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Interventions for Behaviour Change and Self-Management of Risk in Stroke Secondary Prevention: An Overview of Reviews.
Hall, P, Lawrence, M, Blake, C, Lennon, O
Cerebrovascular diseases (Basel, Switzerland). 2024;(1):1-13
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INTRODUCTION Optimised secondary prevention strategies that include lifestyle change are recommended after stroke. While multiple systematic reviews (SRs) address behaviour change interventions, intervention definitions, and associated outcomes differ between reviews. This overview of reviews addresses the pressing need to synthesise high-level evidence for lifestyle-based behavioural and/or self-management interventions to reduce risk in stroke secondary prevention in a structured, consistent way. METHODS Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied to meta-analyses, demonstrating statistically significant effect sizes to establish the certainty of existing evidence. Electronic databases MEDLINE, Embase, Epistemonikos, and the Cochrane Library of Systematic Reviews were systematically searched, current to March 2023. RESULTS Fifteen SRs were identified following screening, with moderate overlap of primary studies demonstrated (5.84% degree of corrected covered area). Interventions identified could be broadly categorised as multimodal; behavioural change; self-management; psychological talk therapies, albeit with overlap between some theoretical domains. Seventy-two meta-analyses addressing twenty-one preventive outcomes of interest were reported. Best-evidence synthesis identifies that for primary outcomes of mortality and future cardiovascular events post-stroke, moderate certainty GRADE evidence supports multimodal interventions to reduce cardiac events, with no available evidence for outcomes of mortality (all-cause or cardiovascular) or recurrent stroke events. For secondary outcomes addressing risk-reducing behaviours, best-evidence synthesis identifies moderate certainty GRADE evidence for multimodal lifestyle-based interventions to increase physical activity participation, and low certainty GRADE evidence for behavioural change interventions to improve healthy eating post-stroke. Similarly, low certainty GRADE evidence supports self-management interventions to improve preventive medication adherence. For mood self-management post-stroke, moderate GRADE evidence supports psychological therapies for remission and/or reduction of depression and low/very low certainty GRADE evidence for reduction of psychological distress and anxiety. Best-evidence for outcomes addressing proxy physiological measures identified low GRADE evidence supporting multimodal interventions to improve blood pressure, waist circumference, and LDL cholesterol. CONCLUSION Effective strategies to redress risk-related health behaviours are required in stroke survivors to complement current pharmacological secondary prevention. Inclusion of multimodal interventions and psychological talk therapies in evidence-based stroke secondary prevention programmes is warranted given the moderate GRADE of evidence that supports their role in risk reduction. Given the overlap in primary studies across reviews, often with overlapping theoretical domains between broad intervention categories, further research is required to identify optimal intervention behavioural change theories and techniques employed in behavioural/self-management interventions.
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Home Insulin Pump Use in Hospitalized Children With Type 1 Diabetes.
Owens, J, Courter, J, Schuler, CL, Lawrence, M, Hornung, L, Lawson, S
JAMA network open. 2024;(2):e2354595
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IMPORTANCE Pediatric data on inpatient home insulin pumps are absent in the literature. Understanding safety of home insulin pumps, managed by patients or caregivers, during times of illness will help diabetes technology securely move into pediatric hospitals. OBJECTIVE To examine whether insulin can be safely and accurately delivered to hospitalized children through home insulin pumps when managed by patients or caregivers. DESIGN, SETTING, AND PARTICIPANTS This single-center, retrospective, observational cohort study included children with insulin-dependent diabetes admitted to a tertiary children's hospital from January 1, 2016, to December 31, 2021. In all these patients, diabetes was the primary or secondary diagnosis on admission. EXPOSURE Insulin delivery via home insulin pump, hospital insulin pump, or subcutaneous injection. MAIN OUTCOMES AND MEASURES Hyperglycemia (glucose, >250 mg/dL) and hypoglycemia (glucose, <45 mg/dL) rates (quantified as the proportion of total insulin-days), glucose variability, and diabetic ketoacidosis (DKA) recurrences were compared for hospital pumps (manual mode), home pumps (manual mode), and subcutaneous injections using bivariate tests. RESULTS There were 18 096 insulin-days among 2738 patients aged 0.5 to 25 years (median age, 15.8 years [IQR, 12.3-18.3 years]). Overall, 990 (5.5%) of insulin-days involved hospital insulin pumps, and 775 (4.3%) involved home pumps. A total of 155 insulin-days (15.7%) involving hospital pumps were hyperglycemic, compared with 209 (27.0%) involving home pumps and 7374 (45.2%) involving injections (P < .001). Moderate hypoglycemia days comprised 31 insulin-days (3.1%) involving hospital pumps compared with 35 (4.5%) involving home pumps and 830 (5.1%) involving injections (P = .02). Severe hypoglycemia did not differ significantly according to insulin delivery method. Two patients using injections (0.01%) developed DKA; no patients using hospital or home pumps developed DKA. CONCLUSIONS AND RELEVANCE In this cohort study, home insulin pump use was found to be safe in a children's hospital regarding hyperglycemia and hypoglycemia. These data support use of home insulin pumps during pediatric admissions in patients who do not require intensive care and without active DKA.
