The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study: a cluster randomised controlled trial testing the clinical effectiveness and cost-effectiveness of a multifaceted obesity prevention intervention programme targeted at children aged 6-7 years

BACKGROUND

Systematic reviews suggest that school-based interventions can be effective in preventing childhood obesity, but better-designed trials are needed that consider costs, process, equity, potential harms and longer-term outcomes.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) study intervention, compared with usual practice, in preventing obesity among primary school children.

DESIGN

A cluster randomised controlled trial, split across two groups, which were randomised using a blocked balancing algorithm. Schools/participants could not be blinded to trial arm. Measurement staff were blind to allocation arm as far as possible.

SETTING

Primary schools, West Midlands, UK.

PARTICIPANTS

Schools within a 35-mile radius of the study centre and all year 1 pupils (aged 5-6 years) were eligible. Schools with a higher proportion of pupils from minority ethnic populations were oversampled to enable subgroup analyses.

INTERVENTIONS

The 12-month intervention encouraged healthy eating/physical activity (PA) by (1) helping teachers to provide 30 minutes of additional daily PA, (2) promoting 'Villa Vitality' (interactive healthy lifestyles learning, in an inspirational setting), (3) running school-based healthy cooking skills/education workshops for parents and children and (4) highlighting information to families with regard to local PA opportunities.

MAIN OUTCOME MEASURES

The primary outcomes were the difference in body mass index z-scores (BMI-zs) between arms (adjusted for baseline body mass index) at 3 and 18 months post intervention (clinical outcome), and cost per quality-adjusted life-year (QALY) (cost-effectiveness outcome). The secondary outcomes were further anthropometric, dietary, PA and psychological measurements, and the difference in BMI-z between arms at 27 months post intervention in a subset of schools.

RESULTS

Two groups of schools were randomised: 27 in 2011 (n = 650 pupils) [group 1 (G1)] and another 27 in 2012 (n = 817 pupils) [group 2 (G2)]. Primary outcome data were available at first follow-up (n = 1249 pupils) and second follow-up (n = 1145 pupils) from 53 schools. The mean difference (MD) in BMI-z between the control and intervention arms was -0.075 [95% confidence interval (CI) -0.183 to 0.033] and -0.027 (95% CI -0.137 to 0.083) at 3 and 18 months post intervention, respectively. The main analyses showed no evidence of between-arm differences for any secondary outcomes. Third follow-up included data on 467 pupils from 27 G1 schools, and showed a statistically significant difference in BMI-z (MD -0.20, 95% CI -0.40 to -0.01). The mean cost of the intervention was £266.35 per consented child (£155.53 per child receiving the intervention). The incremental cost-effectiveness ratio associated with the base case was £46,083 per QALY (best case £26,804 per QALY), suggesting that the intervention was not cost-effective.

LIMITATIONS

The presence of baseline primary outcome imbalance between the arms, and interschool variation in fidelity of intervention delivery.

CONCLUSIONS

The primary analyses show no evidence of clinical effectiveness or cost-effectiveness of the WAVES study intervention. A post hoc analysis, driven by findings at third follow-up, suggests a possible intervention effect, which could have been attenuated by baseline imbalances. There was no evidence of an intervention effect on measures of diet or PA and no evidence of harm.

FUTURE WORK

A realist evidence synthesis could provide insights into contextual factors and strategies for future interventions. School-based interventions need to be integrated within a wider societal framework and supported by upstream interventions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN97000586.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 8. See the NIHR Journals Library website for further project information.

Association between serum progesterone concentration in early pregnancy and duration of pregnancy: a cohort study

Objective: To examine the association between progesterone concentration in early pregnancy and duration of pregnancy and risk of preterm delivery.Methods: Women enrolled in the Born in Guangzhou Cohort Study from 2013-2014, with a singleton pregnancy, who had serum progesterone measured at least one time between 4 and 10 weeks of gestation were included. The association between progesterone concentration both continuous and as categorical variable (quartile) and the risk of preterm delivery was assessed with Cox proportional hazards regression. Differences of length of gestation in four progesterone concentration quartiles were assessed using the Log-rank test.Results: We studied 1860 mother-newborn pairs. The mean overall progesterone concentration was 65.7 ± 21.3 nmol/L, with mean progesterone concentrations in the four quartiles of 42.4 ± 6.2 nmol/L (n = 463), 56.2 ± 3.3 nmol/L (n = 462), 68.9 ± 4.5 nmol/L (n = 470), and 95.1 ± 15.3 nmol/L (n = 465). There was no significantly difference in duration of gestation in four progesterone concentration groups (p=.511). There was no relation between progesterone level and preterm delivery (adjusted hazard ratio (HR) per 10 nmol/l progesterone level 1.00 (95% confidence interval (CI) 0.90, 1.11)). After adjusting for potential confounders, the HR of any preterm delivery for quartiles 1, 2 and 3 versus the highest quartile of progesterone level (> 77.3 nmol/L) was 1.04 (95% CI 0.52, 2.07), 1.17 (95% CI 0.60, 2.28), and 1.46 (95% CI 0.76, 2.78), respectively. When analysis was done for spontaneous preterm delivery only, also no association with first trimester progesterone was found.Conclusion: Lower first trimester serum progesterone concentration is not associated with reduction of length of gestation or increased risk of preterm delivery.

