Compared with individuals who had less than 3 servings/day of fruit and vegetables, the pooled RR of CHD was 0.93 (95% CI: 0.86–1.00, P=0.06) for those with 3–5 servings/day and 0.83 (0.77–0.89, P<0.0001) for those with more than 5 servings/day. Subgroup analyses showed that both fruits and vegetables had a significant protective effect on CHD. Our meta-analysis of prospective cohort studies demonstrates that increased consumption of fruit and vegetables from less than 3 to more than 5 servings/day is related to a 17% reduction in CHD risk, whereas increased intake to 3–5 servings/day is associated with a smaller and borderline significant reduction in CHD risk. These results provide strong support for the recommendations to consume more than 5 servings/day of fruit and vegetables.

'Traffic-light' nutrition labelling and 'junk-food' tax : a modelled comparison of cost-effectiveness for obesity prevention

Introduction: Cost-effectiveness analyses are important tools in efforts to prioritise interventions for obesity prevention.
Modelling facilitates evaluation of multiple scenarios with varying assumptions. This study compares the cost-effectiveness of
conservative scenarios for two commonly proposed policy-based interventions: front-of-pack ‘traffic-light’ nutrition labelling
(traffic-light labelling) and a tax on unhealthy foods (‘junk-food’ tax).
Methods: For traffic-light labelling, estimates of changes in energy intake were based on an assumed 10% shift in consumption
towards healthier options in four food categories (breakfast cereals, pastries, sausages and preprepared meals) in 10% of adults. For the ‘junk-food’ tax, price elasticities were used to estimate a change in energy intake in response to a 10% price increase in seven food categories (including soft drinks, confectionery and snack foods). Changes in population weight and body mass index by sex were then estimated based on these changes in population energy intake, along with subsequent impacts on disability-adjusted life years (DALYs). Associated resource use was measured and costed using pathway analysis, based on a health sector perspective (with some industry costs included). Costs and health outcomes were discounted at 3%. The cost-effectiveness of each intervention was modelled for the 2003 Australian adult population.
Results: Both interventions resulted in reduced mean weight (traffic-light labelling: 1.3 kg (95% uncertainty interval (UI): 1.2;
1.4); ‘junk-food’ tax: 1.6 kg (95% UI: 1.5; 1.7)); and DALYs averted (traffic-light labelling: 45 100 (95% UI: 37 700; 60 100);
‘junk-food’ tax: 559 000 (95% UI: 459 500; 676 000)). Cost outlays were AUD81 million (95% UI: 44.7; 108.0) for traffic-light
labelling and AUD18 million (95% UI: 14.4; 21.6) for ‘junk-food’ tax. Cost-effectiveness analysis showed both interventions were
‘dominant’ (effective and cost-saving).
Conclusion: Policy-based population-wide interventions such as traffic-light nutrition labelling and taxes on unhealthy foods are
likely to offer excellent ‘value for money’ as obesity prevention measures.

Diagnosing bipolar disorder : how can we do it better?

• Accurate diagnosis of bipolar disorder is essential for effective treatment.

• The diagnosis of bipolar disorder is particularly complex, resulting in lengthy delays between first presentation and initiation of appropriate therapy. Inappropriate therapy destabilises the course and outcome of the disease.

• Although the defining features of bipolar disorder are manic or hypomanic episodes, patients typically present for treatment of depression and commonly deny symptoms of mood elevation.

• A correct diagnosis can easily be masked by comorbidities, personality issues and complex phenomenology.

• A diagnosis of bipolar disorder can be assisted by:

   → asking about symptoms of mania or hypomania in every patient presenting with symptoms of depression.

   → recognising mixed states in which manic and depressive symptoms occur simultaneously.

   → identifying the features of bipolar depression that distinguish it from unipolar depression.

• There is a risk of over-diagnosis of bipolar disorder among patients who are histrionic, show abnormal illness behaviour MJA 2006; 184: 459–462 and/or have issues of secondary gain.

Effect of diet versus diet and exercise on weight loss and body composition in class II and III obesity: A systematic review

Class II and III obesity (BMI >35 kg·m2) have increased dramatically in recent years. Current clinical guidelines suggest diet and exercise as first line treatment for adults throughout the spectrum of overweight and obesity. However, to date there is no systematic review that examines the effects of diet and exercise on this high risk population. This systematic review will examine the combined effects of diet versus diet and exercise on body composition in severe obesity. Medline and Cinahl were searched for randomised controlled trials comparing diet and exercise to diet alone. Studies published until July 2013 were included if they used reliable methods for analysing body composition in adults with BMI ≥ 35 kg·m2. Five of 459 studies met the inclusion criteria. Two studies, both in older adults, reported that exercise reduced lean mass loss during weight loss. Two studies showed that exercise facilitated (greater) fat mass loss. The remaining study reported no differences in body composition when exercise is added to energy restriction. Exercise training during energy restriction for individuals with BMI ≥35 kg.m2 may influence body composition outcomes but the evidence is limited. Further studies should focus on the efficacy of different exercise protocols during energy restriction for this population in order to better inform decision making for the treatment of severe obesity in respect to favourable body composition outcomes.

