Benjamin Philpot

Depression: an important comorbidity with metabolic syndrome in a general population.

OBJECTIVE—There is a recognized association among depression, diabetes, and cardiovascular disease. The aim of this study was to examine in a sample representative of the general population whether depression, anxiety, and psychological distress are associated with metabolic syndrome and its components. RESEARCH DESIGN AND METHODS—Three cross-sectional surveys including clinical health measures were completed in rural regions of Australia during 2004–2006. A stratified random sample (n = 1,690, response rate 48%) of men and women aged 25–84 years was selected from the electoral roll. Metabolic syndrome was defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III (NCEP ATP III), and International Diabetes Federation (IDF) criteria. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale and psychological distress by the Kessler 10 measure. RESULTS—Metabolic syndrome was associated with depression but not psychological distress or anxiety. Participants with the metabolic syndrome had higher scores for depression (n = 409, mean score 3.41, 95% CI 3.12–3.70) than individuals without the metabolic syndrome (n = 936, mean 2.95, 95% CI 2.76–3.13). This association was also present in 338 participants with the metabolic syndrome and without diabetes (mean score 3.37, 95% CI 3.06–3.68). Large waist circumference and low HDL cholesterol showed significant and independent associations with depression. CONCLUSIONS—Our results show an association between metabolic syndrome and depression in a heterogeneous sample. The presence of depression in individuals with the metabolic syndrome has implications for clinical management.

Type 2 diabetes prevalence varies by socio-economic status within and between migrant groups: analysis and implications for Australia

BackgroundEthnic diversity is increasing through migration in many developed countries. Evidence indicates that type 2 diabetes mellitus (T2DM) prevalence varies by ethnicity and socio-economic status (SES), and that in many settings, migrants experience a disproportionate burden of disease compared with locally-born groups. Given Australia’s multicultural demography, we sought to identify groups at high risk of T2DM in Victoria, Australia.MethodsUsing population data from the Australian National Census and diabetes data from the National Diabetes Services Scheme, prevalence of T2DM among immigrant groups in Victoria in January 2010 was investigated, and prevalence odds versus Australian-born residents estimated. Distribution of T2DM by SES was also examined.ResultsPrevalence of diagnosed T2DM in Victoria was 4.1% (n = 98671) in men and 3.5% (n = 87608) in women. Of those with T2DM, over 1 in 5 born in Oceania and in Southern and Central Asia were aged under 50 years. For both men and women, odds of T2DM were higher for all migrant groups than the Australian-born reference population, including, after adjusting for age and SES, 6.3 and 7.2 times higher for men and women born in the Pacific Islands, respectively, and 5.2 and 5.0 times higher for men and women born in Southern and Central Asia, respectively. Effects of SES varied by region of birth.ConclusionsLarge socio-cultural differences exist in the distribution of T2DM. Across all socio-economic strata, all migrant groups have higher prevalence of T2DM than the Australian-born population. With increasing migration, this health gap potentially has implications for health service planning and delivery, policy and preventive efforts in Australia.

Scaling up diabetes prevention in Victoria, Australia: policy development, implementation and evaluation

OBJECTIVE The Australian lifestyle intervention program Life! is only the second reported, large-scale diabetes prevention program. This article describes the genesis and the successful establishment of Life! and its key outcomes for participants and implementation. RESEARCH DESIGN AND METHODS Life!, a behavior-change intervention, comprises six group sessions over 8 months. The Victorian Department of Health funded Diabetes Australia–Victoria to implement the program. Experience of the Greater Green Triangle diabetes prevention implementation trial was used for intervention design, workforce development, training, and infrastructure. Clinical and anthropometric data from participants, used for program evaluation, were recorded on a central database. RESULTS Life! has a statewide workforce of 302 trained facilitators within 137 organizations. Over 29,000 Victorians showed interest in Life!, and 15,000 individuals have been referred to the program. In total, 8,412 participants commenced a Life! program between October 2007 and June 2011, and 37% of the original participants completed the 8-month program. Participants completing sessions 1 to 5 lost an average of 1.4 kg weight (P < 0.001) and waist circumference of 2.5 cm (P < 0.001). Those completing six sessions lost an average of 2.4 kg weight (P < 0.001) and waist circumference of 3.8 cm (P < 0.001). The weight loss of 2.4 kg represents 2.7% of participants’ starting body weight. CONCLUSIONS The impact of Life! is attributable to applying available evidence for the system’s design of the intervention and collaboration between policy makers, implementers, and evaluators using the principles of continuous quality improvement to support successful, large-scale recruitment and implementation.

Scaling-up from an implementation trial to state-wide coverage: results from the preliminary Melbourne Diabetes Prevention Study.

