Effect of a community-based intervention on nutritional behaviour in a developing country setting: the Isfahan Healthy Heart Programme

Lipid accumulation product and visceral adiposity index for incidence of cardiovascular diseases and mortality; results from 13 years follow-up in Isfahan cohort study

Background

/Aims: Visceral adiposity index (VAI) and lipid accumulation product (LAP) are novel anthropometric indices that have shown an association with metabolic syndrome; however, limited data are available regarding the predictive performance of these indices for the incidence of cardiovascular diseases (CVD) and mortality.

Methods

This study was performed on the data retrieved from Isfahan Cohort Study (ICS). ICS is an ongoing population-based cohort study conducted in 3 counties in central Iran. Pearson correlation analysis was performed between LAP, VAI, and metabolic parameters. Cox regression analysis and receiver operative characteristics (ROC) curve analysis were performed in order to evaluate the ability of VAI and LAP for the incidence of CVD, CVD-associated mortality, and all-cause mortality. We further compared the predictive performance of VAI and LAP with body mass index (BMI).

Results

LAP and VAI were significantly correlated with all metabolic variables, including blood pressure, fasting blood glucose, and lipid profile components. Univariate regression analysis indicated a significant association between LAP and VAI and CVD incidence. In multivariate analysis, only VAI was significantly associated with CVD incidence. Regarding CVD mortality, only VAI in the multivariate analysis revealed a significant association. Interestingly, Both VAI and LAP were negatively associated with all-cause mortality. ROC curve analysis indicated the superior performance of LAP and VAI for predicting CVD incidence compared to BMI; however, BMI was better in predicting all-cause mortality.

Conclusion

Compared to BMI, LAP and VAI have better predictive performance for the incidence of CVD. In contrast, BMI was superior to VAI and LAP in the prediction of all-cause mortality.

A healthy diet, physical activity, or either in relation to cardiovascular and all-cause mortality: A prospective cohort study

OBJECTIVES

The aim of our study was to compare four lifestyles-healthy diet and low activity, unhealthy diet and high activity, unhealthy diet and low activity, and healthy diet and high activity-in relation to the risk of cardiovascular disease (CVD) and all-cause mortality.

METHODS

A total of 6504 adults ages ≥35 y were recruited to participate in the Isfahan Cohort Study and followed for 13 y. Diet was assessed using a validated 48-item food frequency questionnaire, and the quality of diet was assessed using the Dietary Quality Index. Physical activity (PA) was evaluated using the International Physical Activity Questionnaire. The primary outcomes were CVD and all-cause mortality. Cox proportional hazards regression was used to calculate the hazard ratio (HR) and the 95% CIs.

RESULTS

During 771 440 person-years of follow-up, 390 and 147 deaths occurred due to all causes and CVD, respectively. High PA, either with a healthy or unhealthy diet, was associated with a lower risk of death from CVD (HR = 0.43; 95% CI, 0.26-0.69, and HR = 0.32; 95% CI, 0.18-0.56, respectively) and also all-cause mortality(HR = 0.53, 95% CI, 0.39-0.71, and HR = 0.5, 95% CI, 0.36-0.68). Moreover, type of PA was important, such that when leisure time PA was considered, none of the lifestyles was associated with a lower risk of CVD and all-cause mortality. However, for occupational PA, the result was the same as the total PA.

CONCLUSIONS

Having high PA (total or occupational), with or without adhering to a healthy diet, is associated with a lower risk of death from any cause and CVD; although leisure time PA, irrespective of adhering to a healthy diet, was not associated with a lower risk of all-cause and CVD mortality.

The association between adherence to diet quality index and cardiometabolic risk factors in overweight and obese women: a cross-sectional study

Background

Obesity and overweight status increase the risk of cardiovascular disease. Diet quality can also predict the risk of cardiovascular diseases in obese and overweight patients. Therefore, in this study, we sought to examine the relationship between diet quality index (DQI) and cardiometabolic risk factors in obese and overweight women.

Method

A cross-sectional study was conducted on 197 Iranian women with a Body Mass Index (BMI) > 25, 18-48 years, and recruited from 20 Tehran Health Centers. Nutrition intake and DQI were assessed using a 147-item semi-quantitative food frequency questionnaire (FFQ). Additionally, anthropometric measurements, body composition, biochemical evaluations, and cardiometabolic risk factors were evaluated.

Results

There was an association between DQI and waist-to-hip ratio (WHR), atherogenic index of plasma (AIP), and CHOLINDEX in obese women, after adjusting for potential confounders. Whereas, there were no significant associations of the tertiles of DQI compared with the first tertile in other cardiometabolic risk factors, before and after adjustment.

Conclusion

This study provides evidence that dietary intake and DQI are associated with cardiometabolic risk factors and that dietary modification may be a predictor for reducing WHR, AIP, and CHOLINDEX. However, more research is needed to develop a DQI that reflects changes in cardiometabolic risk factors by considering women's eating habits and patterns.

Longitudinal association of dietary habits and the risk of cardiovascular disease among Iranian population between 2001 and 2013: the Isfahan Cohort Study

There has been a steady rise in the incidence of cardiovascular disease (CVD) in the Iranian population. The aim of this study is to investigate the association between Global Dietary Index (GDI) and CVD risk among the Iranian adult population. This study was conducted based on Isfahan Cohort Study, a longitudinal study that collected data between 2001 and 2013 on 6405 adults. Dietary intakes were assessed by a validated food frequency questionnaire to calculate GDI. All participants were followed every two years by phone call to ask about death, any hospitalization, or cardiovascular events to examine CVD events. The Average age of participants was 50.70 ± 11.63 and the median of GDI score was 1 (IQR: 0.29). A total of 751 CVD events (1.4 incidence rate, per 100 person-year) occurred during 52,704 person-years of follow-up. One-unit GDI increase was associated with a higher risk of MI by 72% (HR: 1.72; 95% CI 1.04-2.84), stroke by 76% (HR: 1.76; 95% CI 1.09-2.85) and CVD by 30% (HR: 1.48; 95% CI 1.02-2.65). In addition, a one-unit GDI increase was associated with a higher risk of coronary heart disease more than 2 times (HR: 2.32; 95% CI 1.50-3.60) and CVD mortality and all-cause mortality over than 3 times [(HR: 3.65; 95% CI 1.90-7.01) and (HR: 3.10; 95% CI 1.90-5.06), respectively]. Higher GDI had a significant relationship with the increased risk of CVD events and all-cause mortality. Further epidemiological studies in other populations are suggested to confirm our findings.