White blood cell count and all-cause and cause-specific mortality in the Guangzhou biobank cohort study

Background

Several studies have shown positive associations between higher WBC count and deaths from all-causes, CHD, stroke and cancer among occidental populations or developed countries of Asia. No study on the association of WBC count with all-cause and cause-specific mortality in Chinese populations was reported. We studied this using prospective data from a large Chinese cohort.

Methods

We used prospective data from the Guangzhou Biobank Cohort Study (GBCS), a total of 29,925 participants in present study. A Cox proportional hazards regression model was used to estimate the hazard ratios (HR) and 95% confidence interval (CI).

Results

The hazard ratios (HR) for all-cause, CHD, and respiratory disease mortality for the highest decile of WBC count (women > 8.2 × 10⁹/L; men > 8.8 × 10⁹/L) was 1.83 (95% confidence interval (CI) 1.54, 2.17), 3.02 (95% CI 1.84, 4.98) and 2.52 (95% CI 1.49, 4.27), respectively, after adjusting for multiple potential confounders. The associations were similar when deaths during the first 2 years of follow-up were excluded. After further adjusting for pulmonary function, the highest decile of WBC count was associated with 90% higher risk of respiratory disease mortality (HR 1.90, 95% CI 1.08, 3.33). No evidence for an association between higher WBC count and cancer mortality was found. Sub-type analysis showed that only granulocyte count remained significantly predictive of all-cause, CHD, and respiratory disease mortality.

Conclusions

Elevated WBC, specifically granulocyte, count was associated with all-cause, CHD and respiratory mortality in southern Chinese. Further investigation is warranted to clarify whether decreasing inflammation would attenuate WBC count associated mortality.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6073-6) contains supplementary material, which is available to authorized users.

Gestational dyslipidaemia and adverse birthweight outcomes: a systematic review and meta-analysis

BACKGROUND

Low and high birthweight is known to increase the risk of acute and longer-term adverse outcomes, such as stillbirth, infant mortality, obesity, type 2 diabetes and cardiovascular diseases. Gestational dyslipidaemia is associated with a numbers of adverse birth outcomes, but evidence regarding birthweight is still inconsistent to reliably inform clinical practice and treatment recommendations.

OBJECTIVE

The aim of this study was to explore the relationship between maternal gestational dyslipidaemia and neonatal health outcomes, namely, birthweight, metabolic factors and inflammatory parameters.

METHODS

We searched systematically Embase, MEDLINE, PubMed, CINAHL Plus and Cochrane Library up to 1 August 2016 (with an updated search in MEDLINE at the end of July 2017) for longitudinal studies that assessed the association of maternal lipid levels during pregnancy with neonatal birthweight, or metabolic and inflammatory parameters up to 3 years old.

RESULTS

Data from 46 publications including 31,402 pregnancies suggest that maternal high triglycerides and low high-density-lipoprotein cholesterol levels throughout pregnancy are associated with increased birthweight, higher risk of large for gestational age and macrosomia and lower risk of small-for-gestational age. The findings were consistent across the studied populations, but stronger associations were observed in women who were overweight or obese prior to pregnancy.

CONCLUSIONS

This meta-analysis suggested that the potential under-recognized adverse effects of intrauterine exposure to maternal dyslipidaemia may warrant further investigation into the relationship between maternal dyslipidaemia and birthweight in large prospective cohorts or in randomized trials.

Total Fluid Intake and the Risk of Recurrence in Patients With Non-Muscle Invasive Bladder Cancer: A Prospective Cohort Study

Objectives:

To investigate the role of fluid intake from beverages before and after a diagnosis of bladder cancer in relation to the risk of developing bladder cancer recurrence.

Study Design:

Prospective cohort study.

Methods:

716 patients with non-muscle invasive bladder cancer (NMIBC), who received transurethral resection of a primary bladder tumour (TURBT) and completed self-administrated questionnaires on usual fluid intake from beverages at time of diagnosis (over the year before diagnosis) and during follow-up (over the year after diagnosis), were included. Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals of developing recurrent bladder cancer in relation to the intake of total fluid, total alcohol, and individual beverages.

Results:

During 2,025 person-years of follow-up, 238 (33%) of the included 716 NMIBC patients developed one or more recurrences of bladder cancer. Total fluid intake before diagnosis was not associated with a first recurrence of bladder cancer when comparing the highest and lowest intake group (HR = 0.98, 95% C.I. 0.70–1.38, p = 0.91). Comparable results were obtained for total fluid intake pre-diagnosis and the risk of developing multiple recurrences of bladder cancer (HR = 1.01, 95% C.I. 0.87–1.19, p = 0.85). A total of 379 of the 716 patients reported on usual fluid intake within 1 year of diagnosis. No significant associations between total fluid intake 1 year after diagnosis and a first recurrence of bladder cancer were found when comparing the highest and lowest intake group (HR = 0.91; 95% C.I. 0.60–1.37, p = 0.65) or with multiple recurrences of bladder cancer (HR = 1.06; 95% C.I. 0.89–1.26, p = 0.54). In addition, total alcohol intake and individual beverages were not associated with bladder cancer recurrence.

Conclusions:

The results indicate that an individual’s fluid intake from beverages is unlikely to have an important role in bladder cancer recurrence.

