Zoe E. Davidson

Weight loss from lifestyle interventions and severity of sleep apnoea: A systematic review and meta-analysis

BACKGROUND Excess body weight is a risk factor for obstructive sleep apnoea (OSA). The aim of the systematic review was to establish whether weight loss via lifestyle interventions such as diet and exercise are useful in the treatment of OSA. METHODS A literature search was conducted between 1980 and February 2012. Systematic reviews and randomised controlled trials (RCTs) with participants who had OSA, were overweight or obese, and who had undergone lifestyle interventions with the aim of improving sleep apnoea were included. Meta analyses were conducted for a subset of RCTs with appropriate data. RESULTS Two systematic reviews and eight RCTs were included. Meta-analyses were conducted for four RCTs comparing intensive lifestyle interventions to a control. The overall weighted mean differences for weight change, change in apnoea -hypopnoea index (AHI) and change in oxygen desaturation index of ≥4% were as follows: -13.76 kg (95% confidence interval (CI) -19.21, --8.32), -16.09 (95% CI -25.64, -6.54) and -14.18 (95% CI -24.23, -4.13), respectively. Although high heterogeneity within the meta analyses, all studies favoured the interventions. Long-term follow-up data from three RCTs suggest that improvements in weight and AHI are maintained for up to 60 months. CONCLUSIONS Intensive lifestyle interventions are effective in the treatment of OSA, resulting in significant weight loss and a reduction in sleep apnoea severity. Weight loss via intensive lifestyle interventions could be encouraged as a treatment for mild to moderate OSA.

Do Glucocorticosteroids Alter Vitamin D Status? A Systematic Review with Meta-Analyses of Observational Studies

CONTEXT Vitamin D supplementation is an important adjunct therapy for the prevention and management of glucocorticoid-induced osteoporosis. There has been little exploration of the relationship between glucocorticosteroid (GCS) use and serum 25-hydroxyvitamin D [25(OH)D]. OBJECTIVE The aim of this study was to systematically explore how serum 25(OH)D is altered in adult patients receiving GCS. DATA SOURCES We reviewed Medline and Cinahl databases between January 1970 and August 2011. STUDY SELECTION Experimental studies were included where 25(OH)D was measured in patients more than 18 yr of age receiving GCS therapy. Studies were excluded if patients received at least 400 IU/d (10 μg/d) vitamin D, if GCS treatment was less than 2-wk duration, if more than 50% of the study population received GCS for renal or hepatic disease or after transplant, or if the study population included patients with Cushings syndrome. A consensus method was used to classify studies. Of identified studies, 3% met the selection criteria. DATA EXTRACTION Data were extracted by a single author. Study quality was assessed using criteria developed by the American Dietetic Association. DATA SYNTHESIS The weighted mean 25(OH)D (by sample size or sd) was 22.4 [95% confidence interval (CI), 19.4, 25.3] ng/ml and 21.0 (95% CI, 13.5, 28.5) ng/ml, respectively. Random effects meta-analysis was used to compare serum 25(OH)D in patients treated with GCS compared to steroid-naive controls (either healthy or with active disease) and in patients before and after GCS administration. Serum 25(OH)D in GCS users was on average -0.5 (95% CI, -1.0, -0.1) ng/ml lower than in healthy controls (P=0.03; I2=56.4%). Serum 25(OH)D did not differ between GCS users and disease controls [standardized mean difference=0.0 (95% CI, -0.2, 0.3) ng/ml; P=0.793; I2=16.2%]. CONCLUSION The suboptimal concentrations of serum 25(OH)D found in adults receiving GCS are inadequate for prevention and management of glucocorticoid-induced osteoporosis. Recommendations for vitamin D supplementation should be adjusted accordingly.

