Ailsa J. McKay

Prevalences of overweight, obesity, hyperglycaemia, hypertension and dyslipidaemia in the Gulf: systematic review

Objectives To examine the prevalence of risk factors for diabetes and its complications in the Co-operation Council of the Arab States of the Gulf (GCC) region. Design Systematic review. Setting Co-operation Council of the Arab States of the Gulf (GCC) states (United Arab Emirates, Bahrain, Saudi Arabia, Oman, Qatar, Kuwait). Participants Residents of the GCC states participating in studies on the prevalence of overweight and obesity, hyperglycaemia, hypertension and dyslipidaemia. Main outcome measures Prevalences of overweight, obesity and hyperglycaemia, hypertension and hyperlipidaemia. Results Forty-five studies were included in the review. Reported prevalences of overweight and obesity in adults were 25–50% and 13–50%, respectively. Prevalence appeared higher in women and to hold a non-linear association with age. Current prevalence of impaired glucose tolerance was estimated to be 10–20%. Prevalence appears to have been increasing in recent years. Estimated prevalences of hypertension and dyslipidaemia were few and used varied definitions of abnormality, making review difficult, but these also appeared to be high and increasing, Conclusions There are high prevalences of risk factors for diabetes and diabetic complications in the GCC region, indicative that their current management is suboptimal. Enhanced management will be critical if escalation of diabetes-related problems is to be averted as industrialization, urbanization and changing population demographics continue.

Prevalence of Type 2 Diabetes in the States of The Co-Operation Council for the Arab States of the Gulf: A Systematic Review

Aims The recent and ongoing worldwide expansion in prevalence of Type 2 Diabetes (T2DM) is a considerable risk to individuals, health systems and economies. The increase in prevalence has been particularly marked in the states of the Co-operation Council for the Arab States of the Gulf (GCC), and these trends are set to continue. We aimed to systematically review the current prevalence of T2DM within these states, and also within particular sub-populations. Methods We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched using terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, prevalence, epidemiology and Gulf States. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion and exclusion criteria, and where suitable for inclusion, data extraction and quality assessment was achieved using a specifically-designed tool. All studies where prevalence of diabetes was investigated were eligible for inclusion. The inclusion criteria required that the study population be of a GCC country, but otherwise all ages, sexes and ethnicities were included, resident and migrant populations, urban and rural, of all socioeconomic and educational backgrounds. No limitations on publication type, publication status, study design or language of publication were imposed. However, we did not include secondary reports of data, such as review articles without novel data synthesis. Conclusions The prevalence ofT2DM is an increasing problem for all GCC states. They may therefore benefit to a relatively high degree from co-ordinated implementation of broadly consistent management strategies. Further study of prevalence in children and in national versus expatriate populations would also be useful.

Prevalence of COPD in India: a systematic review

BACKGROUND The increasing burden of chronic diseases is a particular risk to countries with developing health systems. Chronic obstructive pulmonary disease (COPD) is contributing to the burden of chronic diseases. Understanding the current prevalence of COPD in India is important for the production of sustainable management strategies. AIMS To provide a systematic review of studies assessing the prevalence of COPD in India. METHODS Database searches, journal hand searches, and scanning of reference lists were used to identify studies. Studies of general adult populations resident in India were included. Data extraction and quality assessment were carried out using pre-tested proformas. Owing to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used. RESULTS We did not identify any studies from which we could draw a rigorous estimate of the prevalence of COPD by standard definition. Reliable standard estimates of chronic bronchitis were only available for rural populations. We identified four studies that gave estimated prevalences between 6.5% and 7.7%, and others suggestive that prevalences in some environmentally atypical regions may lie outside this range. Sex and smoking status were relatively important predictors of COPD prevalence. Residential environs, age, and domestic smoke exposure are also important, but investigation of their effect was limited by study heterogeneity. CONCLUSIONS Although limited by the number and heterogeneity of studies and their unsuitability for meta-analysis, we found the most rigorous existing estimates of the general prevalence of chronic bronchitis in rural areas to lie between 6.5% and 7.7%. These figures are unlikely to apply to all Indian subpopulations, so the general prevalence of chronic bronchitis in India remains unknown. Accurate estimates of the prevalence of chronic bronchitis/COPD from across the country are required to supplement existing data if optimal management strategies are to be devised.

Quality of Type 2 Diabetes Management in the States of The Co-Operation Council for the Arab States of the Gulf: A Systematic Review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.

Implications of the imposition of the junior doctor contract in England.