Predictions of Preterm Birth from Early Pregnancy Characteristics: Born in Guangzhou Cohort Study

Preterm birth (PTB, <37 weeks) is the leading cause of death in children <5 years of age. Early risk prediction for PTB would enable early monitoring and intervention. However, such prediction models have been rarely reported, especially in low- and middle-income areas. We used data on a number of easily accessible predictors during early pregnancy from 9044 women in Born in Guangzhou Cohort Study, China to generate prediction models for overall PTB and spontaneous, iatrogenic, late (34–36 weeks), and early (<34 weeks) PTB. Models were constructed using the Cox proportional hazard model, and their performance was evaluated by Harrell’s c and D statistics and calibration plot. We further performed a systematic review to identify published models and validated them in our population. Our new prediction models had moderate discrimination, with Harrell’s c statistics ranging from 0.60–0.66 for overall and subtypes of PTB. Significant predictors included maternal age, height, history of preterm delivery, amount of vaginal bleeding, folic acid intake before pregnancy, and passive smoking during pregnancy. Calibration plots showed good fit for all models except for early PTB. We validated three published models, all of which were from studies conducted in high-income countries; the area under receiver operating characteristic for these models ranged from 0.50 to 0.56. Based on early pregnancy characteristics, our models have moderate predictive ability for PTB. Future studies should consider inclusion of laboratory markers for the prediction of PTB.

Maternal dietary patterns during pregnancy and preterm delivery: a large prospective cohort study in China

Background

Evidence about the associations between maternal dietary patterns and preterm delivery is scarce in Eastern countries. The purpose of this study was to examine the associations between maternal dietary patterns during pregnancy and preterm delivery in a Chinese population.

Methods

A total of 7352 mothers were included in the Born in Guangzhou Cohort Study, a prospective study in China. A validated self-administered food frequency questionnaire (FFQ) was used to assess maternal diet at 24–27 weeks of gestation. Dietary patterns were identified by cluster analysis. Gestational age was obtained from routine medical records. Preterm delivery was defined as delivery before 37 completed weeks of gestation, and was further classified into spontaneous and iatrogenic preterm delivery, and also early/moderate and late preterm delivery. Associations between dietary patterns and preterm delivery outcomes were assessed using logistic regression analyses.

Results

Six dietary patterns were identified, including ‘Milk’, ‘Cereals, eggs, and Cantonese soups’, ‘Meats’, ‘Fruits, nuts, and Cantonese desserts’, ‘Vegetables’, and ‘Varied’. There were 351 (4.8%) preterm deliveries in this study population. Among those of preterm delivery, 16.2 and 83.8% were early/moderate and late preterm delivery, respectively. Compared with women of ‘Vegetables’ pattern, those of ‘Milk’ pattern had greater odds of overall preterm delivery (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.11, 2.29, p < 0.05), spontaneous preterm delivery (adjusted OR 1.73, 95% CI 1.14, 2.62, p < 0.05) and late preterm delivery (adjusted OR 1.73, 95% CI 1.08, 2.62, p < 0.05); those of ‘Cereals, eggs, and Cantonese soups’ and ‘Fruits, nuts, and Cantonese desserts’ patterns had greater odds of late preterm delivery (adjusted OR 1.54, 95% CI 1.01, 2.35 for ‘Cereals, eggs, and Cantonese soups’, adjusted OR 1.61, 95% CI 1.04, 2.50 for ‘Fruits, nuts, and Cantonese desserts’, respectively).

Conclusion

Maternal diet with frequent consumption of milk and less frequent consumption of vegetables during pregnancy might be associated with increased odds of preterm delivery. Future interventions should investigate whether increasing vegetable intake reduces preterm deliveries.

Electronic supplementary material

The online version of this article (10.1186/s12937-018-0377-3) contains supplementary material, which is available to authorized users.

Early life vitamin D status and asthma and wheeze: a systematic review and meta-analysis

BACKGROUND

Vitamin D deficiency has been linked to an increased risk of asthma. This study aimed to quantify the effect of early life vitamin D status on asthma and wheeze later in life.

METHODS

PubMed, Embase, CINAHL, and CNKI databases, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to July 2017. We included randomized controlled trials (RCTs) and cohort studies with vitamin D level in blood (maternal or cord or infant) or intake (maternal intake during pregnancy or infant intake) and asthma and/or wheeze. Two reviewers independently extracted data. Fixed- and random-effects models were used to summarize the risk estimates of comparisons between highest vs. lowest vitamin D categories.

RESULTS

Of the 1485 studies identified, three RCTs and 33 cohort studies were included. We did not include the RCTs (1619 participants) in the meta-analysis as the comparators and outcome definitions were heterogenous. Three RCTs reported a non-statistically significant effect of vitamin D supplementation during pregnancy on offspring wheeze/asthma at 3 years of age. Pooled estimates of cohort studies suggest no association between antenatal blood vitamin D levels or vitamin D intake and offspring asthma assessed either > 5 years or ≤ 5 years. The estimate for blood vitamin D remained unchanged when two studies assessing asthma in adulthood were excluded, but a significant inverse association emerged between vitamin D intake and childhood asthma. We found no association between antenatal vitamin D level and wheeze. On the other hand, vitamin D intake during pregnancy may have a protective effect against wheeze.