The association between daytime sleep and general obesity risk differs by sleep duration in Iranian adults

BACKGROUND

Sleep duration and daytime napping and obesity are related to adiposity; however, it is not clear whether the association between daytime napping and adiposity measures can differ by sleep duration.

AIM

To clarify the association between daytime napping and general and abdominal obesity based on sleep duration of participants.

SUBJECTS AND METHODS

This cross-sectional study was conducted on 1,683 individuals (837 men and 846 women) aged ≥ 35 years. Height, weight and waist circumference (WC) were measured according to the standard protocols. Body mass index (BMI) was calculated. Self-reported sleep duration (in a 24-hour cycle) was recorded. The odds of general and abdominal obesity were compared between nappers and non-nappers, stratified by their sleep duration (≤ 6 h, 6-8 h, ≥ 8 h).

RESULTS

The mean (SD) age of participants was 47.48 ± 9.35 years. Nappers with a short sleep duration (≤ 6 h) had greater BMI and higher risk for overweight/obesity compared with counterpart non-nappers after adjustment for potential confounders (OR = 1.61, 95% CI = 1.07-2.41). In subjects with moderate sleep duration (6-8 h), nappers had a tendency towards higher BMI in comparison with non-nappers (28.04 ± 0.25 vs. 26.93 ± 0.51 kg/m²; p = 0.05), however, no significant difference was observed for the risk of obesity. Daytime napping was not related to the risk of obesity in long sleepers. No significant association was observed for abdominal obesity measures.

CONCLUSIONS

Daytime napping is associated with increased risk of overweight/obesity in short sleepers. However, in subjects with longer sleep duration, it is not related to the risk of overweight/obesity.

Evaluating the Dissemination and Implementation of a Community Health Worker-Based Community Wide Campaign to Improve Fruit and Vegetable Intake and Physical Activity among Latinos along the U.S.-Mexico Border

This study evaluated the dissemination and implementation of a culturally tailored community-wide campaign (CWC), Tu Salud ¡Si Cuenta! (TSSC), to augment fruit and vegetable (FV) consumption and physical activity (PA) engagement among low-income Latinos of Mexican descent living along the U.S.-Mexico Border in Texas. TSSC used longitudinal community health worker (CHW) home visits as a core vehicle to enact positive change across all socioecological levels to induce behavioral change. TSSC's reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) was examined. A dietary questionnaire and the Godin-Shepherd Exercise Questionnaire measured program effectiveness on mean daily FV consumption and weekly PA engagement, respectively. Participants were classified based on CHW home visits into "low exposure" (2-3 visits) and "high exposure" (4-5 visits) groups. The TSSC program reached low-income Latinos (n = 5686) across twelve locations. TSSC demonstrated effectiveness as, compared to the low exposure group, the high exposure group had a greater FV intake (mean difference = +0.65 FV servings daily, 95% CI: 0.53-0.77) and an increased PA (mean difference = +185.6 MET-minutes weekly, 95% CI: 105.9-265.4) from baseline to the last follow-up on a multivariable linear regression analysis. Multivariable logistic regression revealed that the high exposure group had higher odds of meeting both FV guidelines (adjusted odds ratio (AOR) = 2.03, 95% CI: 1.65-2.47) and PA guidelines (AOR = 1.36, 95% CI: 1.10-1.68) at the last follow-up. The program had a 92.3% adoption rate, with 58.3% of adopting communities meeting implementation fidelity, and 91.7% of communities maintaining TSSC. TSSC improved FV consumption and PA engagement behaviors among low-income Latinos region wide. CHW delivery and implementation funding positively influenced reach, effectiveness, adoption, and maintenance, while lack of qualified CHWs negatively impacted fidelity.

Community-Based Interventions to Reduce Fat Intake in Healthy Populations: A Systematic Review and Meta-Analysis

Background:

Reducing fat intake is a major focus of most dietary recommendations aiming to prevent chronic diseases. Thus, this study aimed to summarize community-based interventions for reducing fat consumption among healthy people.

Methods:

According to PRISMA guidelines, in this systematic review and meta-analysis databases including PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of Science, ProQuest, and Google Scholar were searched up to January 2021. Randomized clinical trials (RCTs) or quasi-experimental studies reporting the effect of community-based interventions to reduce fat intake in a healthy populations were included. The quality of studies was assessed using the Cochrane Collaboration tool and The Joanna Briggs Institute Critical Appraisal Checklist. Meta-analysis was performed using CMA2 software.

Results:

Our search strategy resulted in a total of 1,621 articles, 43 of which were included in the study after screening. Of the 43 included studies, 35 studies reported a significant decrease in fat intake using educational and multiple intervention methods. About 82% of studies using the technology were effective (significant decrease in fat intake) in reducing fat intake. Moreover, studies specifically designed to change fat intake were more effective than multicomponent interventions. The meta-analysis of high-quality studies showed that the differences in total fat (-0.262 g/d) and saturated fat (-0.350 g/d) intake between the intervention and control groups were statistically significant (P<0.05).

Conclusion:

Based on the high-quality studies, educational and multiple interventions are suggested in the community settings to decrease fat intake. For a concise conclusions, long-term and high frequency interventions focusing on reducing fat intake are desirable.

How different domains of quality of life are associated with latent dimensions of mental health measured by GHQ-12

BACKGROUND AND OBJECTIVES

A short form of the General Health Questionnaire (GHQ-12) is a useful screening instrument for assessing mental health. Furthermore, Quality of life (QoL) is a critical treatment outcome in many clinical and health care research settings. This study aimed to reassess the dimensionality of GHQ-12 using Multidimensional Graded Response Model (MGRM) and evaluate how its extracted dimensions are associated with the QoL's domains.

METHODS

Isfahan Cohort Study 2 (ICS2) is a population-based, ongoing prospective cohort study among adults aged 35 years and older who were free of cardiovascular diseases (CVDs) at the beginning of the study in 2013. A total of 1316 participants, all living in urban and rural areas of Isfahan and Najafabad, Iran was completed the GHQ-12 and WHO QoL-brief version at baseline. Five competing MGRMs with different latent structures were specified for GHQ-12. Factor scores derived from the best fitted model were used to associate with various domains of QoL.