Three years ago, the British Medical Association and National Health Service Employers entered negotiations about the contract for junior doctors working in England’s National Health Service. The discussions did not progress smoothly, and in late 2015, the government began to threaten imposition of a new contract of its own design. Mediated negotiation, between December 2015 and February 2016, nevertheless aided progress on the issue. Despite this, and even though the government did not have a fully developed proposal prepared, imposition of a new contract was announced by the Department of Health on 11 February 2016. For doctors, the contract imposition is distressing for several reasons. First, the contract is incompletely developed, and there are errors in the associated ‘pay calculator’, and heavily criticised, unrealistic rotas have been published. Doctors are therefore unable to determine the hours they are likely to work under the new contract, how these will be distributed across the week, and the impact on their salaries. This uncertainty is compounded by lack of clarity around the government’s rationale for imposition: provision of a ‘seven-day National Health Service’. The government has not clearly defined what it means by this, and the proposed rotas do not redistribute services evenly across the week. Indeed it is unclear whether the new rotas will provide any enhancement of weekend cover. Nor is it known what impact the proposed new working patterns of junior doctors will have on clinical outcomes, mortality and National Health Service productivity. A second source of frustration for doctors is the government’s apparent lack of understanding about the work junior doctors do, and its unwillingness to engage further on this issue. For example, in discussion pertaining to the imposed contract, National Health Service Employers suggested that, ‘Exceptionally, because of unforeseen circumstance, a trainee may feel a professional duty to work beyond the hours described in their work schedule’. Junior doctors routinely supply the National Health Service with many hours of service additional to those they are contracted to work, because the service is insufficiently staffed. To suggest that doctors should not be undertaking such additional work except in ‘exceptional circumstances’ is unrealistic. What do National Health Service Employers think would happen to patients if surgeons and anaesthetists walked out of theatres at the end of their shift, and do they expect patients to be turned away from routinely overbooked clinics at 5 pm? If this was to happen through a loss of goodwill on the part of junior doctors – or if they were to insist on payment for any extra hours worked – this would have a substantial effect on the National Health Service. A third concern for doctors is working for an employer that is potentially putting patient safety at risk with untested changes in working patterns. Although the government’s definition of a ‘sevenday National Health Service’ is unclear, the government wants to increase weekend services without reducing weekday services and while claiming to reduce the average number of hours that junior doctors will work. Without additional doctors, this means doctors will be redistributed from weekdays to weekends. This has implications for patient safety, and neither the clinicalnor the cost-effectiveness of this change in working practices has been tested. Any doctor would feel unable to use a new treatment without information on its effectiveness, cost and safety profile. Yet, this contract will force doctors to change their working patterns without evidence that this will improve clinical outcomes and with high-associated risks to doctors as well as patients. These issues are such a concern that the new contract appears unworkable to most junior doctors. Many are leaving for better working conditions in other countries or other professions. Others feel

Clinical impact of lifestyle interventions for the prevention of diabetes: an overview of systematic reviews

Objectives To review the clinical outcomes of combined diet and physical activity interventions for populations at high risk of type 2 diabetes. Design Overview of systematic reviews (search dates April–December 2015). Setting Any level of care; no geographical restriction. Participants Adults at high risk of diabetes (as per measures of glycaemia, risk assessment or presence of risk factors). Interventions Combined diet and physical activity interventions including ≥2 interactions with a healthcare professional, and ≥12 months follow-up. Outcome measures Primary: glycaemia, diabetes incidence. Secondary: behaviour change, measures of adiposity, vascular disease and mortality. Results 19 recent reviews were identified for inclusion; 5 with AMSTAR scores <8. Most considered only randomised controlled trials (RCTs), and RCTs were the major data source in the remainder. Five trials were included in most reviews. Almost all analyses reported that interventions were associated with net reductions in diabetes incidence, measures of glycaemia and adiposity, at follow-up durations of up to 23 years (typically <6). Small effect sizes and potentially transient effect were reported in some studies, and some reviewers noted that durability of intervention impact was potentially sensitive to duration of intervention and adherence to behaviour change. Behaviour change, vascular disease and mortality outcome data were infrequently reported, and evidence of the impact of intervention on these outcomes was minimal. Evidence for age effect was mixed, and sex and ethnicity effect were little considered. Conclusions Relatively long-duration lifestyle interventions can limit or delay progression to diabetes under trial conditions. However, outcomes from more time-limited interventions, and those applied in routine clinical settings, appear more variable, in keeping with the findings of recent pragmatic trials. There is little evidence of intervention impact on vascular outcomes or mortality end points in any context. ‘Real-world’ implementation of lifestyle interventions for diabetes prevention may be expected to lead to modest outcomes.

Strategies for tobacco control in India: a systematic review.