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Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses.
Lane, MM, Gamage, E, Du, S, Ashtree, DN, McGuinness, AJ, Gauci, S, Baker, P, Lawrence, M, Rebholz, CM, Srour, B, et al
BMJ (Clinical research ed.). 2024;:e077310
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OBJECTIVE To evaluate the existing meta-analytic evidence of associations between exposure to ultra-processed foods, as defined by the Nova food classification system, and adverse health outcomes. DESIGN Systematic umbrella review of existing meta-analyses. DATA SOURCES MEDLINE, PsycINFO, Embase, and the Cochrane Database of Systematic Reviews, as well as manual searches of reference lists from 2009 to June 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews and meta-analyses of cohort, case-control, and/or cross sectional study designs. To evaluate the credibility of evidence, pre-specified evidence classification criteria were applied, graded as convincing ("class I"), highly suggestive ("class II"), suggestive ("class III"), weak ("class IV"), or no evidence ("class V"). The quality of evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework, categorised as "high," "moderate," "low," or "very low" quality. RESULTS The search identified 45 unique pooled analyses, including 13 dose-response associations and 32 non-dose-response associations (n=9 888 373). Overall, direct associations were found between exposure to ultra-processed foods and 32 (71%) health parameters spanning mortality, cancer, and mental, respiratory, cardiovascular, gastrointestinal, and metabolic health outcomes. Based on the pre-specified evidence classification criteria, convincing evidence (class I) supported direct associations between greater ultra-processed food exposure and higher risks of incident cardiovascular disease related mortality (risk ratio 1.50, 95% confidence interval 1.37 to 1.63; GRADE=very low) and type 2 diabetes (dose-response risk ratio 1.12, 1.11 to 1.13; moderate), as well as higher risks of prevalent anxiety outcomes (odds ratio 1.48, 1.37 to 1.59; low) and combined common mental disorder outcomes (odds ratio 1.53, 1.43 to 1.63; low). Highly suggestive (class II) evidence indicated that greater exposure to ultra-processed foods was directly associated with higher risks of incident all cause mortality (risk ratio 1.21, 1.15 to 1.27; low), heart disease related mortality (hazard ratio 1.66, 1.51 to 1.84; low), type 2 diabetes (odds ratio 1.40, 1.23 to 1.59; very low), and depressive outcomes (hazard ratio 1.22, 1.16 to 1.28; low), together with higher risks of prevalent adverse sleep related outcomes (odds ratio 1.41, 1.24 to 1.61; low), wheezing (risk ratio 1.40, 1.27 to 1.55; low), and obesity (odds ratio 1.55, 1.36 to 1.77; low). Of the remaining 34 pooled analyses, 21 were graded as suggestive or weak strength (class III-IV) and 13 were graded as no evidence (class V). Overall, using the GRADE framework, 22 pooled analyses were rated as low quality, with 19 rated as very low quality and four rated as moderate quality. CONCLUSIONS Greater exposure to ultra-processed food was associated with a higher risk of adverse health outcomes, especially cardiometabolic, common mental disorder, and mortality outcomes. These findings provide a rationale to develop and evaluate the effectiveness of using population based and public health measures to target and reduce dietary exposure to ultra-processed foods for improved human health. They also inform and provide support for urgent mechanistic research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023412732.
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A randomised controlled trial of a digital intervention (Renewed) to support symptom management, wellbeing and quality of life in cancer survivors.
Little, P, Bradbury, K, Stuart, B, Barnett, J, Krusche, A, Steele, M, Heber, E, Easton, S, Smith, KA, Slodkowska-Barabasz, J, et al
The British journal of general practice : the journal of the Royal College of General Practitioners. 2023
Abstract
BACKGROUND Many cancer survivors following primary treatment have prolonged poor quality of life. AIM: To determine the effectiveness of a bespoke digital intervention to support cancer survivors. DESIGN Pragmatic parallel open randomised trial. SETTING UK general practices. METHODS People having finished primary treatment (<= 10 years previously) for colo-rectal, breast or prostate cancers, with European-Organization-for-Research-and-Treatment-of-Cancer QLQ-C30 score <85, were randomised by online software to: 1)detailed 'generic' digital NHS support ('LiveWell';n=906), 2) a bespoke complex digital intervention ('Renewed';n=903) addressing symptom management, physical activity, diet, weight loss, distress, or 3) 'Renewed-with-support' (n=903): 'Renewed' with additional brief email and telephone support. RESULTS Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n's respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified. CONCLUSION Cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global health enablement and symptom management, with substantially lower NHS costs.
