Vera J. C. McCarthy

Defining Metabolically Healthy Obesity: Role of Dietary and Lifestyle Factors

Background There is a current lack of consensus on defining metabolically healthy obesity (MHO). Limited data on dietary and lifestyle factors and MHO exist. The aim of this study is to compare the prevalence, dietary factors and lifestyle behaviours of metabolically healthy and unhealthy obese and non-obese subjects according to different metabolic health criteria. Method Cross-sectional sample of 1,008 men and 1,039 women aged 45-74 years participated in the study. Participants were classified as obese (BMI ≥30kg/m2) and non-obese (BMI <30kg/m2). Metabolic health status was defined using five existing MH definitions based on a range of cardiometabolic abnormalities. Dietary composition and quality, food pyramid servings, physical activity, alcohol and smoking behaviours were examined. Results The prevalence of MHO varied considerably between definitions (2.2% to 11.9%), was higher among females and generally increased with age. Agreement between MHO classifications was poor. Among the obese, prevalence of MH was 6.8% to 36.6%. Among the non-obese, prevalence of metabolically unhealthy subjects was 21.8% to 87%. Calorie intake, dietary macronutrient composition, physical activity, alcohol and smoking behaviours were similar between the metabolically healthy and unhealthy regardless of BMI. Greater compliance with food pyramid recommendations and higher dietary quality were positively associated with metabolic health in obese (OR 1.45-1.53 unadjusted model) and non-obese subjects (OR 1.37-1.39 unadjusted model), respectively. Physical activity was associated with MHO defined by insulin resistance (OR 1.87, 95% CI 1.19-2.92, p = 0.006). Conclusion A standard MHO definition is required. Moderate and high levels of physical activity and compliance with food pyramid recommendations increase the likelihood of MHO. Stratification of obese individuals based on their metabolic health phenotype may be important in ascertaining the appropriate therapeutic or intervention strategy.

Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism

BACKGROUND The use of levothyroxine to treat subclinical hypothyroidism is controversial. We aimed to determine whether levothyroxine provided clinical benefits in older persons with this condition. METHODS We conducted a double‐blind, randomized, placebo‐controlled, parallel‐group trial involving 737 adults who were at least 65 years of age and who had persisting subclinical hypothyroidism (thyrotropin level, 4.60 to 19.99 mIU per liter; free thyroxine level within the reference range). A total of 368 patients were assigned to receive levothyroxine (at a starting dose of 50 μg daily, or 25 μg if the body weight was <50 kg or the patient had coronary heart disease), with dose adjustment according to the thyrotropin level; 369 patients were assigned to receive placebo with mock dose adjustment. The two primary outcomes were the change in the Hypothyroid Symptoms score and Tiredness score on a thyroid‐related quality‐of‐life questionnaire at 1 year (range of each scale is 0 to 100, with higher scores indicating more symptoms or tiredness, respectively; minimum clinically important difference, 9 points). RESULTS The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women. The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year, this level had decreased to 5.48 mIU per liter in the placebo group, as compared with 3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg. We found no differences in the mean change at 1 year in the Hypothyroid Symptoms score (0.2±15.3 in the placebo group and 0.2±14.4 in the levothyroxine group; between‐group difference, 0.0; 95% confidence interval [CI], ‐2.0 to 2.1) or the Tiredness score (3.2±17.7 and 3.8±18.4, respectively; between‐group difference, 0.4; 95% CI, ‐2.1 to 2.9). No beneficial effects of levothyroxine were seen on secondary‐outcome measures. There was no significant excess of serious adverse events prespecified as being of special interest. CONCLUSIONS Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism. (Funded by European Union FP7 and others; TRUST ClinicalTrials.gov number, NCT01660126.)