Background Tobacco control needs in India are large and complex. Evaluation of outcomes to date has been limited. Aim To review the extent of tobacco control measures, and the outcomes of associated trialled interventions, in India. Methods Information was identified via database searches, journal hand-searches, reference and citation searching, and contact with experts. Studies of any population resident in India were included. Studies where outcomes were not yet available, not directly related to tobacco use, or not specific to India, were excluded. Pre-tested proformas were used for data extraction and quality assessment. Studies with reliability concerns were excluded from some aspects of analysis. The Framework Convention on Tobacco Control (FCTC) was use as a framework for synthesis. Heterogeneity limited meta-analysis options. Synthesis was therefore predominantly narrative. Results Additional to the Global Tobacco Surveillance System data, 80 studies were identified, 45 without reliability concerns. Most related to education (FCTC Article 12) and tobacco-use cessation (Article 14). They indicated widespread understanding of tobacco-related harm, but less knowledge about specific consequences of use. Healthcare professionals reported low confidence in cessation assistance, in keeping with low levels of training. Training for schoolteachers also appeared suboptimal. Educational and cessation assistance interventions demonstrated positive impact on tobacco use. Studies relating to smoke-free policies (Article 8), tobacco advertisements and availability (Articles 13 and 16) indicated increasingly widespread smoke-free policies, but persistence of high levels of SHS exposure, tobacco promotions and availability—including to minors. Data relating to taxation/pricing and packaging (Articles 6 and 11) were limited. We did not identify any studies of product regulation, alternative employment strategies, or illicit trade (Articles 9, 10, 15 and 17). Conclusions Tobacco-use outcomes could be improved by school/community-based and adult education interventions, and cessation assistance, facilitated by training for health professionals and schoolteachers. Additional tobacco control measures should be assessed.

Junior Doctors in England Strike for the First Time in 40 Years.

The UK government recently stated its intention to impose a new junior doctor contract in England. Related negotiations between the British Medical Association and government representatives started in 2013. These have to-date failed to reassure doctors, who are concerned about risks to their welfare, patient safety, and the future of Englands National Health Service. With the impending imposition of the new contract, and lack of progress, junior doctors felt the risks of striking had fallen below those of inaction. Hence, the first strike staged by the English medical workforce for 40 years occurred in January 2016.

Are primary care factors associated with hospital episodes for adverse drug reactions? A national observational study

Objective Identification of primary care factors associated with hospital admissions for adverse drug reactions (ADRs). Design and setting Cross-sectional analysis of 2010–2012 data from all National Health Service hospitals and 7664 of 8358 general practices in England. Method We identified all hospital episodes with an International Classification of Diseases (ICD) 10 code indicative of an ADR, in the 2010–2012 English Hospital Episode Statistics (HES) admissions database. These episodes were linked to contemporary data describing the associated general practice, including general practitioner (GP) and patient demographics, an estimate of overall patient population morbidity, measures of primary care supply, and Quality and Outcomes Framework (QOF) quality scores. Poisson regression models were used to examine associations between primary care factors and ADR-related episode rates. Results 212 813 ADR-related HES episodes were identified. Rates of episodes were relatively high among the very young, older and female subgroups. In fully adjusted models, the following primary care factors were associated with increased likelihood of episode: higher deprivation scores (population attributable fraction (PAF)=0.084, 95% CI 0.067 to 0.100) and relatively poor glycated haemoglobin (HbA1c) control among patients with diabetes (PAF=0.372; 0.218 to 0.496). The following were associated with reduced episode likelihood: lower GP supply (PAF=−0.016; −0.026 to −0.005), a lower proportion of GPs with UK qualifications (PAF=−0.035; −0.058 to −0.012), lower total QOF achievement rates (PAF=−0.021; −0.042 to 0.000) and relatively poor blood pressure control among patients with diabetes (PAF=−0.144; −0.280 to −0.022). Conclusions Various aspects of primary care are associated with ADR-related hospital episodes, including achievement of particular QOF indicators. Further investigation with individual level data would help develop understanding of the associations identified. Interventions in primary care could help reduce the ADR burden. ADRs are candidates for primary care sensitive conditions.

Management of chronic obstructive pulmonary disease in India: a systematic review:

Objectives Chronic diseases are fast becoming the largest health burden in India. Despite this, their management in India has not been well studied. We aimed to systematically review the nature and efficacy of current management strategies for chronic obstructive pulmonary disease (COPD) in India. Methods We used database searches (MEDLINE, EMBASE, IndMED, CENTRAL and CINAHL), journal hand-searches, scanning of reference lists and contact with experts to identify studies for systematic review. We did not review management strategies aimed at chronic diseases more generally, nor management of acute exacerbations. Due to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used. Setting India Participants All adult populations resident in India Main outcome measures 1. Trialled interventions and outcomes 2. Extent and efficacy of current management strategies 3. Above outcomes by subgroup Results We found information regarding current management – particularly regarding the implementation of national guidelines and primary prevention – to be minimal. This led to difficulty in interpreting studies of management strategies, which were varied and generally of positive effect. Data regarding current management outcomes were very few. Conclusions The current understanding of management strategies for COPD in India is limited due to a lack of published data. Determination of the extent of current use of management guidelines, availability and use of treatment, and current primary prevention strategies would be useful. This would also provide evidence on which to interpret existing and future studies of management outcomes and novel interventions.