N. J. Wareham

Diabetes risk score: towards earlier detection of Type 2 diabetes in general practice

Type 2 diabetes is common, costly and often goes unrecognised for many years. When patients are diagnosed, the majority exhibit associated tissue damage or established cardiovascular risk. Evidence is accumulating that earlier detection and management of diabetes and related metabolic abnormalities may be beneficial. We aimed to develop and evaluate a score based on routinely collected information to identify people at risk of having undetected diabetes.

Interventions to prevent weight gain: a systematic review of psychological models and behaviour change methods.

OBJECTIVE: To identify and review published interventions aimed at the prevention of weight gain.DESIGN: A systematic review of published interventions aimed at the prevention of weight gain.METHODS: Search strategies—we searched eight databases, manually checked reference lists and contacted authors. Inclusion and exclusion criteria—studies of any design, in which participants were selected regardless of weight or age, were included. Interventions targeting a specific subgroup, multifactorial interventions, interventions aimed at weight loss, and those with an ambiguous aim were excluded. Data extraction—data were extracted on behaviours targeted for change, psychological model, behaviour change methods and modes of delivery, methodological quality, characteristics of participants, and outcomes related to body weight and self-reported diet and physical activity. Classification and validation—a taxonomy of behaviour change programmes was developed and used for classification of underlying model, behaviour change methods, and modes of delivery. The data extraction and subsequent classification were independently validated.RESULTS: Eleven publications were included, describing five distinct interventions in schools and four in the wider community. Where diet and physical activity were described, positive effects were usually obtained, but all were measured by self-report. Effects on weight were mixed but follow-up was generally short. Smaller effects on weight gain were found among low-income participants, students and smokers. Many participants in the community-based studies were overweight or obese. Study dropout was higher among thinner and lower-income subjects.CONCLUSION: Interventions to prevent weight gain exhibited various degrees of effectiveness. Definite statements about the elements of the interventions that were associated with increased effect size cannot be made as only one of the five studies that involved an RCT design reported a significant effect on weight. This intervention involved a correspondence programme and a mix of behaviour change methods including goal setting, self-monitoring and contingencies. Future interventions might be more effective if they were explicitly based on methods of behaviour change that have been shown to work in other contexts. Effective interventions would be more easily replicated if they were explicitly described. Effectiveness might be more precisely demonstrated if more objective measures of physical activity and diet were used, and if the follow-up was over a longer period.

Dietary fiber and subsequent changes in body weight and waist circumference in European men and women

BACKGROUND Dietary fiber may play a role in obesity prevention. Until now, the role that fiber from different sources plays in weight change had rarely been studied. OBJECTIVE Our aim was to investigate the association of total dietary fiber, cereal fiber, and fruit and vegetable fiber with changes in weight and waist circumference. DESIGN We conducted a prospective cohort study with 89,432 European participants, aged 20-78 y, who were free of cancer, cardiovascular disease, and diabetes at baseline and who were followed for an average of 6.5 y. Dietary information was collected by using validated country-specific food-frequency questionnaires. Multiple linear regression analysis was performed in each center studied, and estimates were combined by using random-effects meta-analyses. Adjustments were made for follow-up duration, other dietary variables, and baseline anthropometric, demographic, and lifestyle factors. RESULTS Total fiber was inversely associated with subsequent weight and waist circumference change. For a 10-g/d higher total fiber intake, the pooled estimate was -39 g/y (95% CI: -71, -7 g/y) for weight change and -0.08 cm/y (95% CI: -0.11, -0.05 cm/y) for waist circumference change. A 10-g/d higher fiber intake from cereals was associated with -77 g/y (95% CI: -127, -26 g/y) weight change and -0.10 cm/y (95% CI: -0.18, -0.02 cm/y) waist circumference change. Fruit and vegetable fiber was not associated with weight change but had a similar association with waist circumference change when compared with intake of total dietary fiber and cereal fiber. CONCLUSION Our finding may support a beneficial role of higher intake of dietary fiber, especially cereal fiber, in prevention of body-weight and waist circumference gain.