RESULTS

The Three-Dimensional model for GHQ-12 was the best-fitted model explaining the Social Function (SF), Self Confidence (SC), and Anxiety/Depression (A/D) as three correlated yet different latent dimensions of mental health. Our findings in full adjusted multivariate regression models showed that a one-SD increase in dimensions of SC and SF was associated with a 38- to 48%-SD and 27- to 38%-SD increase in the domains scores of QoL, respectively. Moreover, for each one-SD increase in score of A/D dimension, the domains scores of QoL decreased by 29- to 40%-SD. The highest to the lowest standardized coefficients for all latent dimensions of mental health were respectively related to the psychological, physical health, social relationships, and environmental condition domains of QoL. Furthermore, SC, A/D, and SF dimensions of GHQ-12 showed the highest to the lowest degree of association with all domains of QoL.

CONCLUSIONS

Our findings confirm that the GHQ-12 as a multidimensional rather than unitary instrument measures distinct dimensions of mental health. Furthermore, all aspects of QoL changed when the intensity of latent dimensions of mental health increased. Moreover, the psychological domain of QoL is the most affected by all latent dimensions of mental health, followed by physical health, social relationships, and environmental condition domains. It seems that in an attempt to full recovery as assessed by improved QoL outcomes, treatment of clinical symptoms may not be sufficient. Identifying and differentiating the structures of mental health in each community as well as implementing intervention programs aimed at focusing on specific dimensions may help in the prevention of further deterioration of mental health and improved QoL in the community.

Longitudinal association between an overall diet quality index and latent profiles of cardiovascular risk factors: results from a population based 13-year follow up cohort study

BACKGROUND

Cardiovascular diseases (CVDs) are associated with an unhealthy lifestyle, including poor diet. Indices reflecting the overall quality of diets are more effective than single food or nutrient-based approaches in clarifying the diet disease relationship. The present study aims to use latent variable modeling to examine the longitudinal joint relationships between the latent profiles of CVDs risk factors and the diet quality index (DQI).

METHODS

A total of 4390 Iranian adults aged 35 and older within the framework of the Isfahan Cohort Study were included in the current secondary analysis. DQI focused on food groups, including fast foods, sweets, vegetables, fruits, fats, and proteins, based on a validated food frequency questionnaire. The score of DQI has a range between 0 (indicating healthy and high diet quality) and 2 (indicating unhealthy and low diet quality). Blood pressure (BP), anthropometric measurements, blood glucose, serum lipids, and high-sensitivity C-Reactive Protein (hs-CRP) were measured according to standard protocols in 2001, 2007, and 2013 to evaluate the profiles of CVDs risk factors. A Bayesian Multidimensional Graded Responses Linear Mixed Model was used for data analysis.

RESULTS

At baseline, the participants' mean ± standard deviation age was 50.09 ± 11.21, and 49.5% of them were male. Three latent profiles of CVDs risk factors were derived: (1) Fit Pre-Metabolic Syndrome (FPMS) profile characterized by normal anthropometric indices and some impaired metabolic risk factors; (2) DysLipoproteinemia Central Obese (DLCO) profile with abdominal obesity and impaired low-density lipoprotein cholesterol as well as other normal risk factors; (3) Impaired Laboratory Inflammatory State (ILIS) profile with impaired high-density lipoprotein cholesterol and hs-CRP and other normal risk factors. In general, higher scores of the extracted latent profiles indicated more impaired function in the related risk factors. After controlling for various potential fixed and time-varying confounding variables, a significant positive longitudinal association was found between FPMS, DLCO, and ILIS profiles and DQI (β (95% CrI): 0.26 (0.03,0.51), 0.14 (0.01,0.27), and 0.24 (0.11,0.38), respectively), demonstrating that lower overall diet quality was associated with more impaired function of the related risk factors.

CONCLUSIONS

More adherence to a healthy quality diet is associated with lower levels of all emerging latent profiles of CVDs risk factors. Increasing the knowledge of the community about the importance of the quality of consumed foods may help to prevent CVDs. It is recommended that further investigations, particularly interventional studies, be conducted to confirm our results.

Effectiveness of Community-Based Health Promotion Interventions in Urban Areas: A Systematic Review

Over the past few decades, a community-based approach was seen to be the "gold standard" for health promotion and disease prevention, especially in the field of socially deprived neighborhoods in urban areas. Up to the beginning of the 2000s, earlier reviews provide valuable information on activities in this context. However, in their conclusions they were limited to North America and Europe. Therefore, we conducted a systematic literature review on community-based health promotion and prevention programs worldwide. The Pubmed and PsycINFO databases were screened for relevant articles published between January 2002 and December 2018, revealing 101 potentially eligible publications out of 3646 hits. After a systematic review process including searching the reference lists, 32 papers met the inclusion criteria and were included in the review. Twenty-four (75.0%) articles reported improvements in at least one health behavior, health service access, health literacy, and/or a range of health status outcomes. Large-scale community-based health promotion programs, however, often resulted in limited or missing population-wide changes. Possible reasons are methodological limitations, concurrent context effects, and limitations of the interventions used. Our results confirm that community-based interventions are promising for health promotion and disease prevention but so far their potential is not fully realized. For the future, such interventions should aim at proximal outcomes and invest in community capacity building.

Is urinary sodium excretion related to anthropometric indicators of adiposity in adults?

Background

Although increasing salt intake is associated with greater odds of obesity, little is known about its relationship with body fat. We investigated the relation of urinary sodium (UNa) with obesity indices, including Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE), a body shape index (ABSI), body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR).

Materials and Methods

A total of 508 free-living adults aged ≥ 19 years were selected through stratified multistage random method as a representative of general population from central parts of Iran and were included in this cross-sectional study. Dietary sodium intake was measured using 24-h UNa (24-UNa) excretion. Weight, height, and WC were measured using standard protocols and calibrated equipment and used to measure obesity indicators, including BMI, WHtR, ABSI, and CUN-BAE. Adjusted univariate multiple logistic regression was used to assess the risk of having greater obesity measures across the tertiles of 24-UNa.

