Rebecca Muckelbauer

Physical Activity and Mortality in Individuals With Diabetes Mellitus: A Prospective Study and Meta-analysis.

BACKGROUND Physical activity (PA) is considered a cornerstone of diabetes mellitus management to prevent complications, but conclusive evidence is lacking. METHODS This prospective cohort study and meta-analysis of existing studies investigated the association between PA and mortality in individuals with diabetes. In the EPIC study (European Prospective Investigation Into Cancer and Nutrition), a cohort was defined of 5859 individuals with diabetes at baseline. Associations of leisure-time and total PA and walking with cardiovascular disease (CVD) and total mortality were studied using multivariable Cox proportional hazards regression models. Fixed- and random-effects meta-analyses of prospective studies published up to December 2010 were pooled with inverse variance weighting. RESULTS In the prospective analysis, total PA was associated with lower risk of CVD and total mortality. Compared with physically inactive persons, the lowest mortality risk was observed in moderately active persons: hazard ratios were 0.62 (95% CI, 0.49-0.78) for total mortality and 0.51 (95% CI, 0.32-0.81) for CVD mortality. Leisure-time PA was associated with lower total mortality risk, and walking was associated with lower CVD mortality risk. In the meta-analysis, the pooled random-effects hazard ratio from 5 studies for high vs low total PA and all-cause mortality was 0.60 (95% CI, 0.49-0.73). CONCLUSIONS Higher levels of PA were associated with lower mortality risk in individuals with diabetes. Even those undertaking moderate amounts of activity were at appreciably lower risk for early death compared with inactive persons. These findings provide empirical evidence supporting the widely shared view that persons with diabetes should engage in regular PA.

Association between sudden infant death syndrome and diphtheria-tetanus-pertussis immunisation: an ecological study

BackgroundSudden infant death syndrome (SIDS) continues to be one of the main causes of infant mortality in the United States. The objective of this study was to analyse the association between diphtheria-tetanus-pertussis (DTP) immunisation and SIDS over time.MethodsThe Centers for Disease Control and Prevention provided the number of cases of SIDS and live births per year (1968–2009), allowing the calculation of SIDS mortality rates. Immunisation coverage was based on (1) the United States Immunization Survey (1968–1985), (2) the National Health Interview Survey (1991–1993), and (3) the National Immunization Survey (1994–2009). We used sleep position data from the National Infant Sleep Position Survey. To determine the time points at which significant changes occurred and to estimate the annual percentage change in mortality rates, we performed joinpoint regression analyses. We fitted a Poisson regression model to determine the association between SIDS mortality rates and DTP immunisation coverage (1975–2009).ResultsSIDS mortality rates increased significantly from 1968 to 1971 (+27% annually), from 1971 to 1974 (+47%), and from 1974 to 1979 (+3%). They decreased from 1979 to 1991 (−1%) and from 1991 to 2001 (−8%). After 2001, mortality rates remained constant. DTP immunisation coverage was inversely associated with SIDS mortality rates. We observed an incidence rate ratio of 0.92 (95% confidence interval: 0.87 to 0.97) per 10% increase in DTP immunisation coverage after adjusting for infant sleep position.ConclusionsIncreased DTP immunisation coverage is associated with decreased SIDS mortality. Current recommendations on timely DTP immunisation should be emphasised to prevent not only specific infectious diseases but also potentially SIDS.

Longitudinal Association between Body Mass Index and Health-Related Quality of Life

Objective Health-related quality of life (HRQoL) is an important outcome in individuals with a high risk for cardiovascular diseases. We investigated the association of HRQoL and body mass index (BMI) as an indicator for obesity. Design Secondary longitudinal analysis of the ORBITAL study, an intervention study which included high-risk cardiovascular primary care patients with hypercholesterolemia and an indication for statin therapy. Methods HRQoL was determined with the generic Short Form (SF)-12 health status instrument. Body weight and height were assessed at baseline and at months 6, 12, 18, 24, 30, and 36. We used a linear and a linear mixed-effects regression model to investigate the association between BMI and SF-12 summary scores at baseline as well as between change in BMI and SF-12 summary scores over 3 years. We adjusted for age, sex, smoking status, and in the longitudinal analysis also for the study arm and its interaction term with time. Results Of the 7640 participants who completed the baseline questionnaire, 6726 participants (mean age: 61 years) were analyzed. The baseline BMI was inversely associated with physical and mental SF-12 summary scores (β [95% CI] per 1 kg/m2: −0.36 [−0.41; −0.30] and −0.05 [−0.11; −0.00], respectively). A significant association between the change in BMI and physical SF-12 summary scores over time was only present in women (−0.18 [−0.27; −0.09]) and only in obese participants (−0.19 [−0.29; −0.10]). A change in BMI was directly associated with mental SF-12 summary scores (0.12 [0.06; 0.19]) in the total population. Conclusion Increases in BMI were associated with decreases in physical HRQoL, particularly in obese individuals and in women. In contrast, the mental HRQoL seemed to increase with increasing BMI over time. Thus, body weight management with respect to the HRQoL should be evaluated differentially by sex and body weight status. Trial Registration ClinicalTrials.gov NCT00379249