Dysphagia in Duchenne muscular dystrophy: practical recommendations to guide management

Abstract Purpose: Duchenne muscular dystrophy (DMD) is a rapidly progressive neuromuscular disorder causing weakness of the skeletal, respiratory, cardiac and oropharyngeal muscles with up to one third of young men reporting difficulty swallowing (dysphagia). Recent studies on dysphagia in DMD clarify the pathophysiology of swallowing disorders and offer new tools for its assessment but little guidance is available for its management. This paper aims to provide a step-by-step algorithm to facilitate clinical decisions regarding dysphagia management in this patient population. Methods: This algorithm is based on 30 years of clinical experience with DMD in a specialised Centre for Neuromuscular Disorders (Inkendaal Rehabilitation Hospital, Belgium) and is supported by literature where available. Results: Dysphagia can worsen the condition of ageing patients with DMD. Apart from the difficulties of chewing and oral fragmentation of the food bolus, dysphagia is rather a consequence of an impairment in the pharyngeal phase of swallowing. By contrast with central neurologic disorders, dysphagia in DMD accompanies solid rather than liquid intake. Symptoms of dysphagia may not be clinically evident; however laryngeal food penetration, accumulation of food residue in the pharynx and/or true laryngeal food aspiration may occur. The prevalence of these issues in DMD is likely underestimated. Conclusions: There is little guidance available for clinicians to manage dysphagia and improve feeding for young men with DMD. This report aims to provide a clinical algorithm to facilitate the diagnosis of dysphagia, to identify the symptoms and to propose practical recommendations to treat dysphagia in the adult DMD population. Implications for Rehabilitation Little guidance is available for the management of dysphagia in Duchenne dystrophy. Food can penetrate the vestibule, accumulate as residue or cause aspiration. We propose recommendations and an algorithm to guide management of dysphagia. Penetration/residue accumulation: prohibit solid food and promote intake of fluids. Aspiration: if cough augmentation techniques are ineffective, consider tracheostomy.

Predicting resting energy expenditure in boys with Duchenne muscular dystrophy.

BACKGROUND Understanding how best to predict energy needs in Duchenne muscular dystrophy (DMD) is fundamental to weight management in clinical practice; however there is a large gap in the literature regarding information on the most appropriate method. We aimed to ascertain the most valid predictive equation that can be used to predict REE in steroid treated ambulatory boys with DMD. METHODS REE was measured in 9 boys with DMD using indirect calorimetry after an overnight fast. REE was predicted using five different equations, based on height, weight, or body composition variables. RESULTS Mean measured REE was 5.4 (SD 0.4) MJ/day. The inclusion of fat free mass in the prediction equation provided no benefit over body weight. The exclusion of height, when compared with weight alone, improved predictive performance, as seen with the Schofield equations, in which a minimal bias and root means squared error is seen. CONCLUSIONS The most accurate and precise equation was the Schofield weight equation (Bias -0.2 MJ, 95% CI: -1.3-0.9 MJ), which can easily be calculated in a clinical setting and provides a solid foundation from which clinicians can establish energy requirements to support nutritional management in boys with DMD.

Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control

AIMS The purpose of this study is to systematically review evidence in English and Chinese publications to determine the size of glycemic effect of different diabetes education approaches for Chinese patients. METHODS CINAHL Plus, Embase, Ovid Medline, Scopus and the China National Knowledge Infrastructure database were searched. Studies were included if they were randomised controlled trials with a detailed description of education approach, with more than 50 Chinese-adult participants, reporting actual glycemic outcome and with at least 3-month follow-up. Data was systematically extracted and cross-checked by the authors. Methodological quality was assessed. RESULTS Fifty-three studies, including five English and 48 Chinese publications, were included. The overall weighted mean difference (WMD) in glycated haemoglobin (HbA1c) was -1.19% (-13mmol/mol). Ongoing regular education was most-commonly employed, with a reported WMD of -2.02% (-22mmol/mol). Glycemic control was further enhanced in studies using information reinforcement strategies. CONCLUSIONS Diabetes education in any format generates glycemic improvement for Chinese patients, but is particularly effective when an ongoing regular education is employed. Innovative strategies aligned with cultural concepts, such as employing patient examination to reinforce diabetes management knowledge and/or involving family in patient care deserve further trial to determine whether they enhance glycemic control in this group.