Results

Individuals in the top tertile of 24-UNa in comparison with those in the first tertile had greater body weight (72.02 ± 1.00 vs. 66.02 ± 0.89 kg; P < 0.0001), BMI (26.14 ± 0.33 vs. 24.82 ± 0.29 kg/m²; P = 0.007), and CUN-BAE (29.89 ± 0.42 vs. 28.38 ± 0.78; P = 0.036). There was a trend toward an increment in WC by increasing sodium intake (P = 0.073). After controlling for potential confounders, individuals with greater sodium consumption had greater chance for overweight (odds ratio [OR]: 1.004, 95% confidence interval [CI]: 1.001-1.007; P = 0.015), abdominal obesity (OR: 1.004, 95% CI: 1.00-1.008; P = 0.031), and more body fat (OR: 1.007, 95% CI: 1.003-1.01; P = 0.001). No significant association was found for sodium and WHtR and ABSI.

Conclusion

Greater 24-UNa excretion was associated with greater means of body weight, BMI, WC, and CUN-BAE. Although changes in obesity indices per each additional 24-UNa excretion were small, our findings are relevant because of the rising obesity epidemic.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Trend of salt intake measured by 24-hour urine collection samples among Iranian adults population between 1998 and 2013: The Isfahan salt study

BACKGROUND AND AIM

Few population-based studies conducted in the Eastern Mediterranean region assessed salt intake by the measurement of 24-h sodium urine excretion (24-hUNa). The current study aimed to assess the trend of mean salt intake in Iranian adults between 1998 and 2013.

METHODS AND RESULTS

These cross-sectional studies were performed on 564, 157, 509 and 837 randomly selected healthy adults aged >18 years from Isfahan city, Iran, in 1998, 2001, 2007 and 2013, respectively. BP was measured using a mercury sphygmomanometer according to a standard protocol. Single 24-h urine was collected to assess 24-hUNa as a surrogate of salt intake, and 24-h urinary K (24-hUK). The estimated trend of salt intake was 9.5, 9.7, 9.6 and 10.2 g/day in total population (P < 0.001). The increase in salt intake between 1998 and 2013 was significant only in men, (P < 0.001). The risk of pre-hypertension was 21% and 18% significantly greater in the highest quartiles of UNa/UK after adjustment for potential confounders in 2001 and 2013, respectively, [OR (95% CI): 1.21 (1.03-1.64) and 1.18 (1.02-1.38), respectively].

CONCLUSIONS

This population-based study indicated that mean salt intake was about two times of recommendation in Isfahan city, Iran, and suggest that it would be essential to implement a salt reduction strategy program in Iranian population. Longitudinal national studies with larger samples examining the trend of salt intake are warranted.

The effect of educational and encouragement interventions on anthropometric characteristics, obestatin and adiponectin levels

BACKGROUND

Lifestyle modification is the most important strategy for control of obesity and overweight. Obestatin and adiponectin are the biomarkers of obesity. Thus, this study was performed to examine the effect of educational and encouragement interventions and lifestyle modifications on obesity anthropometric as well as obestatin and adiponectin levels.

METHODS

This semi-experimental study was conducted on a subsample of TABASSOM study. Participants were 41 overweight and obese children and adolescents aged 6-18 years old and 45 overweight and obese adults aged 19-65 years old. Anthropometric characteristics including height, weight, waist and hip circumferences, and body fat percentage (BFP) were measured at the first and after one year at the end of study. We implemented some educational and encouragement interventions regarding dietary modification and physical activity during the study. Obestatin and adiponectin levels were measured at the first and end of study by enzyme-linked immunosorbent assay (ELISA) method.

RESULTS

The study did not show significant effect on anthropometric characteristics such as body mass index (BMI) and waist circumference (WC). BFP decreased significantly in boys, total children and adolescent group, and waist-to-hip ratio (WHR) decreased significantly only in adolescent boys after 1 year (P < 0.050).

CONCLUSION

Educational and encouraging interventions and lifestyle modifications could lead to decrease of body WHR and BFP in adolescent boys. This is helpful in controlling the increasing rate of obesity.

Association of socioeconomic status and hypertension based on habitual smoking among Iranian population: IHHP study

BACKGROUND

Along with tripartiteclose relationship of socioeconomic level,  smoking, and prevalence of hypertension, the present study aimed to assess the relationship between socioeconomic status (SES) and hypertension based on habitual smoking in Iranian population. Methods: The present study analyzed the individuals subsample consisted of 9623 subjects, out of all people resident in Isfahan province in Iran of the wave of the Isfahan Heart Health Project (IHHP) in three cities in Iran: Isfahan, Najafabad and Arak. Systolic and diastolic blood pressures were measured in supine position using an automated blood pressure monitor. Smokers were defined as persons who were smoked prior to the survey and never smokers were defined as a person who had never smoked.  Results: Those individuals who experienced cigarette smoking, SES class was significantly lower in hypertensive patients compared with normotensive subject so 7.8% of hypertensive patients and 92.2% of normotensive ones classified in SES class IV (p < 0.001). Univariate analysis showed hypertension was related to lower SES class when compared with normotension status in both smoker and nonsmoker groups (p < 0.001). In stepwise logistic regression models adjusting sex, age, global dietary index and leisure time physical activity, hypertension could be predicted by lower SES in nonsmoker group, while this predictive role for SES could not be reveal in smoker group.  Conclusion: the significant SES-smoking association may determinate in the increasing blood pressure even adjusted for other covariates such as demographics as well as dietary behaviors and leisure time physical activity.

Determinants of Changes in Metabolic Syndrome Components in a 12-Year Cohort of Iranian Adults

BACKGROUND

The prevalence of metabolic syndrome (MetS) and its components have been increasing globally; therefore, there is a need for better understanding of MetS components and their risk factors, as well as their development and changes over time. This study was designed to identify the determinants of the changes in the components of MetS in a cohort of Iranian adults from 2001 to 2013.

METHODS

A total of 6504 adults, ≥35 years of age, were recruited from central Iran in 2001and were followed up in an ongoing longitudinal population-based study for 12 years. Of the total, 3356 subjects were followed between 2001 and 2007 and 1385 subjects were followed between 2001 and 2013. MetS components and its risk factors were measured by standard methods in 2001, 2007, and 2013. Mean changes in the MetS components from 2001 to 2013 were assessed using the Generalized Estimating Equations test with three time points. Multivariate linear regression model was applied to examine the association between socioeconomic and behavioral characteristics and changes in MetS components. Furthermore, multivariate logistic regression analysis was carried out to examine various factors associated with the development of abnormality of MetS components.