CONCLUSIONS

The pooled estimates from cohort studies show no association between antenatal blood vitamin D level and asthma/wheeze in later life. Whereas, the pooled estimates from cohort studies suggest that antenatal vitamin D intake may have an effect on childhood asthma > 5 years or childhood wheeze. The inconsistent results from studies assessing vitamin D either in blood or intake may be explained by previously reported non-linear association between blood vitamin D3 and childhood asthma. Further trials with enough power and longer follow-up time should be conducted to confirm the results.

The association between smoking cessation before and after diagnosis and non-muscle-invasive bladder cancer recurrence: a prospective cohort study

BACKGROUND

Smoking is a major risk factor for bladder cancer, but the relationship between smoking cessation after initial treatment and bladder cancer recurrence has been investigated less frequently and not prospectively yet.

METHODS

722 non-muscle-invasive bladder cancer (NMIBC) patients (pTa, pT1, and CIS) from the prospective Bladder Cancer Prognosis Programme (BCPP) cohort, selected in the UK between 2005 and 2011, provided complete data on smoking behavior before and up to 5 years after diagnosis. The impact of smoking behavior on NMIBC recurrence was explored by multivariable Cox regression models investigating time-to-first NMIBC recurrence.

RESULTS

Over a median follow-up period of 4.21 years, 403 pathologically confirmed NMIBC recurrences occurred in 210 patients. Only 25 current smokers at diagnosis quit smoking (14%) during follow-up and smoking cessation after diagnosis did not decrease risk of recurrence compared to continuing smokers (p = 0.352).

CONCLUSIONS

Although quitting smoking after diagnosis might reduce the risk of recurrence based on retrospective evidence, this is not confirmed in this prospective study because the number of NMIBC patients quitting smoking before their first recurrence was too low. Nevertheless, this indicates an important role for urologists and other health care professionals in promoting smoking cessation in NMIBC.

Relationship between pulmonary function and peripheral vascular function in older Chinese: Guangzhou biobank cohort study-CVD

BACKGROUND

Findings describing the relationship between pulmonary function and peripheral vascular function have been inconclusive. We explored this relationship in Guangzhou Biobank Cohort Study-Cardiovascular Subcohort (GBCS-CVD).

METHODS

Brachial-ankle pulse wave velocity (baPWV) and ankle brachial index (ABI) were measured by a waveform analyser, and pulmonary function by turbine flowmeter spirometry. Predicted forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were derived using equations for Chinese. Regression analyses were used to investigate the association.

RESULTS

Of 1528 older Chinese, 980 (64.1%) had arterial stiffness (baPWV ≥1400 cm/s), but only 29 (1.9%) had peripheral arterial disease (PAD) (ABI < 0.9). The mean (±standard deviation, SD) baPWV was 1547 (±298) cm/s and mean (±SD) ABI 1.09 (±0.09). Before and after adjusting for potential confounders, baPWV was negatively associated with FEV1 and FVC % predicted (% predicted = observed/predicted × 100%) (adjusted β: - 0.95 and - 1.16 respectively, p < 0.05), and ABI was marginally non-significantly positively associated with FEV1% predicted (adjusted β 0.02, p = 0.32) and FVC% predicted (adjusted β 0.02, p = 0.18). Compared to participants in the highest tertile of pulmonary function, those in the lowest had higher risk of arterial stiffness (adjusted odds ratio (AOR) 1.51, 95% CI 1.09-2.10 for FEV1 and AOR 1.69, 95% CI 1.22-2.33 for FVC), but the higher risk of PAD was marginally non-significant (AOR 1.64, p = 0.42 for FEV1 and AOR 1.65, p = 0.24 for FVC).

CONCLUSION

In older relatively healthy normal weight Chinese, pulmonary function was inversely dose-dependently associated with arterial stiffness, while the association with PAD was much weaker.

Exploring the roles of urinary HAI-1, EpCAM & EGFR in bladder cancer prognosis & risk stratification

Objectives

To investigate whether elevated urinary HAI-1, EpCAM and EGFR are independent prognostic biomarkers within non-muscle-invasive bladder cancer (NMIBC) patients, and have utility for risk stratification to facilitate treatment decisions.

Results

After accounting for EAU risk group in NMIBC patients, the risk of BC-specific death was 2.14 times higher (95% CI: 1.08 to 4.24) if HAI-1 was elevated and 2.04 times higher (95% CI: 1.02 to 4.07) if EpCAM was elevated. The majority of events occurred in the high-risk NMIBC group and this is where the biggest difference is seen in the survival curves when plotted for EAU risk groups separately. In MIBC patients, being elevated for any of the three biomarkers was significantly associated with BC-specific mortality after accounting for other risk factors, HR = 4.30 (95% CI: 1.85 to 10.03).

Patients and Methods

Urinary levels of HAI-1, EpCAM and EGFR were measured by ELISA in 683 and 175 patients with newly-diagnosed NMIBC and MIBC, respectively, recruited to the Bladder Cancer Prognosis Programme. Associations between biomarkers and progression, BC-specific mortality and all-cause mortality were evaluated using univariable and multivariable Cox regression models, adjusted for European Association of Urology (EAU) NMIBC risk groups. The upper 25% of values for each biomarker within NMIBC patients were considered as elevated. Exploratory analyses in urine from MIBC patients were also undertaken.

Conclusion

Urinary HAI-1 and EpCAM are prognostic biomarkers for NMIBC patients. These biomarkers have potential to guide treatment decisions for high-risk NMIBC patients. Further analyses are required to define the roles of HAI-1, EpCAM and EGFR in MIBC patients.