BackgroundThe successful Greater Green Triangle Diabetes Prevention Program (GGT DPP), a small implementation trial, has been scaled-up to the Victorian state-wide ‘Life!’ programme with over 10,000 individuals enrolled. The Melbourne Diabetes Prevention Study (MDPS) is an evaluation of the translation from the GGT DPP to the Life! programme. We report results from the preliminary phase (pMDPS) of this evaluation.MethodsThe pMDPS is a randomised controlled trial with 92 individuals aged 50 to 75 at high risk of developing type 2 diabetes randomised to Life! or usual care. Intervention consisted of six structured 90-minute group sessions: five fortnightly sessions and the final session at 8 months. Participants underwent anthropometric and laboratory tests at baseline and 12 months, and provided self-reported psychosocial, dietary, and physical activity measures. Intervention group participants additionally underwent these tests at 3 months. Paired t tests were used to analyse within-group changes over time. Chi-square tests were used to analyse differences between groups in goals met at 12 months. Differences between groups for changes over time were tested with generalised estimating equations and analysis of covariance.ResultsIntervention participants significantly improved at 12 months in mean body mass index (−0.98 kg/m2, standard error (SE)%20=%200.26), weight (−2.65 kg, SE%20=%200.72), waist circumference (−7.45 cm, SE%20=%201.15), and systolic blood pressure (−3.18 mmHg, SE%20=%201.26), increased high-density lipoprotein-cholesterol (0.07 mmol/l, SE%20=%200.03), reduced energy from total (−2.00%, SE%20=%200.78) and saturated fat (−1.54%, SE%20=%200.41), and increased fibre intake (1.98 g/1,000 kcal energy, SE%20=%200.47). In controls, oral glucose at 2 hours deteriorated (0.59 mmol/l, SE%20=%200.27). Only waist circumference reduced significantly (−4.02 cm, SE%20=%200.95).Intervention participants significantly outperformed controls over 12 months for body mass index and fibre intake. After baseline adjustment, they also showed greater weight loss and reduced saturated fat versus total energy intake.At least 5% weight loss was achieved by 32% of intervention participants versus 0% controls.ConclusionspMDPS results indicate that scaling-up from implementation trial to state-wide programme is possible. The system design for Life! was fit for purpose of scaling-up from efficacy to effectiveness.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12609000507280

The association of levels of physical activity with metabolic syndrome in rural Australian adults.

BackgroundPhysical activity (PA) reduces risk factors related to metabolic syndrome. Rurality influences the way people incorporate physical activity into daily life. The aim of this study is to determine the association of PA level with metabolic syndrome in a rural Australian population. The influence of adiposity on these associations is also investigated.MethodsThree cross-sectional population health surveys were conducted in south-east Australia during 2004–2006 using a random population sample (n = 1563, participation rate 49%) aged 25–74 years. PA was assessed via a self-administered questionnaire, and components of the metabolic syndrome via anthropometric measurements taken by specially trained nurses and laboratory tests.ResultsApproximately one-fifth of participants were inactive in leisure-time and over one-third had metabolic syndrome (men 39%, women 33%; p = 0.022). There was an inverse association between level of PA and metabolic syndrome (p < 0.001). Men who were inactive in leisure-time were more than twice as likely and women more than three times as likely to have metabolic syndrome compared with those having high PA. Body mass index (BMI) is a mediating factor in the association between level of PA and metabolic syndrome.ConclusionSome PA is better than none if adults, particularly women, are to reduce their risk of metabolic syndrome and associated vascular diseases. Specialised interventions that take rurality into consideration are recommended for adults who are inactive.

Predicting changes in lifestyle and clinical outcomes in preventing diabetes: the Greater Green Triangle Diabetes Prevention Project.

OBJECTIVES To analyse how psychosocial determinants of lifestyle changes targeted in the Greater Green Triangle Diabetes Prevention Project conducted in Southeast Australia in 2004-2006 predict changes in dietary behaviour and clinical risk factors. METHODS A longitudinal pre-test and post-test study design was used. The group program was completed by 237 people at high risk of type 2 diabetes. Associations between changes in the variables were examined by structural equation modelling using a path model in which changes in psychological determinants for lifestyle predicted changes in dietary behaviours (fat and fibre intake), which subsequently predicted changes in waist circumference and other clinical outcomes. Standardised regression weights are presented, with β=±0.1 and β=±0.3 representing small and medium associations, respectively. RESULTS Improvements in coping self-efficacy and planning predicted improvements in fat (β=-0.15, p<0.05 and β=-0.32, p<0.001, respectively) and fibre intake (β=0.15, p<0.05 and β=0.23, p<0.001, respectively) which in turn predicted improvements in waist circumference (β=0.18, p<0.01 and β=-0.16, p<0.05, respectively). Improvements in waist circumference predicted improvements in diastolic blood pressure (β=0.13, p<0.05), HDL (β=-0.16, p<0.05), triglycerides (β=0.17, p<0.01), and fasting glucose (β=0.15, p<0.05). CONCLUSIONS Psychological changes predicted behaviour changes, resulting in 12-month biophysical changes. The findings support the theoretical basis of the interventions.