RESULTS

Examining the biochemical and anthropometric characteristics of individuals from 2001 to 2013 revealed a significant increase in systolic and diastolic blood pressure, fasting blood sugar, waist circumference, and body mass index, and a significant decrease in total cholesterol, triglyceride, and physical activity levels. Results also indicated that age, gender, marital status, education levels, and area of residence were significantly associated with the changes in MetS components.

CONCLUSION

This study concluded that baseline sociodemographic characteristics are important in determining changes of MetS components.

Whole systems approaches to obesity and other complex public health challenges: a systematic review

BACKGROUND

Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease.

METHODS

Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken.

RESULTS

Sixty-five articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance.

CONCLUSIONS

Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Effectiveness of health promotion regarding diet and physical activity among Nepalese mothers and their young children: The Heart-health Associated Research, Dissemination, and Intervention in the Community (HARDIC) trial

Background: Nepal, like many low- and middle-income countries, exhibits rising burden of cardiovascular diseases. Misconceptions, poor behavior, and a high prevalence of risk factors contribute to this development. Health promotion efforts along with primary prevention strategies, including risk factor reduction in both adults and children, are therefore critical. Objectives: This study assessed the effectiveness of a health promotion intervention on mothers' knowledge, attitude and practice (KAP) and their children's behavior regarding diet and physical activity. Methods: The Heart-health Associated Research, Dissemination and Intervention in the Community (HARDIC), a community-based trial, used peer education to target mothers with 1-9-year-old children in the peri-urban Jhaukhel-Duwakot Health Demographic Surveillance Site, Nepal, during August-November 2016. In the intervention area, 47 peer mothers were trained to conduct four education classes for about 10 fellow mothers (N = 391). After 3 months, all eligible mothers in the intervention and control areas were interviewed and the results were compared with the KAP of all eligible mothers at baseline. Results: Post-intervention, mothers' KAP median scores had improved regarding heart-healthy diet and physical activity. More mothers had 'good' KAP (>75% of maximum possible scores), and mothers with 'good' knowledge increased from 50% to 81%. Corresponding control values increased only from 58% to 63%. Mothers' attitude and practice improved. Additionally, mothers in the intervention area reported improvement in their children's diet and physical activity behavior. Moreover, Difference in Differences analysis showed that the HARDIC intervention significantly increased mothers' KAP scores and children's behavior scores in the intervention area compared to the control area. Conclusions: Our intervention improves KAP scores regarding diet and physical activity and shows potential for expansion via community health workers, volunteers, and/or local women. Moreover, HARDIC can contribute to Nepal's Package of Essential Noncommunicable Diseases Initiative, which currently lacks a specific package for health promotion.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in November 2016.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included.Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, or odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality (MB, LS, RTM). One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among seven campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the eight studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Tu Salud ¡Sí Cuenta! Your Health Matters! A Community-wide Campaign in a Hispanic Border Community in Texas

OBJECTIVE

To evaluate a community-wide campaign, Tu Salud ¡Si Cuenta! (TSSC), in improving eating behaviors and anthropometric outcomes in Hispanic border communities.

DESIGN

A quasi-experimental study with matched intervention and comparison communities. Cross-sectional assessments with randomly sampled adults, examined by actual exposure and site (unexposed intervention, exposed intervention, and unexposed comparison).

SETTING AND PARTICIPANTS

Predominately Mexican Americans located in Brownsville, TX (intervention) and Laredo, TX (control).

INTERVENTION

The TSSC campaign included television and radio segments, community health worker discussions, and newsletters delivered in Brownsville from 2005 to 2010.

MAIN OUTCOME MEASURES

Healthy and unhealthy eating indices and average hip and waist circumferences.

ANALYSIS

Univariable and multivariable regression models.

RESULTS

The sample (n = 799; 400 comparison and 399 intervention) was 98% of Mexican origin; 54% had completed grade 9 or higher. Exposure to any TSSC component was associated with a lower rate of unhealthy food consumption. Compared with the unexposed intervention group, the exposed intervention for the newsletter had a higher rate of healthy eating (adjusted rate ratio = 1.18; P < .01). Compared with the unexposed intervention, the exposed intervention for the community health worker discussion had a smaller hip circumference (adjusted mean difference = -5.77 cm; P < .05) and a smaller waist circumference (adjusted mean difference = -5.25 cm; P < .05).

CONCLUSIONS AND IMPLICATIONS

This study provides evidence for the use of community-wide campaigns for nutrition and obesity-related outcomes in Hispanic communities.

Association of Animal and Plant Proteins Intake with Hypertension in Iranian Adult Population: Isfahan Healthy Heart Program

Background:

There is evidence regarding the relationship between dietary proteins intake and blood pressure (BP), but they had inconsistent results. Therefore, this study was designed to assess the association between different kinds of protein intake (animal and plant protein) and BP.

Materials and Methods:

Data were collected from Isfahan Healthy Heart Program. We performed a cross-sectional study among 9660 randomly selected Iranian adults aged ≥19-year-old that they were selected from three large Iranian regions in 2007. A simplified validated 48-item-food frequency questionnaire was used to assess dietary intake including all kinds of protein. Systolic and diastolic BPs were measured in duplicate by trained personnel using a standard protocol. Multivariable regressions were applied to assess the relationship between protein intake and BP levels and the presence of hypertension (HTN).

Results:

More frequent consumption of animal, plant, and total protein intake were inversely associated with BP in a crude model (P < 0.001); however, after adjustment for potential confounders this relationship remained only for plant protein (P = 0.04). The risk of HTN occurrence decreased in the highest quintile of total and plant protein consumption by 19% (odds ratio [OR] = 0.81; confidence interval [CI]: [0.65–0.96]; P for trend = 0.004) and 18% (OR = 0.82; [CI: (0.67–0.94]; P for trend = 0.03), respectively.

Conclusions:

More frequent protein intake, especially plant protein consumption was inversely associated with BP and risk of HTN among Iranian adults.