High relative risk of all-cause mortality attributed to smoking in China: Guangzhou Biobank Cohort Study

BACKGROUND

Prediction of disease burden in China arising from smoking based on earlier cohorts in the West and China could not reflect the disease burden at the current stage accurately. No cohort studies in China focused specifically on people born since 1950. We examined the risk of all-cause mortality attributed to smoking in adults in Guangzhou, the city with the most rapidly expanding economy in China.

METHODS AND FINDINGS

This population-based prospective cohort included 21,658 women and 8,284 men aged 50+ years enrolled from 2003-2008 and followed until January 2016. During an average follow-up of 8.8 (standard deviation = 1.8) years, 2,986 (1,586 women, 1,400 men) deaths were recorded. After adjustment for confounders, the hazards ratios (95% confidence interval (CI)) of all-cause mortality in current versus never smokers increased from 1.61 (95% CI 1.45-1.80) in those born in 1920-1939 to 2.02 (95% CI 1.74-2.34), and 4.40 (95% CI 3.14-6.17), in those born in the 1940s and 1950s, respectively (P for trend 0.009).

CONCLUSIONS

In smokers born after 1949 in Guangzhou and other areas which have the longest history of smoking, the mortality risk could have reached three fold that of non-smokers, as in the UK, US and Australia. If confirmed, unless China quickly and strictly complies with the WHO Framework Convention on Tobacco Control with massive smoking cessation in the population, this is a more striking warning that China will be facing an even larger disease burden from tobacco use than previous forecasts.

Fruit and vegetable intake and the risk of recurrence in patients with non-muscle invasive bladder cancer: a prospective cohort study

Introduction

There is some evidence that greater consumption of fruit and vegetables decreases the risk of bladder cancer. The role of fruit and vegetables in bladder cancer recurrence is still unknown.

Objective

The role of total fruit and vegetable intake in relation to the risk of developing bladder cancer recurrence in a prospective cohort study.

Methods

728 patients with non-muscle invasive bladder cancer (NMIBC), who completed self-administrated questionnaires on fruit and vegetable intake at time of diagnosis (over the year before diagnosis) and 1 year after diagnosis, were included. Hazard ratios and 95% confidence intervals were calculated by multivariable Cox regression for developing recurrent bladder cancer in relation to fruit and vegetable intake.

Results

During 2,051 person-years of follow-up [mean (SD) follow-up 3.7 (1.5) years], 241 (33.1%) of the included 728 NMIBC patients developed a recurrence of bladder cancer. The sum of total fruit and vegetables before diagnosis was not related to a first bladder cancer recurrence (HR 1.07; 95% CI 0.78–1.47, p = 0.66). No association was found between greater consumption of fruit and vegetables over the year before diagnosis and the risk of developing multiple recurrences of bladder cancer (HR 1.02; 95% CI 0.90–1.15, p = 0.78). Among the remaining 389 NMIBC patients who reported on fruit and vegetable intake 1 year after diagnosis, no association was found between greater consumption of fruit and vegetables and a first recurrence of bladder cancer (HR 0.65; 95% CI 0.42–1.01, p = 0.06) nor with multiple recurrences of bladder cancer (HR 1.00, 95% CI 0.85–1.18, p = 1.00). Similar results were obtained when investigating the association between total intakes of fruit and vegetables separately and bladder cancer recurrence.

Conclusion

Results from this study did not indicate a protective role for total fruit and vegetables in the development of a recurrence of NMIBC.

Electronic supplementary material

The online version of this article (10.1007/s10552-018-1029-9) contains supplementary material, which is available to authorized users.

Impact of dietary patterns and the main food groups on mortality and recurrence in cancer survivors: a systematic review of current epidemiological literature

OBJECTIVE

To determine whether there is an association between dietary patterns/indices and foods from the main food groups (highest vs lowest intakes) prior to or after cancer diagnosis and mortality and cancer recurrence in cancer survivors.

PARTICIPANTS

Survivors of common cancers with a 10-year survival rate of ≥50%: bladder, bowel, breast, cervical, kidney, laryngeal, prostate, testicular, uterine cancer, malignant melanoma and (non-)Hodgkin's lymphoma.

OUTCOME MEASURES

Mortality (overall, cancer-specific, from other causes) and cancer recurrence.

INFORMATION SOURCES

PubMed, Embase and the Cochrane Library were searched from inception to April 2017. Additional studies were identified by searching reference lists. Two authors independently screened titles and abstracts, assessed study quality and extracted the data.

RESULTS

A total of 38 studies were included. The risk of bias was rated low for the included randomised controlled trials (RCTs) and moderate for the cohort studies. The quality of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach and was rated moderate (RCTs), and (very)low (cohort studies). Reducing the amount of fat after diagnosis appears to decrease the risk of breast cancer recurrence. Adherence to a high-quality diet and prudent diet after diagnosis appears to decrease the risk of death from other causes (and overall mortality for high-quality diet) in breast cancer survivors. Adherence to a Western diet, before and after diagnosis, appears to increase the risk of overall mortality and death from other causes among breast cancer survivors. Evidence from studies among other cancer survivors was too limited or could not be identified.