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Progress towards Achieving the Recommendations of the Commission on Ending Childhood Obesity: A Comprehensive Review and Analysis of Current Policies, Actions and Implementation Gaps in Thailand.
Phulkerd, S, Nakraksa, P, Mo-Suwan, L, Lawrence, M
Nutrients. 2021;(6)
Abstract
Despite a significant commitment to tackling childhood overweight and obesity, questions remain about the progress the Thai Government has made in implementing childhood obesity prevention policies and actions. This study aimed to review and assess the implementation of the government's policies and actions for childhood obesity prevention in Thailand compared with the recommendations of the Commission on Ending Childhood Obesity and to identify the implementation gaps. Policy data were collected from governmental and NGO websites and publications and via direct contact with government officials. Stakeholder meetings were held to seek further information and advice on implementation gaps and to give recommendations. The analysis of each policy was conducted against pre-determined criteria formulated from literature assessments and stakeholder consultations. The policies and actions that were implemented by the Government were consistent with 33 broad policy actions and 55 specific policy actions. Preconception and pregnancy care was the policy area that was most implemented. Six broad policy actions were assessed as 'high' performance, these were: sugar-sweetened beverage taxation, nutrient labeling, nutrition guidance for preconception and pregnancy care, the International Code of Marketing of Breast-milk Substitutes, regulatory measures for supporting maternal breastfeeding, and regulations on the marketing of complementary foods and beverages. Policy coherence and monitoring and evaluation (M&E) were identified as major implementation gaps. Increasing the effectiveness of childhood obesity prevention in Thailand will require national immediate attention towards building infrastructure to enhance coherence among the policies and to put in place M&E mechanisms for each policy.
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Ultra-Processed Foods and Health Outcomes: A Narrative Review.
Elizabeth, L, Machado, P, Zinöcker, M, Baker, P, Lawrence, M
Nutrients. 2020;12(7)
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Ultra-processed food (UPF) is prevalent in diets world-wide. This review aims to look at the results of studies that have investigated associations between levels of UPF consumption and health outcomes on healthy participants. 43 studies were reviewed; studies covered all age groups (including children and adolescents) in a number of different countries. Studies looked at overweight, obesity and cardio-metabolic risks as outcomes as well as cancer, cardiovascular disease, type 2 diabetes, mortality, gastrointestinal disorders, depression, frailty and asthma. In 37 studies, there was at least one statistically significant association between UPF exposure and at least one adverse health outcome. No study reported an association between UPF exposure and beneficial health outcomes. This review has shown that a high intake of UPFs is associated with a range of adverse health outcomes, disorders and conditions. This has the potential to significantly influence the global burden of disease. As well as this; evidence suggests a higher risk of all-cause mortality with high consumption of UPFs. No study reported an association between UPF and beneficial health outcomes. The review has also shown beneficial outcomes were associated with diets higher in unprocessed and minimally processed foods.
Abstract
The nutrition literature and authoritative reports increasingly recognise the concept of ultra-processed foods (UPF), as a descriptor of unhealthy diets. UPFs are now prevalent in diets worldwide. This review aims to identify and appraise the studies on healthy participants that investigated associations between levels of UPF consumption and health outcomes. This involved a systematic search for extant literature; integration and interpretation of findings from diverse study types, populations, health outcomes and dietary assessments; and quality appraisal. Of 43 studies reviewed, 37 found dietary UPF exposure associated with at least one adverse health outcome. Among adults, these included overweight, obesity and cardio-metabolic risks; cancer, type-2 diabetes and cardiovascular diseases; irritable bowel syndrome, depression and frailty conditions; and all-cause mortality. Among children and adolescents, these included cardio-metabolic risks and asthma. No study reported an association between UPF and beneficial health outcomes. Most findings were derived from observational studies and evidence of plausible biological mechanisms to increase confidence in the veracity of these observed associations is steadily evolving. There is now a considerable body of evidence supporting the use of UPFs as a scientific concept to assess the 'healthiness' of foods within the context of dietary patterns and to help inform the development of dietary guidelines and nutrition policy actions.
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Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers.
Baker, P, Machado, P, Santos, T, Sievert, K, Backholer, K, Hadjikakou, M, Russell, C, Huse, O, Bell, C, Scrinis, G, et al
Obesity reviews : an official journal of the International Association for the Study of Obesity. 2020;(12):e13126
Abstract
Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.
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Generating political commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening nutrition actor networks.