Are low-to-middle-income households experiencing food insecurity in Victoria, Australia? An examination of the Victorian Population Health Survey, 2006?2009.

Food insecurity affects health and wellbeing. Little is known about the relationship between food insecurity across income levels. This study aims to investigate the prevalence and frequency of food insecurity in low-to-middle-income Victorian households over time and identify factors associated with food insecurity in these households. Prevalence and frequency of food insecurity was analysed across household income levels using data from the cross-sectional 2006-09 Victorian Population Health Surveys (VPHS). Respondents were categorised as food insecure, if in the last 12 months they had run out of food and were unable to afford to buy more. Multivariable logistic regression was used to describe factors associated with food insecurity in low-to-middle-income households (A

Describing nutrition in spinal muscular atrophy: A systematic review.

40000-

A bedside measure of body composition in Duchenne muscular dystrophy.

80000 in 2008). Between 4.9 and 5.5% for total survey populations and 3.9-4.8% in low-to-middle-income respondents were food insecure. Food insecurity was associated with limited help from friends, home ownership status, inability to raise money in an emergency and cost of some foods. Food insecurity exists in households beyond those on a very low income. Understanding the extent and implications of household food insecurity across all income groups in Australia will inform effective and appropriate public health responses.

Accuracy of Parent-Reported Energy Intake and Physical Activity Levels in Boys With Duchenne Muscular Dystrophy

Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease of variable severity. Progressive muscle wasting and impairment in functional ability in SMA have a profound influence on nutritional outcomes. This systematic review summarises the existing evidence on nutrition in SMA. The search strategy was conducted across five databases in August 2014, and updated in March 2016, using key terms relating to growth, nutrition requirements, dietary intake and nutrition management. Studies were selected for inclusion using a two pass method, and data systematically extracted using standardised forms. Thirty-nine studies met eligibility criteria. Body composition is abnormal in patients with SMA, and feeding and swallowing issues are prevalent among sufferers of SMA types I and II. Nutritional management practices vary internationally. There is a paucity of literature regarding nutrition requirements in SMA, although it appears that energy expenditure may be reduced. Children with SMA require individualised nutritional management in order to address their growth and nutrition requirements. There is an urgent need for larger, coordinated, prospective intervention studies of nutrition in SMA.

Strong correlation between the 6-minute walk test and accelerometry functional outcomes in boys with Duchenne muscular dystrophy

BACKGROUND In clinical practice, monitoring body composition is a critical component of nutritional assessment and weight management in boys with Duchenne muscular dystrophy. We aimed to evaluate the accuracy of a simple bedside measurement tool for body composition, namely bioelectrical impedance analysis, in boys with Duchenne muscular dystrophy. METHODS Measures of fat-free mass were determined using a bioelectrical impedance analysis machine and compared against estimations obtained from a reference body composition model. Additionally, the use of raw impedance values was analyzed using three existing predictive equations for the estimation of fat-free mass. Accuracy of bioelectrical impedance analysis was assessed by comparison against the reference model by calculation of biases and limits of agreement. RESULTS Body composition was measured in 10 boys with Duchenne muscular dystrophy, mean age 9.01 ± 2.34 years. The bioelectrical impedance analysis machine values of fat-free mass were on average 2.3 ± 14.1 kg higher than reference values. Limits of agreement (based on 95% confidence interval of the mean) were -7.4 to 2.9 kg. There was a significant correlation between the mean fat-free mass and difference in fat-free mass between the bioelectrical impedance analysis machine and the reference model (r = -0.86; P = 0.02) suggesting that the bias was not consistent across the range of measurements. The most accurate predictive equation for the estimation of fat-free mass using raw impedance values was the equation by Pietrobelli et al. (mean difference, -0.7 kg; 95% limits of agreement, -3.5 to 2.0 kg). CONCLUSIONS In a clinical setting, where a rapid assessment of body composition is advantageous, the use of raw impedance values, combined with the equation by Pietrobelli et al., is recommended for the accurate estimation of fat-free mass, in boys with Duchenne muscular dystrophy.