CONCLUSION

For many cancer survivors, there is little evidence to date to indicate that particular dietary behaviours influence outcomes with regard to recurrence and mortality. Notwithstanding, limited evidence suggests that a low-fat diet, a high-quality diet and a prudent diet are beneficial for breast cancer survivors, while a Western diet is detrimental for breast cancer survivors.

Effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6 and 7 year olds: cluster randomised controlled trial (WAVES study)

OBJECTIVE

To assess the effectiveness of a school and family based healthy lifestyle programme (WAVES intervention) compared with usual practice, in preventing childhood obesity.

DESIGN

Cluster randomised controlled trial.

SETTING

UK primary schools from the West Midlands.

PARTICIPANTS

200 schools were randomly selected from all state run primary schools within 35 miles of the study centre (n=980), oversampling those with high minority ethnic populations. These schools were randomly ordered and sequentially invited to participate. 144 eligible schools were approached to achieve the target recruitment of 54 schools. After baseline measurements 1467 year 1 pupils aged 5 and 6 years (control: 28 schools, 778 pupils) were randomised, using a blocked balancing algorithm. 53 schools remained in the trial and data on 1287 (87.7%) and 1169 (79.7%) pupils were available at first follow-up (15 month) and second follow-up (30 month), respectively.

INTERVENTIONS

The 12 month intervention encouraged healthy eating and physical activity, including a daily additional 30 minute school time physical activity opportunity, a six week interactive skill based programme in conjunction with Aston Villa football club, signposting of local family physical activity opportunities through mail-outs every six months, and termly school led family workshops on healthy cooking skills.

MAIN OUTCOME MEASURES

The protocol defined primary outcomes, assessed blind to allocation, were between arm difference in body mass index (BMI) z score at 15 and 30 months. Secondary outcomes were further anthropometric, dietary, physical activity, and psychological measurements, and difference in BMI z score at 39 months in a subset.

RESULTS

Data for primary outcome analyses were: baseline, 54 schools: 1392 pupils (732 controls); first follow-up (15 months post-baseline), 53 schools: 1249 pupils (675 controls); second follow-up (30 months post-baseline), 53 schools: 1145 pupils (621 controls). The mean BMI z score was non-significantly lower in the intervention arm compared with the control arm at 15 months (mean difference -0.075 (95% confidence interval -0.183 to 0.033, P=0.18) in the baseline adjusted models. At 30 months the mean difference was -0.027 (-0.137 to 0.083, P=0.63). There was no statistically significant difference between groups for other anthropometric, dietary, physical activity, or psychological measurements (including assessment of harm).

CONCLUSIONS

The primary analyses suggest that this experiential focused intervention had no statistically significant effect on BMI z score or on preventing childhood obesity. Schools are unlikely to impact on the childhood obesity epidemic by incorporating such interventions without wider support across multiple sectors and environments.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN97000586.

HumanMethylation450K Array-Identified Biomarkers Predict Tumour Recurrence/Progression at Initial Diagnosis of High-risk Non-muscle Invasive Bladder Cancer

Background:

High-risk non-muscle invasive bladder cancer (HR-NMIBC) is a clinically unpredictable disease. Despite clinical risk estimation tools, many patients are undertreated with intra-vesical therapies alone, whereas others may be over-treated with early radical surgery. Molecular biomarkers, particularly DNA methylation, have been reported as predictive of tumour/patient outcomes in numerous solid organ and haematologic malignancies; however, there are few reports in HR-NMIBC and none using genome-wide array assessment. We therefore sought to identify novel DNA methylation markers of HR-NMIBC clinical outcomes that might predict tumour behaviour at initial diagnosis and help guide patient management.

Patients and methods:

A total of 21 primary initial diagnosis HR-NMIBC tumours were analysed by Illumina HumanMethylation450 BeadChip arrays and subsequently bisulphite Pyrosequencing. In all, 7 had not recurred at 1 year after resection and 14 had recurred and/or progressed despite intra-vesical BCG. A further independent cohort of 32 HR-NMIBC tumours (17 no recurrence and 15 recurrence and/or progression despite BCG) were also assessed by bisulphite Pyrosequencing.

Results:

Array analyses identified 206 CpG loci that segregated non-recurrent HR-NMIBC tumours from clinically more aggressive recurrence/progression tumours. Hypermethylation of CpG cg11850659 and hypomethylation of CpG cg01149192 in combination predicted HR-NMIBC recurrence and/or progression within 1 year of diagnosis with 83% sensitivity, 79% specificity, and 83% positive and 79% negative predictive values.

Conclusions:

This is the first genome-wide DNA methylation analysis of a unique HR-NMIBC tumour cohort encompassing known 1-year clinical outcomes. Our analyses identified potential novel epigenetic markers that could help guide individual patient management in this clinically unpredictable disease.