Baker, P, Brown, AD, Wingrove, K, Allender, S, Walls, H, Cullerton, K, Lee, A, Demaio, A, Lawrence, M
Obesity reviews : an official journal of the International Association for the Study of Obesity. 2019;:30-44
Abstract
Generating political commitment for ending all forms of malnutrition represents a key challenge for the global nutrition community. Without commitment, the policies, programs, and resources needed to improve nutrition are unlikely to be adopted, effectively implemented, nor sustained. One essential driver of commitment is nutrition actor network (NAN) effectiveness, the web of individuals and organizations operating within a given country who share a common interest in improving nutrition and who act collectively to do so. To inform new thinking and action towards strengthening NAN effectiveness, we use a systems dynamics theoretical approach and literature review to build initial causal loop diagrams (CLDs) of political commitment and NAN effectiveness and a qualitative group model building (GMB) method involving an expert workshop to strengthen model validity. First, a "nutrition commitment system" CLD demonstrates how five interrelated forms of commitment-rhetorical, institutional, operational, embedded, and system-wide-can dynamically reinforce or diminish one another over time. Second, we present CLDs demonstrating factors shaping NAN effectiveness organized into three categories: actor features, resources, and capacities; framing strategies, evidence, and norms; and institutional, political, and societal contexts. Together, these models generate hypotheses on how political commitment and NAN effectiveness could be strengthened in future and may provide potential starting points for country-specific conversations for doing so.
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ZMYM2 inhibits NANOG-mediated reprogramming.
Lawrence, M, Theunissen, TW, Lombard, P, Adams, DJ, Silva, JCR
Wellcome open research. 2019;:88
Abstract
Background: NANOG is a homeodomain-containing transcription factor which forms one of the hubs in the pluripotency network and plays a key role in the reprogramming of somatic cells and epiblast stem cells to naïve pluripotency. Studies have found that NANOG has many interacting partners and some of these were shown to play a role in its ability to mediate reprogramming. In this study, we set out to analyse the effect of NANOG interactors on the reprogramming process. Methods: Epiblast stem cells and somatic cells were reprogrammed to naïve pluripotency using MEK/ERK inhibitor PD0325901, GSK3β inhibitor CHIR99021 and Leukaemia Inhibitory Factor (together termed 2i Plus LIF). Zmym2 was knocked out using the CRISPR/Cas9 system or overexpressed using the PiggyBac system. Reprogramming was quantified after ZMYM2 deletion or overexpression, in diverse reprogramming systems. In addition, embryonic stem cell self renewal was quantified in differentiation assays after ZMYM2 removal or overexpression. Results: In this work, we identified ZMYM2/ZFP198, which physically associates with NANOG as a key negative regulator of NANOG-mediated reprogramming of both epiblast stem cells and somatic cells. In addition, ZMYM2 impairs the self renewal of embryonic stem cells and its overexpression promotes differentiation. Conclusions: We propose that ZMYM2 curtails NANOG's actions during the reprogramming of both somatic cells and epiblast stem cells and impedes embryonic stem cell self renewal, promoting differentiation.
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A review of methods and tools to assess the implementation of government policies to create healthy food environments for preventing obesity and diet-related non-communicable diseases.
Phulkerd, S, Lawrence, M, Vandevijvere, S, Sacks, G, Worsley, A, Tangcharoensathien, V
Implementation science : IS. 2016;:15
Abstract
BACKGROUND Policies to create healthy food environments are recognized as critical components of efforts to prevent obesity and diet-related non-communicable diseases. There has not been a systematic review of existing methods and tools used to assess the implementation of these government policies. The purpose of this study was to review methods and tools used for assessing the implementation of government policies to create healthy food environments. The study conducted a systematic literature search. Multiple databases as well as the grey literature were searched. All study designs and review papers on assessing the implementation of government policies to create healthy food environments were included. A quality assessment of the methods and tools identified from relevant studies was carried out using the following four criteria: comprehensiveness, relevance, generalizability and feasibility. This quality assessment was completed by two independent reviewers. RESULTS The review identified 52 studies across different policy areas, levels and settings. Self-administered questionnaires and policy checklists were most commonly applied to assess the extent of policy implementation, whereas semi-structured interviews were most commonly used to evaluate the implementation process. Measures varied widely, with the existence of policy implementation the aspect most commonly assessed. The most frequently identified barriers and facilitators for policy implementation were infrastructure support, resources and stakeholder engagement. The assessment of policy implementation on food environments was usually undertaken in combination with other policy areas, particularly nutrition education and physical activity. Three tools/methods were rated 'high' quality and 13 tools/methods received 'medium' quality ratings. CONCLUSIONS Harmonization of the available high-quality methods and tools is needed to ensure that assessment of government policy implementation can be compared across different countries and settings and over time. This will contribute to efforts to increase government accountability for their actions to improve the healthiness of food environments.