Determinants of incident prediabetes and type 2 diabetes in a 7-year cohort in a developing country: The Isfahan Cohort Study

BACKGROUND

This study aimed to identify determinants of new onset type-2 diabetes (T2D) and prediabetes in a region with high rate of T2D but scarcity of evidence.

METHODS

Participants free of T2D were identified in a population-based study of adults older than 35 years living in the rural and urban areas of three districts in Iran in 2001 and were re-examined after 7 years. Biochemical measurements, anthropometric data, blood pressure, smoking status and dietary intake were determined at both measurement points through identical protocols and procedures. Data analysis was done using multivariate ordered logistic regressions.

RESULTS

Incidence rate of prediabetes and T2D was 32.3 (95%CI, 29.7-35.1) and 18.9 (17.1-20.9) per 1000 person-year, respectively. Odds of progression to prediabetes and T2D were increased with ageing, living in rural area (OR = 1.28), unhealthy diet (OR = 1.32), overweight (OR = 1.45), obesity (OR = 1.97), waist gain (OR = 1.37), high waist-to-hip ratio (OR = 1.35), hypertension (OR = 1.35), and hypertriglyceridemia (OR = 1.50); but reduced with higher education (OR = 0.76) and weight loss (OR = 0.67) in the adjusted models. In those with prediabetes at baseline, parental history of T2D (OR = 2.26), obesity (OR = 2.59), high waist circumference (OR = 2.03), and hypertriglyceridemia (OR = 1.94) were associated with developing T2D. No factor was found to be associated with regression from prediabetes to normoglycemia in adjusted models.

CONCLUSIONS

Current data endorses proposed statistical projections for the future trend of diabetes, and highlights the potential role of obesity specifically visceral type.

The metabolic syndrome and associated lifestyle factors among the Iranian population

Background:

This study aims to evaluate the impact of the Isfahan Healthy Heart Program (IHHP) interventions concerning healthy behavior, on the prevalence of the metabolic syndrome (MetS) and its components in the Iranian population.

Materials and Methods:

The IHHP targeted the population at large in three districts in central Iran from 2000 to 2007. Numerous interventional activities were performed to improve lifestyle. The main intervention strategies were public education through mass media, intersectional cooperation, health professional education, marketing and organizational development, legislation and policy development, as well as research and evaluation. MetS was defined based on the Adult Treatment Panel (ATP) III definition. The logistic regression method was applied to explore the relationship between lifestyle factors with components of metabolic risk factors.

Results:

The mean age of the participants was 44.68 ± 14.43 years in 2001. The mean values of the MetS components differed from 2001 to 2007. The mean of systolic blood pressure (SBP) decreased from 126.7 ± 22.31 to 124.21 ± 20.0 and from 129.47 ± 23.08 to 126.26 ± 21.88 among females in both the intervention and reference areas. Similar changes were observed among males. The mean diastolic blood pressure (DBP) and triglycerides decreased significantly in the intervention area and increased significantly in the reference area in both sexes. High density protein cholesterol (HDL-C) was decreased in both sexes, from 2001 to 2007, in both areas. A strong relationship between tobacco control with high SBP and hypertriglyceridemia was found (P < 0.01).

Conclusion:

Lifestyle improvement programs could be useful to improve the MetS status among men and women.

Inverse association between the frequency of nut consumption and obesity among Iranian population: Isfahan Healthy Heart Program

PURPOSE

Recently, controversies have arisen concerning the association between nut intake and obesity. This study was performed to investigate the relationship between nut consumption and obesity among Iranian adults.

METHODS

In a cross-sectional survey, 9,660 randomly chosen adults aged ≥19 years were selected based on gender, age and their settlement distributions in three districts of central Iran in 2007. Nutritional behaviors including regular intake of walnuts, almonds, pistachios, hazelnuts and sunflower seed were assessed by validated 48-item-food-frequency questionnaire and a 24-h recall questionnaire. Using hierarchical logistic regression test, odds ratio (OR) 95% CI of obesity based on nut consumption was determined in an unadjusted and four adjusted models.

RESULTS

The results showed a significant association between high nut consumption and lower prevalence of overweight or general obesity as well as abdominal obesity in women (p = 0.01 and p = 0.047, respectively), but not men. The frequency of nut consumption was associated with lower risk of overweight or general obesity [OR (95% CI) 0.57 (0.38-0.86)] and abdominal obesity [OR (95% CI) 0.51 (0.28-0.95)] only in women. After adjusting for gender, age and other potential confounders, the strength of the associations was blunted, but they were still significant.

CONCLUSIONS

Frequent nuts and seeds consumption, particularly ≥1 time/day, had an inverse association with all classes of obesity among women.

Inverse association of legume consumption and dyslipidemia: Isfahan Healthy Heart Program

BACKGROUND

Dietary intervention for improving serum lipids emphasizes on dietary fiber, plant protein, and flavonoids. This study was performed to examine whether regular legume consumption could alter serum lipids level and prevalence of dyslipidemia.

MATERIALS AND METHODS

This cross-sectional study was performed among 9660 randomly selected Iranian adults in 3 districts in the central part of Iran, using data collected in the Isfahan Healthy Heart Program in 2007. Dietary behavior including frequency of legume consumption was assessed by 48-item food frequency questionnaire. Fasting serum lipids were measured by standard enzymatic methods. We applied analysis covariance test to compare adjusted mean of serum lipids across legume consumption quartile and logistic regression test was used to determine odds ratio 95% confidence interval of dyslipidemia based on legume consumption in unadjusted and 4-adjusted models.

RESULTS

Adjusted mean triglyceride significantly reduced and high-density lipoprotein cholesterol (HDL-C) enhanced by increasing legume consumption (P = .04). The frequency of legume consumption associated with occurrence of all kinds of dyslipidemia except for hypercholesterolemia, especially for those who had consumed legume more than 1 time per day in adjusted models (hypertriglyceridemia: 0.82 [0.68-0.98]; high low-density lipoprotein [LDL-C]: 0.76 [0.60-0.97], and low HDL-C: 0.81 [0.71-0.92]).

CONCLUSION

We found an inverse dose-response association between the frequency of legume consumption and the risk of hypertriglyceridemia, high LDL-C, and low HDL-C. Therefore it is suggested that increasing legume intake may be an important part of a dietary approach for primary prevention of cardiovascular disease.

Incident hypertension and its predictors: the Isfahan Cohort Study

OBJECTIVES

The present study aimed to investigate the incidence and predictors of hypertension in an Iranian adult population.