Physical activity and dietary behaviour in a population-based sample of British 10-year old children: the SPEEDY study (Sport, Physical activity and Eating behaviour: environmental Determinants in Young people).

BackgroundThe SPEEDY study was set up to quantify levels of physical activity (PA) and dietary habits and the association with potential correlates in 9–10 year old British school children. We present here the analyses of the PA, dietary and anthropometry data.MethodsIn a cross-sectional study of 2064 children (926 boys, 1138 girls) in Norfolk, England, we collected anthropometry data at school using standardised procedures. Body mass index (BMI) was used to define obesity status. PA was assessed with the Actigraph accelerometer over 7 days. A cut-off of ≥ 2000 activity counts was used to define minutes of moderate-to-vigorous PA (MVPA). Dietary habits were assessed using the Health Behaviour in School Children food questionnaire. Weight status was defined using published international cut-offs (Cole, 2000). Differences between groups were assessed using independent t-tests for continuous data and chi-squared tests for categorical data.ResultsValid PA data (>500 minutes per day on ≥ 3 days) was available for 1888 children. Mean (± SD) activity counts per minute among boys and girls were 716.5 ± 220.2 and 635.6 ± 210.6, respectively (p < 0.001). Boys spent an average of 84.1 ± 25.9 minutes in MVPA per day compared to 66.1 ± 20.8 among girls (p < 0.001), with an average of 69.1% of children accumulating 60 minutes each day. The proportion of children classified as overweight and obese was 15.0% and 4.1% for boys and 19.3% and 6.6% for girls, respectively (p = 0.001). Daily consumption of at least one portion of fruit and of vegetables was 56.8% and 49.9% respectively, with higher daily consumption in girls than boys and in children from higher socioeconomic backgrounds.ConclusionResults indicate that almost 70% of children meet national PA guidelines, indicating that a prevention of decline, rather than increasing physical activity levels, might be an appropriate intervention target. Promotion of daily fruit and vegetable intake in this age group is also warranted, possibly focussing on children from lower socioeconomic backgrounds.

Residential area deprivation predicts smoking habit independently of individual educational level and occupational social class. A cross sectional study in the Norfolk cohort of the European Investigation into Cancer (EPIC-Norfolk)

Objectives: To investigate the independent association between individual and area based measures of socioeconomic status and cigarette smoking habit. Design and setting: Cross sectional, population based study. Participants and methods: 12 579 men and 15 132 women aged 39–79 years living in the general community participating in the EPIC-Norfolk Study in 1993–1997. The association between social class, educational status, Townsend residential deprivation level, and cigarette smoking status was examined. Main outcome measures: Cigarette smoking status at baseline survey. Results: Social class, educational level, and residential deprivation level independently related to cigarette smoking habit in both men and women. Multivariate age adjusted odds ratios for current smoking in men were 1.62 (95% CI 1.45 to 1.81) for manual compared with non-manual social class, 1.32 (95% CI 1.17 to 1.48) for those with educational level less than O level compared with those with O level qualifications or higher and 1.84 (95% CI 1.62 to 2.08) for high versus low area deprivation level. For women, the odds ratios for current smoking for manual social class were 1.14 (95% CI 1.03 to 1.27); 1.31 (95% CI 1.18 to 1.46) for low educational level and 1.68 (95% CI 1.49 to 1.90) for high residential deprivation respectively. Conclusions: Residential deprivation level using the Townsend score, individual social class, and educational level all independently predict smoking habit in both men and women. Efforts to reduce cigarette smoking need to tackle not just individual but also area based factors. Understanding the specific factors in deprived areas that influence smoking habit may help inform preventive efforts.