Associations between maternal exposure to incense burning and blood pressure during pregnancy

Incense burning is a popular practice in Asian and Arabic countries. Previous studies show that incense burning was associated with increased risks of adverse outcomes among non-pregnant population. However, very few studies explored its health effects among pregnant women, who are more susceptible to environmental stressor. We aimed to examine the association between incense burning at home and hypertensive disorders as well as blood pressure levels during pregnancy, using data from 10,563 pregnant women recruited in Born in Guangzhou Cohort Study, China between January 2013 and December 2015. Information on frequency and duration of exposure to incense burning were collected at early and late pregnancy using questionnaire. Data on outcome variables, including hypertensive disorders diagnosis and blood pressure levels at the final antenatal visit before delivery, were extracted from medical records. We used Poisson regression model and general linear model to examine the associations between incense exposure and the outcomes. We found incense use at early pregnancy was not significantly associated with outcomes. Pregnant women who frequently smelled the incense burning at late pregnancy was associated with higher risk of hypertensive disorders (relative risk, 1.84; 95% confidence interval, 1.14-2.98) and higher levels of blood pressure (1.6mmHg increase of systolic blood pressure; 95% confidence interval, 0.4-2.8mmHg) before delivery, compared to those did not burn incense. These associations tended to more evident among women without active and passive smoking. We did not observe significant dose-response relationship between exposure duration and the risk of hypertensive disorders. We firstly reported exposure to incense burning was associated with the risk of hypertensive disorders and blood pressure levels during pregnancy. Given hypertensive disorders in pregnancy are well-established risk factors for a variety of adverse outcomes and the incense burning is a modifiable factor, our finding may have important public health significance.

Age at menarche and depressive symptoms in older Southern Chinese women: A Mendelian randomization study in the Guangzhou Biobank Cohort Study

To clarify the causal role of age at menarche in depressive symptoms we conducted a Mendelian randomization study using a large Southern Chinese cohort (n = 12,233). A genetic allele score was derived using stepwise regression with cross validation. Older age at menarche was not associated with geriatric depression scale score. Our findings suggest that higher rates of depression in women are likely attributable to other factors which require investigation.

Males with prolactinoma are at increased risk of incident cardiovascular disease

OBJECTIVE

To investigate whether the risk of incident cardiovascular disease (CVD) is increased in patients with prolactinoma.

DESIGN

Population-based, retrospective, open-cohort study using The Health Improvement Network (THIN) database.

PATIENTS

A total of 2233 patients with prolactinoma and 10 355 matched controls (1:5 ratio) from UK General Practices contributing to THIN were included. Sex, age, body mass index and smoking status were used as matching parameters. The primary outcome was any incident CVD, defined by Read codes suggesting myocardial infarction, angina pectoris, stroke, transient ischaemic attack or heart failure. Sex-specific-adjusted incidence rate ratios (aIRRs) were calculated with Poisson regression, using clinically relevant parameters as model covariates. Sensitivity analyses were performed to check whether a change in the initial assumptions could have an impact on the findings.

RESULTS

During the 6-year observation period, the composite CVD outcome was recorded in 54 patients with prolactinoma and 180 "nonexposed" individuals. The incidence rate was 1.8 and 14.8 per 1000 person-years for the females and males with prolactinoma, respectively. The aIRRs for CVD were estimated at 0.99 [95% confidence interval (CI): 0.61-1.61, P = .968)] in female patients and 1.94 (95% CI: 1.29-2.91, P = .001) in male patients. These findings remained robust in sensitivity analyses restricting to patients with documented record of dopamine agonist treatment and those with newly diagnosed prolactinoma.

CONCLUSIONS

In contrast to females, men with prolactinoma have increased risk for incident CVD; the aetiology of this gender-specific finding remains to be elucidated.

The primary health-care system in China

China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an integrated, cooperative primary health-care system, generating knowledge from practice that can support improvements, and bolstered by evidence-based performance indicators and incentives.

Effectiveness of a Kindergarten-Based Intervention for Preventing Childhood Obesity

BACKGROUND AND OBJECTIVES

Interventions to prevent childhood obesity targeting school age children have mostly reported limited effectiveness, suggesting such prevention programs may need to start at an earlier age, but evidence has been scarce. We reported a pilot study aiming to demonstrate the feasibility of a multifaceted intervention for preschool children and to provide a preliminary assessment of the effectiveness.

METHODS

This nonrandomized controlled trial recruited children aged 3 to 6 years from 6 kindergartens in Guangzhou, China. Based on the preference of the School and Parents Committees, 4 kindergartens (648 children) received a 3-component intervention (training of kindergarten staff, initiating healthy curriculum for children, and close collaboration between families and kindergartens) over 12 months, while the other 2 kindergartens (336 children), serving as controls, received routine health care provision. Outcome measures were the changes in BMI z score between baseline and the end of 12 months, and the prevalence of postintervention children who were overweight or obese.

RESULTS

By 12 months, children within the intervention group had a smaller BMI z score increase (0.24) compared to the control (0.41), with a difference of -0.31 (95% CI -0.47 to -0.15). The prevalence of overweight or obesity was also lower among the intervention group at the end of the study (OR: 0.43, 95% CI 0.19 to 0.96), adjusted for baseline status.

CONCLUSIONS

Our results indicated a multicomponent health behavior intervention might be effective in reducing the prevalence of obesity, but the longer term effects will need confirmation from randomized controlled trials.

Cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of an obesity prevention programme for Chinese primary school-aged children: the CHIRPY DRAGON study protocol

INTRODUCTION

Childhood obesity in China has increased more rapidly and over a shorter time period than in other countries. However, there is a paucity of rigorously developed and evaluated prevention interventions. We aim to evaluate the clinical and cost-effectiveness as well as the implementation process of a complex multicomponent intervention developed using the UK Medical Research Council (MRC) framework. This study provides one of the first examples of rigorous development and evaluation of a childhood obesity prevention programme in a non-western population using the MRC methods.