Perceived occupational stress in nurses working in Ireland

BACKGROUND Stress has been seen as a routine and accepted part of the health care workers role. There is a lack of research on stress in nurses in Ireland. AIMS To examine the levels of stress experienced by nurses working in an Irish teaching hospital and investigate differences in perceived stress levels by ward area and associations with work characteristics. METHODS A cross-sectional study design was employed, with a two-stage cluster sampling process. Data collection was by means of a self-administered questionnaire, and nurses were investigated across 10 different wards using the Nursing Stress Scale and the Demand Control Support Scales. RESULTS The response rate was 62%. Using outpatients as a reference ward, perceived stress levels were found to be significantly higher in the medical ward, accident and emergency, intensive care unit and paediatric wards (P < 0.05). There was no significant difference between the wards with regard to job strain; however, differences did occur with levels of support, the day unit and paediatric ward reporting the lowest level of supervisor support (P < 0.01). A significant association was seen between the wards and perceived stress even after adjustment (P < 0.05). CONCLUSIONS The findings suggest that perceived stress does vary within different work areas in the same hospital. Work factors, such as demand and support, are important with regard to perceived stress. Job control was not found to play an important role.

DASH Diet Score and Distribution of Blood Pressure in Middle-Aged Men and Women

BACKGROUND The Dietary Approaches to Stop Hypertension (DASH) Trial provides critical data on the impact of a specific diet pattern (low in salt, fat, and processed foods and high in fruit and vegetables) on blood pressure (BP). The effect of compliance with a DASH-type diet on BP in a general population sample is less well defined. We studied associations between a DASH style diet and BP. METHODS We used cross-sectional data from a study of men and women aged 47-73 years (n = 2,047). Participants completed a physical examination that included 3 standardized clinical BP recordings. A subsample (n = 1,187) had ambulatory BP measurements (ABPM) taken. Diet was assessed using a DASH dietary score constructed from a standard Food Frequency Questionnaire. Lower scores indicated less healthy diets. Hypertension was defined as clinic BP ≥ 140/90 mm Hg on medication or as 24-hour ABPM ≥ 130/80 mmHg. RESULTS Inverse associations were evident between DASH and systolic BP (SBP). There was a difference in clinic SBP of 7.5 mm Hg and 5.1 mm Hg and a difference in ABPM SBP of 6.3mm Hg and 5.4mm Hg in men and women, respectively, between the highest and lowest DASH quintiles. In fully adjusted multivariable regression analysis, DASH score was inversely associated with SBP. Clear population differences in SBP were evident across DASH quintiles. CONCLUSIONS The observed associations indicate that the findings are consistent with the hypothesis that adherence to DASH-equivalent diet can reduce BP at the population level. Public policy promoting a DASH-style healthy diet could have a significant impact on population health by reducing average BP in the population.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

BACKGROUND There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people. AIM To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics. DESIGN AND SETTING Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand. METHOD The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L). RESULTS A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]). CONCLUSION GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.

Comparison of Diabetes Risk Score Estimates and Cardiometabolic Risk Profiles in a Middle-Aged Irish Population

Background To compare diabetes risk assessment tools in estimating risk of developing type 2 diabetes (T2DM) and to evaluate cardiometabolic risk profiles in a middle-aged Irish population. Methods Future risk of developing T2DM was estimated using 7 risk scores, including clinical measures with or without anthropometric, biological and lifestyle data, in the cross-sectional Mitchelstown cohort of 2,047 middle-aged men and women. Cardiometabolic phenotypes including markers of glucose metabolism, inflammatory and lipid profiles were determined. Results Estimates of subjects at risk for developing T2DM varied considerably according to the risk assessment tool used (0.3% to 20%), with higher proportions of males at risk (0–29.2% vs. 0.1–13.4%, for men and women, respectively). Extrapolated to the Irish population of similar age, the overall number of adults at high risk of developing T2DM ranges from 3,378 to 236,632. Numbers of non-optimal metabolic features were generally greater among those at high risk of developing T2DM. However, cardiometabolic profile characterisation revealed that only those classified at high risk by the Griffin (UK Cambridge) score displayed a more pro-inflammatory, obese, hypertensive, dysglycaemic and insulin resistant metabolic phenotype. Conclusions Most diabetes risk scores examined offer limited ability to identify subjects with metabolic abnormalities and at risk of developing T2DM. Our results highlight the need to validate diabetes risk scoring tools for each population studied and the potential for developing an Irish diabetes risk score, which may help to promote self awareness and identify high risk individuals and diabetes hot spots for targeted public health interventions.