Circulating 25-hydroxyvitamin D concentration and the risk of type 2 diabetes: results from the European Prospective Investigation into Cancer (EPIC)-Norfolk cohort and updated meta-analysis of prospective studies

Aims/hypothesisEpidemiological evidence is suggestive, but limited, for an association between circulating 25-hydroxyvitamin D (25[OH]D) and risk of type 2 diabetes. We conducted a systematic review and meta-analysis that included new data from previously unpublished studies.MethodsUsing a nested case–cohort design in the European Prospective Investigation into Cancer (EPIC)-Norfolk study, we identified a random subcohort and incident type 2 diabetes cases occurring between baseline (1993–1997) and 2006. In the Ely prospective study we identified incident type 2 diabetes cases between 1990 and 2003. We conducted a systematic review of prospective studies on 25(OH)D and type 2 diabetes published in MEDLINE or EMBASE until 31 January 2012, and performed a random-effects meta-analysis combining available evidence with results from the EPIC-Norfolk and Ely studies.ResultsIn EPIC-Norfolk, baseline 25(OH)D was lower among incident type 2 diabetes cases (mean [SD] 61.6 [22.4] nmol/l; n = 621) vs non-case subcohort participants (mean 65.3 [23.9] nmol/l; n = 826). There was an inverse association between baseline 25(OH)D and incident type 2 diabetes in multivariable-adjusted analyses: HR (95% CI) 0.66 (0.45, 0.97), 0.53 (0.34, 0.82), 0.50 (0.32, 0.76), p trend <0.001, comparing consecutive increasing 25(OH)D quartiles with the lowest. In Ely, 37 incident type 2 diabetes cases were identified among 777 participants. In meta-analysis, the combined RR of type 2 diabetes comparing the highest with lowest quartile of 25(OH)D was 0.59 (0.52, 0.67), with little heterogeneity (I2 = 2.7%, p = 0.42) between the 11 studies included (3,612 cases and 55,713 non-cases).Conclusions/interpretationThese findings demonstrate an inverse association between circulating 25(OH)D and incident type 2 diabetes. However, causal inference should be addressed through adequately dosed randomised trials of vitamin D supplementation or genetic Mendelian randomisation experiments.

The hypertriglyceridemic-waist phenotype and the risk of coronary artery disease: results from the EPIC-Norfolk Prospective Population Study

Background: Screening for increased waist circumference and hypertriglyceridemia (the hypertriglyceridemic-waist phenotype) has been proposed as an inexpensive approach to identify patients with excess intra-abdominal adiposity and associated metabolic abnormalities. We examined the relationship between the hypertriglyceridemic-waist phenotype to the risk of coronary artery disease in apparently healthy individuals. Methods: A total of 21 787 participants aged 45–79 years were followed for a mean of 9.8 (standard deviation 1.7) years. Coronary artery disease developed in 2109 of them during follow-up. The hypertriglyceridemic-waist phenotype was defined as a waist circumference of 90 cm or more and a triglyceride level of 2.0 mmol/L or more in men, and a waist circumference of 85 cm or more and a triglyceride level of 1.5 mmol/L or more in women. Results: Compared with participants who had a waist circumference and triglyceride level below the threshold, those with the hypertriglyceridemic-waist phenotype had higher blood pressure indices, higher levels of apolipoprotein B and C-reactive protein, lower levels of high-density lipoprotein cholesterol and apolipoprotein A-I, and smaller low-density lipoprotein particles. Among men, those with the hypertriglyceridemic-waist phenotype had an unadjusted hazard ratio for future coronary artery disease of 2.40 (95% confidence interval [CI] 2.02–2.87) compared with men who did not have the phenotype. Women with the phenotype had an unadjusted hazard ratio of 3.84 (95% CI 3.20–4.62) compared with women who did not have the phenotype. Interpretation: Among participants from a European cohort representative of a contemporary Western population, the hypertriglyceridemic-waist phenotype was associated with a deteriorated cardiometabolic risk profile and an increased risk for coronary artery disease.

Fat distribution, body mass index and blood pressure in 22,090 men and women in the Norfolk cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk) study.