Symptoms and distress in children with advanced cancer: prospective patient-reported outcomes from the PediQUEST Study

PURPOSE: Thousands of children are living with advanced cancer; yet patient-reported outcomes (PROs) have rarely been used to describe their experiences. We aimed to describe symptom distress in 104 children age 2 years or older with advanced cancer enrolled onto the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) Study (multisite clinical trial evaluating an electronic PRO system).

METHODS: Symptom data were collected using age- and respondent-adapted versions of the PediQUEST Memorial Symptom Assessment Scale (PQ-MSAS) at most once per week. Clinical and treatment data were obtained from medical records. Individual symptom scores were dichotomized into high/low distress. Determinants of PQ-MSAS scores were explored using linear mixed-effects models.

RESULTS: During 9 months of follow-up, PQ-MSAS was administered 920 times: 459 times in teens (99% self-report), 249 times in children ages 7 to 12 years (96% child/parent report), and 212 times in those ages 2 to 6 years (parent reports). Common symptoms included pain (48%), fatigue (46%), drowsiness (39%), and irritability (37%); most scores indicated high distress. Among the 73 PQ-MSAS surveys administered in the last 12 weeks of life, pain was highly prevalent (62%; 58% with high distress). Being female, having a brain tumor, experiencing recent disease progression, and receiving moderate- or high-intensity cancer-directed therapy in the prior 10 days were associated with worse PQ-MSAS scores. In the final 12 weeks of life, receiving mild cancer-directed therapy was associated with improved psychological PQ-MSAS scores.

CONCLUSION: Children with advanced cancer experience high symptom distress. Strategies to promote intensive symptom management are indicated, especially with disease progression or administration of intensive treatments.

Noninvasive stimulation of the temporoparietal junction: a systematic review

Imaging and lesion studies have suggested numerous roles for the temporoparietal junction (TPJ), for example in attention and neglect, social cognition, and self/other processing. These studies cannot establish causal relationships, and the importance and relevance of (and interrelationships between) proposed roles remain controversial. This review examined studies that use noninvasive transcranial stimulation (NTS) to explore TPJ function. Of 459 studies identified, 40 met selection criteria. The strengths and weaknesses of NTS-relevant parameters used are discussed, and methodological improvements suggested. These include the need for careful selection of stimulation sites and experimental tasks, and use of neuronavigation and concurrent functional activity measures. Without such improvements, overlapping and discrete functions of the TPJ will be difficult to disentangle. Nevertheless, the contributions of these studies to theoretical models of TPJ function are discussed, and the clinical relevance of TPJ stimulation explored. Some evidence exists for TPJ stimulation in the treatment of auditory hallucinations, tinnitus, and depersonalisation disorder. Further examination of the TPJ in conditions such as autism spectrum disorder is also warranted.

The acute physiological stress response to an emergency alarm and mobilization during the day and at night

The purpose of this study was to investigate the acute physiological stress response to an emergency alarm and mobilization during the day and at night. Sixteen healthy males aged 25 ± 4 years (mean ± SD) spent four consecutive days and nights in a sleep laboratory. This research used a within-participants design with repeated measures for time, alarm condition (alarm or control), and trial (day or night). When an alarm sounded, participants were required to mobilize immediately. Saliva samples for cortisol analysis were collected 0 min, 15 min, 30 min, 45 min, 60 min, 90 min, and 120 min after mobilization, and at corresponding times in control conditions. Heart rate was measured continuously throughout the study. Heart rate was higher in the day (F20,442 = 9.140, P < 0.001) and night (F23,459 = 8.356, P < 0.001) alarm conditions compared to the respective control conditions. There was no difference in saliva cortisol between day alarm and day control conditions. Cortisol was higher (F6,183 = 2.450, P < 0.001) following the night alarm and mobilization compared to the night control condition. The magnitude of difference in cortisol between night control and night alarm conditions was greater (F6,174 = 4.071, P < 0.001) than the magnitude of difference between the day control and day alarm conditions. The augmented heart rate response to the day and night alarms supports previous observations in field settings. Variations in the cortisol responses between conditions across the day and night may relate to differences in participants' ability to interpret the alarm when sleeping versus when awake.