Healthy minds for country youth: Help‐seeking for depression among rural adolescents

OBJECTIVE To assess depression recognition, barriers to accessing help from health professionals and potential sources of help for depression among rural adolescents. DESIGN Cross-sectional survey. SETTING Two rural secondary schools in south-east South Australia. PARTICIPANTS Seventy-four secondary school students aged 14 to 16 years. MAIN OUTCOME MEASURE(S) Depression recognition was measured using a depression vignette. Helpfulness of professionals, barriers to seeking help and help-seeking behaviours for depression were assessed by self-report questionnaire. RESULTS Depression was identified in the vignette by 73% (n = 54) of participants. Participants indicated that it would be more helpful for the vignette character to see other health professionals (98.6%, 95% CI, 92.0-100.0%) than a doctor (82.4%, 72.1-89.6%). Barriers to seeking help from doctors and other health professionals were categorised into logistical and personal barriers. Participants agreed more strongly to personal (mean = 2.86) than logistical barriers (mean = 2.67, P < 0.05) for seeing a doctor. Boys and girls responded differently overall, and to personal barriers to seeing an other health professional. Sources of help were divided into three categories: formal, informal and external. Informal sources of help (mean = 4.02) were identified as more helpful than both formal (mean = 3.66) and external sources (mean = 3.72, P < 0.001). Gender differences were observed within and between the three sources of help categories. CONCLUSIONS Recognising symptoms of depression was demonstrated in this study. Helpfulness of professionals, barriers to seeking help and potential sources of help for depression were identified. More work is required for improving depression literacy and providing effective interventions specifically for rural adolescents.

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. Design Comparison of (1) CVD risk measures between a regional (Greater Green Triangle Risk Factor Study (GGT RFS, cross-sectional study, 2004–2006) and an urban population (North West Adelaide Health Study (NWAHS, longitudinal cohort study, 2004–2006); (2) Australian Bureau of Statistics (ABS) CVD mortality rates between these and other Australian regions; and (3) ABS CVD mortality rates by an area-level indicator of socioeconomic status, the Index of Relative Socioeconomic Disadvantage (IRSD). Setting Greater Green Triangle (GGT, Limestone Coast, Wimmera and Corangamite Shires) of South-Western Victoria and North-West Adelaide (NWA). Participants 1563 GGT RFS and 3036 NWAHS stage 2 participants (aged 25–74) provided some information (self-administered questionnaire +/− anthropometric and biomedical measurements). Primary and secondary outcome measures Age-group specific measures of absolute CVD risk, ABS CVD mortality rates by study group and Australian Standard Geographical Classification (ASGC) region. Results Few significant differences in CVD risk between the study regions, with absolute CVD risk ranging from approximately 5% to 30% in the 35–39 and 70–74 age groups, respectively. Similar mean 2003–2007 (crude) mortality rates in GGT (98, 95% CI 87 to 111), NWA (103, 95% CI 96 to 110) and regional Australia (92, 95% CI 91 to 94). NWA mortality rates exceeded that of other city areas (70, 95% CI 69 to 71). Lower measures of socioeconomic status were associated with worse CVD outcomes regardless of geographic location. Conclusions Metropolitan areas do not always have better CVD risk factor profiles and outcomes than rural/regional areas. Needs assessments are required for different settings to elucidate relative contributions of the multiple determinants of risk and appropriate cardiac healthcare strategies to improve outcomes.

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk

INTRODUCTION Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD). OBJECTIVE This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors. DESIGN, SETTING AND PARTICIPANTS Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self-administered health questionnaire. Overall, 1500 were invited to participate. RESULTS The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone. CONCLUSION Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.

Physical activity behaviours of adults in the Greater Green Triangle region of rural Australia

OBJECTIVE To assess physical activity (PA) behaviours of adults in rural Australia. DESIGN AND SETTING Three cross-sectional surveys in the Greater Green Triangle area covering the south-east of South Australia (Limestone Coast), and south-west (Corangamite Shire) and north-west (Wimmera) of Victoria during 2004-2006. PARTICIPANTS A total of 1546 persons, aged 25- 74 years, randomly selected from the electoral roll. MAIN OUTCOME MEASURES Overall PA, leisure-time PA, occupational PA, active commuting and moderate-to-vigorous PA. RESULTS Approximately 80% of participants, more women than men, engaged in 30 minutes or more of daily PA. Only 30% (95% CI 26.3, 33.0) of men and 21% (95% CI 18.3, 23.9) of women did moderate-to-vigorous PA for at least 20-30 minutes four or more times a week. In leisure time, most participants were moderately active; almost one-fifth were inactive and another fifth highly active. Two-thirds of men engaged in high-level occupational PA, compared with one-sixth of women. Only 30% of participants actively commuted to work. There was a tendency for a positive association between income level and leisure-time PA. CONCLUSIONS One-fifth of adults in rural Australia were inactive. While there was a high prevalence of participants who engaged in daily PA, few did so at moderate-to-vigorous intensity to achieve health benefits. As occupational PA is difficult to change, improvements in levels of PA are more likely during leisure-time and for some people by engaging in commuting PA.