Toxic trace elements in maternal and cord blood and social determinants in a Bolivian mining city

This study assessed lead, arsenic, and antimony in maternal and cord blood, and associations between maternal concentrations and social determinants in the Bolivian mining city of Oruro using the baseline assessment of the ToxBol/Mine-Niño birth cohort. We recruited 467 pregnant women, collecting venous blood and sociodemographic information as well as placental cord blood at birth. Metallic/semimetallic trace elements were measured using inductively coupled plasma mass spectrometry. Lead medians in maternal and cord blood were significantly correlated (Spearman coefficient = 0.59; p < 0.001; 19.35 and 13.50 μg/L, respectively). Arsenic concentrations were above detection limit (3.30 μg/L) in 17.9 % of maternal and 34.6 % of cord blood samples. They were not associated (Fischer’s p = 0.72). Antimony medians in maternal and cord blood were weakly correlated (Spearman coefficient = 0.15; p < 0.03; 9.00 and 8.62 μg/L, respectively). Higher concentrations of toxic elements in maternal blood were associated with maternal smoking, low educational level, and partner involved in mining.

Primary prevention in general practice - views of German general practitioners: a mixed-methods study.

BackgroundPolicy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners’ (GPs) attitudes toward primary prevention.MethodsMixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention.ResultsMost respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs’ health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of “health policing”. GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions.ConclusionsThe mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.

Changes in water and sugar-containing beverage consumption and body weight outcomes in children

An intervention study showed that promoting water consumption in schoolchildren prevented overweight, but a mechanism linking water consumption to overweight was not substantiated. We investigated whether increased water consumption replaced sugar-containing beverages and whether changes in water or sugar-containing beverages influenced body weight outcomes. In a secondary analysis of the intervention study in Germany, we analysed combined longitudinal data from the intervention and control groups. Body weight and height were measured and beverage consumption was self-reported by a 24-h recall questionnaire at the beginning and end of the school year 2006/2007. The effect of a change in water consumption on change in sugar-containing beverage (soft drinks and juices) consumption, change in BMI (kg/m2) and prevalence of overweight and obesity at follow-up was analysed using regression analyses. Of 3220 enroled children, 1987 children (mean age 8·3 (sd 0·7) years) from thirty-two schools were analysed. Increased water consumption by 1 glass/d was associated with a reduced consumption of sugar-containing beverages by 0·12 glasses/d (95 % CI -0·16, -0·08) but was not associated with changes in BMI (P=0·63). Increased consumption of sugar-containing beverages by 1 glass/d was associated with an increased BMI by 0·02 (95 % CI 0·00, 0·03) kg/m2 and increased prevalence of obesity (OR 1·22; 95 % CI 1·04, 1·44) but not with overweight (P=0·83). In conclusion, an increase in water consumption can replace sugar-containing beverages. As sugar-containing beverages were associated with weight gain, this replacement might explain the prevention of obesity through the promotion of water consumption.

Association between water consumption and body weight outcomes in children and adolescents: a systematic review.

Water is recommended to replace sugar‐containing beverages for prevention of childhood obesity. Because this recommendation is not evidence‐based yet, the existing evidence on the association between water consumption and body weight outcomes was summarized.

Ansätze der Übergewichtsprävention durch verbessertes Trinkverhalten im Setting Grundschule

ZusammenfassungIm Bereich der Übergewichtsprävention bei Kindern fehlt es immer noch an nachweislich wirksamen Maßnahmen. Bislang beinhalteten Programme oft nur Maßnahmen der Verhaltensprävention, obwohl die Kombination mit der Verhältnisprävention, die am adipogenen Umfeld ansetzt, bedeutsam für nachhaltige Erfolge scheint. Ein modifizierbarer Faktor bei der Gewichtsentwicklung ist das Trinkverhalten von Kindern. Hier anzusetzen gilt als vielversprechend zur Übergewichtsprävention. Diese Präventionsansätze wurden in der „trinkfit“-Studie kombiniert und auf ihre Wirksamkeit sowie Umsetzbarkeit in einer kontrollierten Interventionsstudie überprüft. Die Intervention zur Übergewichtsprävention zielte allein auf die Erhöhung des Wasserverzehrs bei Grundschulkindern und beinhaltete eine Unterrichtsreihe zum Thema „Wasser“ (Verhaltensprävention) sowie die Bereitstellung von Wasserspendern und Trinkflaschen (Verhältnisprävention). Nach einem Schuljahr war das Risiko für Übergewicht in der Interventionsgruppe reduziert. Dieser präventive Effekt war allerdings bei Kindern mit Migrationshintergrund nicht nachweisbar. Die Prozessevaluation deutet darauf hin, dass die kombinierten Maßnahmen zur Erhöhung des Wasserverzehrs zudem auch nachhaltig und umsetzbar im Setting Schule waren.AbstractThere is still little evidence for effective interventions that prevent childhood overweight. A number of behavioral interventions have been implemented, but in order to achieve sustainable preventive effects, they should be combined with environmental interventions which target the obesogenic environment. A modifiable obesogenic factor is beverage consumption and targeting this behavior seems promising to prevent overweight in children. The behavioral and environmental approaches were combined in the “trinkfit” study, and effectiveness and feasibility were tested in a controlled intervention study. In order to prevent overweight, the intervention focused on increased water consumption of children in elementary schools. The intervention consisted of lessons on water given by the teachers (behavioral intervention) and the provision of water fountains and water bottles (environmental intervention). After one school year, the intervention had been effective in decreasing the risk of overweight in the children of the intervention group. However, this preventive effect was not observed among children with an immigrant background. Process evaluation results indicate that the combined intervention focusing on increased water consumption was sustainable and feasible in the school setting.