METHODS

Isfahan Cohort Study was a longitudinal population-based study that was conducted on adults aged 35 years or older, living in urban and rural areas of three districts in central Iran. After 7 years of follow-up, 3283 participants were re-evaluated using a standard protocol similar to the baseline. At both measurements, participants underwent medical interview, physical examination, and fasting blood measurements. Participants (n = 833) with prevalent hypertension were excluded from the analysis, resulting in a sample size of 2450.

RESULTS

The participants' age was 47.3 ± 9.4 years (mean ± SD) and 50.7% were men. During the follow-up period, 542 (22.1%) individuals developed hypertension, 49.6% of whom were aware of their disease, 42.4% were treated, but only 24.9% were controlled. Incidence rates have shown no sex-specific difference across age and blood pressure (BP) categories. Multivariate-adjusted model controlled for all study covariates showed that age, male sex, general and central obesity, hypertriglyceridemia, impaired fasting glucose, diabetes mellitus, baseline BP at least 120/80  mmHg (nonoptimal BP), and parental history of hypertension independently contributed to the development of hypertension. Higher education level and more than 10% decrease in waist circumference over 7-year follow-up represented protective effects. In men, weight loss decreased and weight gain increased the risk of developing hypertension. Nonoptimal BP along with central obesity and hypertriglyceridemia together were responsible for 71% of the burden of hypertension.

CONCLUSION

Our findings imply that there are other factors in addition to nonoptimal BP that deserve integrating into the risk assessment criteria for developing hypertension.

The relationship between nut consumption and blood pressure in an Iranian adult population: Isfahan Healthy Heart Program

BACKGROUND AND AIMS

Few studies outside of Western countries have evaluated the relationship between consumption of nuts and blood pressure (BP). This study aimed to investigate the relationship between nut consumption and blood pressure in an Iranian adult population.

METHODS AND RESULTS

We performed a cross-sectional investigation among 9660 randomly selected Iranian adults, sampled to represent three large Iranian regions, using data collected in the Isfahan Healthy Heart Program in 2007. The frequency of nut consumption was assessed by a food frequency questionnaire. Systolic and diastolic BPs (SBP and DBP) were measured in duplicate by trained personnel using a standard protocol. Multiple linear and logistic regressions were applied to assess the relationship between nut intake and BP levels and the presence of hypertension as SBP ≥ 140 mmHg, and/or a DBP ≥ 90 mmHg and/or current use of at least one type of anti-hypertensive medication. Those with nut consumption ≥4 times/week showed less mean of BPs and hypertension prevalence, compared to those who consumed nuts <1 times/week (p < 0.001). Compared to no consumption, consuming nuts ≥4 times/week was associated with a 34% lower prevalence of hypertension (multivariate odds ratio (OR) = 0.66; confidence interval (CI) = 0.51-0.87; p for trend = 0.009).

CONCLUSIONS

More frequent nut consumption is associated with lower BP and lower risk of hypertension among Iranian adults.

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981)

INTRODUCTION

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries.

METHODS

We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention.

RESULTS

Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups).

CONCLUSION

Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in February 2013.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series. Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included. Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes. The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality. One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among nine campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the seven studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

The relationship between nut consumption and lipid profile among the Iranian adult population; Isfahan Healthy Heart Program

BACKGROUND/OBJECTIVE

The study was carried out to assess the relationship between nut consumption and lipid profile among Iranian adults.

SUBJECT/METHODS

The study was based on data from the Isfahan Healthy Heart Program across three counties in central Iran in 2007. A cross-sectional survey of 9660 randomly selected adults aged ≥ 19 years were chosen based on sex, age and settlement distributions in each community. Nutritional behaviors were assessed by validated qualitative 48-item food frequency questionnaires, which covered regular intakes of four types of nuts: walnuts, almonds, pistachios and hazelnuts. Analysis of covariance and logistic regression tests were utilized to determine odds ratio (OR) 95% confidence interval of hyperlipidemia according to nut consumption patterns in unadjusted and three-adjusted models.

RESULTS

The results showed a significant link between high nut consumption and lower total cholesterol, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) levels and apo B/apo A ratio (P<0.05) in female subjects and lower TG, LDL-C and apoB/apoA ratio in male subjects (P<0.05). The frequency of nut consumption was inversely associated with dyslipidemia, especially for those who had consumed nuts ≥ 4 times weekly (0.67 (0.57-0.79)). After adjusting for sex, age and other potential confounders, ORs increased enormously. Except for low apo A and high LDL-C, more frequent nut consumption (4 ≤ times per week) had a significant inverse effect on other dyslipidemia risk factors in all four models.

CONCLUSIONS

We concluded that frequent consumption of nuts, particularly ≥ 4 times a week, may result in lower dyslipidemia occurrences and may exert cardioprotective effects.

Population-based intervention for cardiovascular diseases related knowledge and behaviours in Asian Indian women

BACKGROUND & OBJECTIVES

There is poor knowledge and behaviors regarding chronic diseases related nutritional and lifestyle factors among women in low income countries. To evaluate efficacy of a multilevel population-based intervention in improving knowledge and practices for related factors we performed a study in India.

METHODS

Population based study among women 35-70 years was performed in four urban and five rural locations. Stratified sampling was performed and we enrolled 4624 (rural 2616, urban 2008) of eligible 8000 women (58%). Demographic details, medical history, diet, physical activity and anthropometry were recorded and blood hemoglobin, glucose and total cholesterol determined. Knowledge and behaviors regarding diet in chronic diseases were inquired in a randomly selected 100 women at each site (n = 900). A systematic multilevel population based intervention (using posters, handouts, street plays, public lectures, group lectures and focused group discussions) was administered over 6 months at each site. The questionnaire was re-administered at the end in random 100 women (n = 900) and differences determined. Descriptive statistics are reported. Comparison of parameters before and after intervention was assessed using Mann Whitney test.