METHODS AND ANALYSIS

A cluster-randomised controlled trial in 40 primary schools in Guangzhou, China, including children aged 6-7 years at baseline. Schools will be randomly allocated to either the usual practice (n=20) or intervention arm (n=20). The 12-month intervention consists of four components targeting diet and physical activity behaviours in and outside school, with family involvement. The primary objective is to compare the difference in mean body mass index (BMI) z-score between the intervention and control arms at the end of the intervention (starting March/April 2017). A sample size of 1640 pupils recruited from 40 schools is sufficient to detect a difference of 0.17 units in the mean BMI z-score with a power of 80% (ICC=0.01. ICC, intraclass correlation coefficient) and a significance level of 5%. Treatment effects will be tested using a mixed linear model in STATA adjusting for the child baseline BMI z-score and clustering by school. All analyses will be by intention to treat. Secondary analyses will additionally adjust for prespecified school-level and child-level covariates. The incremental cost-effectiveness ratio for the intervention versus usual practice will be 'cost per quality-adjusted life year (QALY)'. Cost per change in BMI z-score will also be assessed. A range of methods will be used to evaluate intervention implementation, mechanisms of impact and contextual factors.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Life and Health Sciences Ethical Review Committee at the University of Birmingham and the Ethical Committee of Guangzhou Centre for Disease Control and Prevention. The primary, secondary, process evaluation and economic evaluation results of the trial will be disseminated through relevant international peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN11867516; Pre-results.

Childhood secondhand smoke exposure and pregnancy loss in never smokers: the Guangzhou Biobank Cohort Study

OBJECTIVE

Studies of secondhand smoke (SHS) exposure especially childhood SHS exposure and pregnancy loss are limited. We used baseline data of the Guangzhou Biobank Cohort Study (GBCS) to examine the association of childhood SHS exposure with a history of pregnancy loss.

METHODS

Never smoking women aged 50 years or above in GBCS from 2003 to 2008 were included. Propensity score matching (PSM) was used to control for confounding. Negative binomial regression and logistic regression were used to examine the association of childhood SHS, assessed by number of smokers in childhood household and frequency of exposure, with past pregnancy loss.

RESULTS

Of 19 562 women, 56.7% (11 096) had SHS exposure during childhood. In negative binomial regression, after adjusting for age, education, past occupational dust exposure, past home fuel exposure, oral contraceptive, adulthood SHS exposure, age at first pregnancy and age at first menarche, compared to non-exposure, the incidence rate ratio of one more pregnancy loss was 1.20 (95% CI1.05 to 1.37) in those who lived with ≥2 smokers in the same household, and 1.14 (95% CI 1.04 to 1.25) in those exposed ≥5 times/week. After similar adjustment, logistic regression showed that the OR of pregnancy loss ≥2 times (versus 0 to 1 time) was 1.25 (95% CI 1.00 to 1.57) and 1.20 (95% CI 1.03 to 1.40) for high density (≥2 smokers in the same household) and frequency (≥5 times/week) of childhood exposure, respectively.

CONCLUSIONS

Childhood SHS exposure was associated with higher risks of pregnancy loss in middle-aged and older Chinese women.

Association of adiposity with pulmonary function in older Chinese: Guangzhou Biobank Cohort Study

OBJECTIVE

We examined the association between different adiposity indices and pulmonary function in Chinese adults in the Guangzhou Biobank Cohort Study (GBCS).

METHODS

Participants with body mass index (BMI) < 18.5 (underweight) were excluded. Adiposity indices including BMI, waist circumference (WC), waist hip ratio, waist height ratio and body fat percentage were measured. Lung function was assessed by spirometry using a turbine flowmeter. We analyzed percent predicted for forced expiratory volume in 1 s (FEV₁%), forced vital capacity (FVC %) and restrictive respiratory defect (FEV₁/FVC ratio > low limits of normal and FVC % <0.80).

RESULTS

Of 16186 participants (mean age 61.4 ± 7.2 years; 74.0% women), 116 (0.7%) had only general obesity (BMI ≥28 kg/m²), 4079 (25.2%) had only central obesity (WC: ≥90 cm in men, ≥80 cm in women) and 1591 (9.8%) had both central obesity and general obesity. Comparing to those with neither central nor general obesity, those with only central adiposity and with both central and general obesity had lower pulmonary function (adjusted β range from -2.85 to -6.02 for FEV₁% and FVC%, adjusted OR range from 1.14 to 1.70, all P < 0.05). But those with only general obesity had better but non-significant pulmonary function. (Crude β range from 1.46 to 2.92 for FEV₁% and FVC%, crude OR range from 0.68 to 0.93, all P > 0.05). Both FEV₁% and FVC% decreased per standard deviation increase in obesity indices (adjusted β from -0.46 to -3.17, all P < 0.002). A positive association of central or general obesity with restrictive respiratory defect was observed (adjusted odds ratio (AOR) from 1.50 to 2.04, all P < 0.002). Further adjustment for WC reversed the inverse association between BMI and pulmonary function (adjusted β from 1.93 to 6.22, all P < 0.001) and restrictive respiratory defect (adjusted AOR from 0.72 to 0.80, all P < 0.001).

CONCLUSION

Central adiposity and its indices, but not general adiposity and BMI, were independently associated with lower pulmonary function and higher risk of restrictive respiratory defect in older Chinese.