[Approaches for the prevention of overweight through modified beverage consumption in the elementary school setting. The "trinkfit" study].

ZusammenfassungIm Bereich der Übergewichtsprävention bei Kindern fehlt es immer noch an nachweislich wirksamen Maßnahmen. Bislang beinhalteten Programme oft nur Maßnahmen der Verhaltensprävention, obwohl die Kombination mit der Verhältnisprävention, die am adipogenen Umfeld ansetzt, bedeutsam für nachhaltige Erfolge scheint. Ein modifizierbarer Faktor bei der Gewichtsentwicklung ist das Trinkverhalten von Kindern. Hier anzusetzen gilt als vielversprechend zur Übergewichtsprävention. Diese Präventionsansätze wurden in der „trinkfit“-Studie kombiniert und auf ihre Wirksamkeit sowie Umsetzbarkeit in einer kontrollierten Interventionsstudie überprüft. Die Intervention zur Übergewichtsprävention zielte allein auf die Erhöhung des Wasserverzehrs bei Grundschulkindern und beinhaltete eine Unterrichtsreihe zum Thema „Wasser“ (Verhaltensprävention) sowie die Bereitstellung von Wasserspendern und Trinkflaschen (Verhältnisprävention). Nach einem Schuljahr war das Risiko für Übergewicht in der Interventionsgruppe reduziert. Dieser präventive Effekt war allerdings bei Kindern mit Migrationshintergrund nicht nachweisbar. Die Prozessevaluation deutet darauf hin, dass die kombinierten Maßnahmen zur Erhöhung des Wasserverzehrs zudem auch nachhaltig und umsetzbar im Setting Schule waren.AbstractThere is still little evidence for effective interventions that prevent childhood overweight. A number of behavioral interventions have been implemented, but in order to achieve sustainable preventive effects, they should be combined with environmental interventions which target the obesogenic environment. A modifiable obesogenic factor is beverage consumption and targeting this behavior seems promising to prevent overweight in children. The behavioral and environmental approaches were combined in the “trinkfit” study, and effectiveness and feasibility were tested in a controlled intervention study. In order to prevent overweight, the intervention focused on increased water consumption of children in elementary schools. The intervention consisted of lessons on water given by the teachers (behavioral intervention) and the provision of water fountains and water bottles (environmental intervention). After one school year, the intervention had been effective in decreasing the risk of overweight in the children of the intervention group. However, this preventive effect was not observed among children with an immigrant background. Process evaluation results indicate that the combined intervention focusing on increased water consumption was sustainable and feasible in the school setting.

European accreditation and the future public health workforce

BACKGROUND In 2011 the Agency for Public Health Education Accreditation (APHEA) was initially launched focusing on Master level (second cycle) education. METHODS Between 2012 and 2013 the Association of Schools of Public Health in the European Region, APHEA and partner schools conducted a study on the compliance of Master level programmes of public health to the accreditation criteria. A web-based survey of second cycle programmes of public health across 29 countries was conducted using the APHEA criteria. The 29 countries were categorized into four regions: Northern, Southern, Central and Eastern and Western. We applied a Chi square test to identify regional differences with regard to the compliance of the programmes to the criteria. RESULTS Data from 51 out of 71 schools contacted were analyzed. The compliance to the two themes of student and faculty exchange and quality management were lowest for programmes of public health throughout the EHEA. There were significant differences in the compliance between the regions with higher compliance in the Northern European region. CONCLUSIONS Student and faculty exchange and quality management are essential for schools and programmes of public health to improve the quality of their education through expanding international knowledge and the pertinence of skills taught within European and national contexts. The results show that there are intrinsic issues with exchange and quality management as well as the role of national accreditation agencies in defining public health education for the future workforce.