RESULTS

Prevalence (%) of chronic disease related lifestyles and risk factors in rural/urban women, respectively, was illiteracy in 63.6/29.4, smoking/tobacco use 39.3/18.9, high fat intake 93.6/93.4, high salt intake 18.2/12.6, low physical activity 59.5/70.2, overweight/obesity 22.5/45.6, truncal obesity 13.0/44.3, hypertension 31.6/48.2, hypercholesterolemia 13.5/27.7, and diabetes in 4.3/15.1 percent. Composite chronic diseases knowledge at baseline vs after intervention increased significantly in overall (32.0 vs 62.0), rural (29.0 vs 63.5) and urban (39.5 vs 60.5) groups (p < 0.001). Significant increase in knowledge regarding diet in hypertension, diabetes, heart disease and anemia as well as importance of dietary proteins, fats, fibres and fruits was observed (p < 0.001). There was insignificant change in most of the practices regarding intake of low fat, high protein, high fibre diet except sieving the flour which declined significantly (80.1 vs 53.6, p < 0.001).

CONCLUSIONS

A short-term multilevel population-wide intervention among women in rural and urban locations in India increased chronic disease knowledge but failed to influence practices.

Association of perceived stress with stressful life events, lifestyle and sociodemographic factors: a large-scale community-based study using logistic quantile regression

OBJECTIVE

The present paper aimed at investigating the association between perceived stress and major life events stressors in Iranian general population.

METHODS

In a cross-sectional large-scale community-based study, 4583 people aged 19 and older, living in Isfahan, Iran, were investigated. Logistic quantile regression was used for modeling perceived stress, measured by GHQ questionnaire, as the bounded outcome (dependent), variable, and as a function of most important stressful life events, as the predictor variables, controlling for major lifestyle and sociodemographic factors. This model provides empirical evidence of the predictors' effects heterogeneity depending on individual location on the distribution of perceived stress.

RESULTS

The results showed that among four stressful life events, family conflicts and social problems were more correlated with level of perceived stress. Higher levels of education were negatively associated with perceived stress and its coefficients monotonically decrease beyond the 30th percentile. Also, higher levels of physical activity were associated with perception of low levels of stress. The pattern of gender's coefficient over the majority of quantiles implied that females are more affected by stressors. Also high perceived stress was associated with low or middle levels of income.

CONCLUSIONS

The results of current research suggested that in a developing society with high prevalence of stress, interventions targeted toward promoting financial and social equalities, social skills training, and healthy lifestyle may have the potential benefits for large parts of the population, most notably female and lower educated people.

Potato consumption and cardiovascular disease risk factors among Iranian population

BACKGROUND

Previous studies investigated the effects of dietary glycaemic index and glycaemic load on cardiovascular risk factors. Little evidence is available regarding the association between potato intake and cardiovascular risk factors in Iran.

OBJECTIVE

This cross-sectional study was conducted in the first stage of Isfahan Healthy Heart Programme.

METHODS

A total of 4774 subjects were included in the present study. Dietary intake was assessed with a 49-item food frequency questionnaire. Biochemical assessments were done according to the standard protocol.

RESULTS

There were significant associations between potato consumption and diabetes mellitus (odds ratio (OR): 1.38; 95% CI: 1.14-1.67; p < 0.001), high fasting blood sugar level (OR: 1.40; 95% CI: 1.17-1.68; p < 0.001) and low serum high density lipoprotein level (OR: 1.10; 95% CI: 1.01-1.20; p = 0.02) remained after adjustments for possible confounding factors.

CONCLUSION

We found a positive relation between potato consumption, high fasting blood glucose level and diabetes mellitus.

Socioeconomic disparities and smoking habits in metabolic syndrome: evidence from isfahan healthy heart program

BACKGROUND

The metabolic syndrome (Mets) consists of major clustering of cardiovascular disease (CVD) risk factors. This study determines the association of socioeconomic determinants and smoking behavior in a population-based sample of Iranians with Mets.

METHODS

This cross-sectional survey comprised 12600 randomly selected men and women aged ≥ 19 years living in three counties in central part of Iran. They participated in the baseline survey of a community-based program for CVD prevention entitled" Isfahan Healthy Heart Program" in 2000-2001. Subjects with Mets were selected based on NCEP- ATPIII criteria. Demographic data, medical history, lifestyle, smoking habits, physical examination, blood pressure, obesity indices and serum lipids were determined.

RESULTS

The mean age of subjects with Mets was significantly higher. The mean age of smokers in both groups was higher than non-smokers but with lower WC and WHR. Marital status, age and residency were not significantly different in smokers with Mets and non-smokers with Mets. Smoking was more common in the middle educational group in the income category of Quartile 1-3. Mets was significantly related to age, sex and education. Middle-aged and elderly smokers were at approximately 4-5 times higher risk among Mets subjects. Low education decreased the risk of Mets by 0.48; similarly in non-smokers, 6-12 years of education decreased the risk of Mets by 0.72.

CONCLUSION

More educated persons had a better awareness and behavior related to their health and role of smoking. In the lower social strata of the Iranian population, more efforts are needed against smoking habits.

Metabolic syndrome in menopausal transition: Isfahan Healthy Heart Program, a population based study

INTRODUCTION

There is a remarkable increase in cardiovascular disease after menopause. On the other hand, metabolic syndrome as a collection of risk factors has a known effect on cardiovascular diseases. Hormone changes are considered as one of the main relevant factor regarding cardiovascular disease as well as some recognized relationship with metabolic syndrome's components. This study was carried out in order to search for prevalence of metabolic syndrome during menopausal transition.

METHOD

In a cross sectional study in urban and rural areas of Isfahan, Najafabad and Arak cities, 1596 women aged more than 45 years were investigated using Isfahan Healthy Heart Program's (IHHP) samples. Participants were categorized into three groups of pre-menopause, menopause and post-menopause. Leisure time physical activity and global dietary index were included as life style factors. The association of metabolic syndrome and its components with menopausal transition considering other factors such as age and life style was analyzed.

RESULTS

there were 303, 233 and 987 women in premenopausal, early menopausal and postmenopausal groups respectively. Metabolic syndrome was found in 136(44.9%) premenopausal participants and significantly increased to 135(57.9%) and 634(64.3%) in early menopausal and postmenopausal participants respectively, when age was considered (P = 0.010). Except for hypertension and hypertriglyceridemia, there was no significant difference between three groups of menopausal transition when metabolic syndrome's components were considered.

CONCLUSION

In contrary to the claims regarding the role of waist circumference and blood glucose in increasing of metabolic syndrome during the menopausal transition, this study showed this phenomenon could be independence of them.