Physician's Prescribing Preference as an Instrumental Variable: Exploring Assumptions Using Survey Data.

Background: Physician’s prescribing preference is increasingly used as an instrumental variable in studies of therapeutic effects. However, differences in prescribing patterns among physicians may reflect differences in preferences or in case-mix. Furthermore, there is debate regarding the possible assumptions for point estimation using physician’s preference as an instrument. Methods: A survey was sent to general practitioners (GPs) in The Netherlands, the United Kingdom, New Zealand, Ireland, Switzerland, and Germany, asking whether they would prescribe levothyroxine to eight fictitious patients with subclinical hypothyroidism. We investigated (1) whether variation in physician’s preference was observable and to what extent it was explained by characteristics of GPs and their patient populations and (2) whether the data were compatible with deterministic and stochastic monotonicity assumptions. Results: Levothyroxine prescriptions varied substantially among the 526 responding GPs. Between-GP variance in levothyroxine prescriptions (logit scale) was 9.9 (95% confidence interval: 8.0, 12) in the initial mixed effects logistic model, 8.3 (6.7, 10) after adding a fixed effect for country and 8.2 (6.6, 10) after adding GP characteristics. The occurring prescription patterns falsified the deterministic monotonicity assumption. All cases in all countries were more likely to receive levothyroxine if a different case of the same GP received levothyroxine, which is compatible with the stochastic monotonicity assumption. The data were incompatible with this assumption for a different definition of the instrument. Conclusions: Our study supports the existence of physician’s preference as a determinant in treatment decisions. Deterministic monotonicity will generally not be plausible for physician’s preference as an instrument. Depending on the definition of the instrument, stochastic monotonicity may be plausible.

Prevalence of potentially inappropriate prescribing in a subpopulation of older European clinical trial participants: a cross-sectional study.

Objectives To estimate and compare the prevalence and type of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) among community-dwelling older adults (≥65 years) enrolled to a clinical trial in three European countries. Design A secondary analysis of the Thyroid Hormone Replacement for Subclinical Hypothyroidism Trial dataset. Participants A subset of 48/80 PIP and 22/34 PPOs indicators from the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) V2 criteria were applied to prescribed medication data for 532/737 trial participants in Ireland, Switzerland and the Netherlands. Results The overall prevalence of PIP was lower in the Irish participants (8.7%) compared with the Swiss (16.7%) and Dutch (12.5%) participants (P=0.15) and was not statistically significant. The overall prevalence of PPOs was approximately one-quarter in the Swiss (25.3%) and Dutch (24%) participants and lower in the Irish (14%) participants (P=0.04) and the difference was statistically significant. The hypnotic Z-drugs were the most frequent PIP in Irish participants, (3.5%, n=4), while it was non-steroidal anti-inflammatory drug and oral anticoagulant combination, sulfonylureas with a long duration of action, and benzodiazepines (all 4.3%, n=7) in Swiss, and benzodiazepines (7.1%, n=18) in Dutch participants. The most frequent PPOs in Irish participants were vitamin D and calcium in osteoporosis (3.5%, n=4). In the Swiss and Dutch participants, they were bone antiresorptive/anabolic therapy in osteoporosis (9.9%, n=16, 8.6%, n=22) respectively. The odds of any PIP after adjusting for age, sex, multimorbidity and polypharmacy were (adjusted OR (aOR)) 3.04 (95% CI 1.33 to 6.95, P<0.01) for Swiss participants and aOR 1.74 (95% CI 0.79 to 3.85, P=0.17) for Dutch participants compared with Irish participants. The odds of any PPOs were aOR 2.48 (95% CI 1.27 to 4.85, P<0.01) for Swiss participants and aOR 2.10 (95% CI 1.11 to 3.96, P=0.02) for Dutch participants compared with Irish participants. Conclusions This study has estimated and compared the prevalence and type of PIP and PPOs among this cohort of community-dwelling older people. It demonstrated a significant difference in the prevalence of PPOs between the three populations. Further research is urgently needed into the impact of system level factors as this has important implications for patient safety, healthcare provision and economic costs.