Objective To determine the relation between fat distribution and blood pressure, independent of body mass index. Design Cross-sectional, population-based study. Participants and methods Participants, 9936 men and 12 154 women aged 45–79 years, were recruited from general practices in Norfolk, United Kingdom for the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk) study. Participants filled in a health and lifestyle questionnaire and their blood pressure and anthropometry were measured at a clinic. We mainly used waist–hip ratio (WHR) to assess body fat distribution. Results Systolic blood pressure (SBP) and diastolic blood pressure (DBP) increased linearly across the whole range of waist–hip ratio in both men and women. The relation was independent of age, body mass index (BMI) and other covariates. Separately, waist and hip circumferences were positively related to SBP and DBP. When adjusted for BMI, waist circumference was positively related to SBP (in women) and DBP (in both men and women), whereas hip circumference was inversely related to SBP (but not DBP) in both men and women. Stratifying by tertiles of waist and hip circumference, age- and BMI-adjusted SBP and DBP were highest among those with high waist and small hip circumference measures. Conclusion Waist–hip ratio was independently related to blood pressure. Waist–hip ratio could reflect the separate and opposite relations of waist and hip circumferences on blood pressure. Characterizing patterns of fat distribution may have implications in the assessment and control of obesity-related blood pressure elevation.

Objectively measured physical activity correlates with indices of insulin resistance in Danish children. The European Youth Heart Study (EYHS)

OBJECTIVE: To explore the association between measures of insulin resistance with objectively assessed physical activity.DESIGN: School-based, cross-sectional study.SUBJECTS: A randomly selected sample of 589 children (310 girls, 279 boys, mean (standard deviations, s.d.) age=9.7 (0.44) y, weight=33.6 (6.4) kg, height=1.39 (0.06) m) from Denmark.METHODS: Fasting blood samples were analysed for serum insulin and glucose. Physical activity was measured with the uniaxial Computer Science and Applications (CSA) model 7164 accelerometer, worn for at least 3 days (≥10 h day−1). Adiposity was assessed by the sum of four skinfolds. Multiple linear regression were performed to model insulin and glucose from average CSA output, adjusted for age, gender, puberty, ethnicity, birth weight, parental smoking, socioeconomic group, and CSA unit. In addition, we adjusted for skinfold thickness.RESULTS: Mean fasting serum glucose ranged from 4.1 to 6.5 mmol l−1 with a mean (s.d.) of 5.1 (0.37) mmol l−1. Fasting insulin was negatively correlated with CSA output on levels of adjustment. Fasting glucose was not significantly associated with physical activity. However, in girls both indices of insulin resistance were significantly related to activity, whereas in boys none of the associations were significant.CONCLUSION: Physical activity is inversely associated with fasting insulin in the nondiabetic range of fasting glucose. The relationship was stronger for insulin than for glucose, indicating compensatory action by the β cells. Our data emphasise the importance of physical activity in children for the maintenance of metabolic control.

Adherence to the mediterranean diet and risk of breast cancer in the European prospective investigation into cancer and nutrition cohort study

Epidemiological evidence suggests that the Mediterranean diet (MD) could reduce the risk of breast cancer (BC). As evidence from the prospective studies remains scarce and conflicting, we investigated the association between adherence to the MD and risk of BC among 335,062 women recruited from 1992 to 2000, in ten European countries, and followed for 11 years on average. Adherence to the MD was estimated through an adapted relative Mediterranean diet (arMED) score excluding alcohol. Cox proportional hazards regression models were used while adjusting for BC risk factors. A total of 9,009 postmenopausal and 1,216 premenopausal first primary incident invasive BC were identified (5,862 estrogen or progesterone receptor positive [ER+/PR+] and 1,018 estrogen and progesterone receptor negative [ER−/PR−]). The arMED was inversely associated with the risk of BC overall and in postmenopausal women (high vs. low arMED score; hazard ratio [HR] = 0.94 [95% confidence interval [CI]: 0.88, 1.00] ptrend = 0.048, and HR = 0.93 [95% CI: 0.87, 0.99] ptrend = 0.037, respectively). The association was more pronounced in ER−/PR− tumors (HR = 0.80 [95% CI: 0.65, 0.99] ptrend = 0.043). The arMED score was not associated with BC in premenopausal women. Our findings show that adherence to a MD excluding alcohol was related to a modest reduced risk of BC in postmenopausal women, and this association was stronger in receptor‐negative tumors. The results support the potential scope for BC prevention through dietary modification.