PP08 Work Status and Blood Pressure – “A Job of Work”

Background The effect of work on blood pressure (BP) relative to a non-working status with appropriate adjustment for confounders is not well defined. High job control has been found to be associated with lower BP and with nocturnal BP dipping. However, with older workers this may be compromised. Methods A cross-sectional study was carried out on a sample of the Irish general population. In total, 2,047 males and females aged 50-69 years were recruited. Data were collected on socio-demographic factors, medication and clinic BP measurements on workers (n = 1,025) and non-workers (n = 950). A sub-sample of the participants had ambulatory blood pressure monitoring (ABPM) done (n = 1,112). Job control was measured using two scales from the Copenhagen Psychosocial Questionnaire (COPSOQ) – possibility for development and influence at work. Nocturnal systolic blood pressure (SBP) dipping was the reduction in SBP from day to night-time and was calculated using the following formula (1-asleep SBP/awake SBP)*100. Results Those who were hypertensive on the clinic and ABPM SBP readings tended to be >58 years, male, overweight/obese and taking anti-hypertensive medication. Typically workers were younger, male, had a normal body mass index and had significantly lower clinic SBP than non-workers (p≤0.02). In analysis adjusted for socio-demographic factors, there was a significant difference between workers and non-workers for SBP dipping (OR 1.69 [95% CI 1.13, 2.53], p=0.01), but not for clinic or asleep SBP. When the analysis was stratified by anti-hypertensive treatment, workers were significantly more likely than non-workers to have a high clinic SBP (1.45 [1.00, 2.11]) and SBP dipping (2.07 [1.19, 3.61]). Looking only at workers, those who were on anti-hypertensive treatment with a high possibility for development were three times more likely to be SBP dippers than those with a low possibility for development (p = 0.03). There was no significant association found for influence at work and SBP dipping. Discussion While workers had higher clinic SBP readings than non-workers they were also more likely to have nocturnal SBP dipping a factor known to be beneficial to cardiovascular health. Furthermore, this study showed that allowing workers to develop their skills in the workplace positively influenced their blood pressure.

PP66 Positively Living Positively Working - Lifestyle Behaviours in a Working and Non-Working Population

Background The difference between a working and a non-working middle to older aged population and their lifestyle behaviours has not been investigated previously. Furthermore, the association between positive job characteristics for current older workers and the co-occurrence of positive lifestyle behaviours (PLBs) is scarcely known. Methods We carried out a cross-sectional study on a sample of 2,047 males and females aged between 50-69 years. Data were collected on socio-demographic factors, and on PLBs (five or more portions of fruit and vegetables a day, ex/non-smoker, light alcohol intake and high/moderate physical activity). Just over half the sample were current workers (n = 1,025). Job characteristics were determined using the Copenhagen Psychosocial Questionnaire, specifically looking at demands and resources at work. Descriptive statistics were used to examine PLBs for the complete sample (workers and non-workers). Multinomial logistic regression was used to investigate job characteristics and the co-occurrence of PLBs for workers only. Results The average PLBs were higher for the worker than the non-worker across most socio-demographic factors. Non-workers, with low levels of education, had lower mean PLBs. Workers with medium or high demands were significantly more likely to have 2 (OR 2.84 [95% CI 1.15, 7.02], p=0.02), 3 (3.54 [1.43, 8.75], p=0.01) and 4 (4.99 [1.90, 13.11], p<0.01). PLBs versus none, in comparison to those with low demands. In addition workers with medium/high possibility for development were more likely to have 2 (2.95 [1.19, 7.29], p=0.02), and 3 (2.81 [1.14, 6.93], p=0.03) PLBs versus 0 in comparison to those with low possibility for development. Discussion Workers and non-workers differ with regard PLBs however, within workers, those with higher demands in work also have more PLBs. This is counter-intuitive, but may be the result of looking at the modern workplace with a modern tool. These findings can help inform health promotion initiatives in our communities and workplaces.