Development and validation of a plasmalogen score as an independent modifiable marker of metabolic health: population based observational studies and a placebo-controlled cross-over study

BACKGROUND

Decreased levels of circulating ethanolamine plasmalogens [PE(P)], and a concurrent increase in phosphatidylethanolamine (PE) are consistently reported in various cardiometabolic conditions. Here we devised, a plasmalogen score (Pls Score) that mirrors a metabolic signal that encompasses the levels of PE(P) and PE and captures the natural variation in circulating plasmalogens and perturbations in their metabolism associated with disease, diet, and lifestyle.

METHODS

We utilised, plasma lipidomes from the Australian Obesity, Diabetes and Lifestyle study (AusDiab; n = 10,339, 55% women) a nationwide cohort, to devise the Pls Score and validated this in the Busselton Health Study (BHS; n = 4,492, 56% women, serum lipidome) and in a placebo-controlled crossover trial involving Shark Liver Oil (SLO) supplementation (n = 10, 100% men). We examined the association of the Pls Score with cardiometabolic risk factors, type 2 diabetes mellitus (T2DM), cardiovascular disease and all-cause mortality (over 17 years).

FINDINGS

In a model, adjusted for age, sex and BMI, individuals in the top quintile of the Pls Score (Q5) relative to Q1 had an OR of 0.31 (95% CI 0.21-0.43), 0.39 (95% CI 0.25-0.61) and 0.42 (95% CI 0.30-0.57) for prevalent T2DM, incident T2DM and prevalent cardiovascular disease respectively, and a 34% lower mortality risk (HR = 0.66; 95% CI 0.56-0.78). Significant associations between diet and lifestyle habits and Pls Score exist and these were validated through dietary supplementation of SLO that resulted in a marked change in the Pls Score.

INTERPRETATION

The Pls Score as a measure that captures the natural variation in circulating plasmalogens, was not only inversely related to cardiometabolic risk and all-cause mortality but also associate with diet and lifestyle. Our results support the potential utility of the Pls Score as a biomarker for metabolic health and its responsiveness to dietary interventions. Further research is warranted to explore the underlying mechanisms and optimise the practical implementation of the Pls Score in clinical and population settings.

FUNDING

National Health and Medical Research Council (NHMRC grant 233200), National Health and Medical Research Council of Australia (Project grant APP1101320), Health Promotion Foundation of Western Australia, and National Health and Medical Research Council of Australia Senior Research Fellowship (#1042095).

A lipidomic based metabolic age score captures cardiometabolic risk independent of chronological age

BACKGROUND

Metabolic ageing biomarkers may capture the age-related shifts in metabolism, offering a precise representation of an individual's overall metabolic health.

METHODS

Utilising comprehensive lipidomic datasets from two large independent population cohorts in Australia (n = 14,833, including 6630 males, 8203 females), we employed different machine learning models, to predict age, and calculated metabolic age scores (mAge). Furthermore, we defined the difference between mAge and age, termed mAgeΔ, which allow us to identify individuals sharing similar age but differing in their metabolic health status.

FINDINGS

Upon stratification of the population into quintiles by mAgeΔ, we observed that participants in the top quintile group (Q5) were more likely to have cardiovascular disease (OR = 2.13, 95% CI = 1.62-2.83), had a 2.01-fold increased risk of 12-year incident cardiovascular events (HR = 2.01, 95% CI = 1.45-2.57), and a 1.56-fold increased risk of 17-year all-cause mortality (HR = 1.56, 95% CI = 1.34-1.79), relative to the individuals in the bottom quintile group (Q1). Survival analysis further revealed that men in the Q5 group faced the challenge of reaching a median survival rate due to cardiovascular events more than six years earlier and reaching a median survival rate due to all-cause mortality more than four years earlier than men in the Q1 group.

INTERPRETATION

Our findings demonstrate that the mAge score captures age-related metabolic changes, predicts health outcomes, and has the potential to identify individuals at increased risk of metabolic diseases.

FUNDING

The specific funding of this article is provided in the acknowledgements section.

Metabolic phenotyping of BMI to characterize cardiometabolic risk: evidence from large population-based cohorts

Obesity is a risk factor for type 2 diabetes and cardiovascular disease. However, a substantial proportion of patients with these conditions have a seemingly normal body mass index (BMI). Conversely, not all obese individuals present with metabolic disorders giving rise to the concept of "metabolically healthy obese". We use lipidomic-based models for BMI to calculate a metabolic BMI score (mBMI) as a measure of metabolic dysregulation associated with obesity. Using the difference between mBMI and BMI (mBMIΔ), we identify individuals with a similar BMI but differing in their metabolic health and disease risk profiles. Exercise and diet associate with mBMIΔ suggesting the ability to modify mBMI with lifestyle intervention. Our findings show that, the mBMI score captures information on metabolic dysregulation that is independent of the measured BMI and so provides an opportunity to assess metabolic health to identify "at risk" individuals for targeted intervention and monitoring.

Dairy product consumption and incident prediabetes in the Australian Diabetes, Obesity and Lifestyle Study with 12 years follow up

BACKGROUND

Investigating modifiable risk factors of early stages of the development of type 2 diabetes is essential for effective prevention. Some studies show protective associations between dairy and prediabetes, yet associations are heterogenous by type and fat content of dairy foods.

OBJECTIVE

To examine the relationship between the consumption of dairy, including different types of dairy products and the risk of prediabetes.

METHODS

The study included 4,891 participants with normal glucose tolerance (aged 49.0±12.3 years, 57% female) of the Australian Diabetes, Obesity and Lifestyle (AusDiab) study, a longitudinal population-based study. Dairy intake was measured at baseline using a food frequency questionnaire. Prediabetes at 5-year and 12-year follow-up was defined according to WHO criteria as fasting plasma glucose levels of 110-125 mg/dl or 2-hour plasma glucose levels of 140-199 mg/dl. Associations were analyzed using Poisson regression, adjusted for social demographics, lifestyle behaviors, family history of diabetes, and food group intake.

RESULTS

765 (15.6%) incident cases of prediabetes were observed. The mean intake of dairy foods was 2.4±1.2 servings/day, mostly consisting of low-fat milk (0.70±0.78) and high-fat milk (0.47±0.72). A higher intake of high-fat dairy (RR_servings/day, 0.92, 95%CI 0.85-1.00), high-fat milk (0.89, 0.80-0.99), and total cheese (0.74, 0.56-0.96)was associated with lower prediabetes risk. Low-fat milk intake was associated non-linearly with prediabetes risk. Low-fat dairy foods, total milk, yogurt, low-fat cheese, and ice cream were not associated with prediabetes risk.

CONCLUSION

In this large Australian cohort, protective associations were found for high-fat dairy types, while neutral associations were seen for low-fat dairy. Studies with more detail on sugar content of types of dairy foods and products eaten with dairy foods (e.g., cereals or jam), as well as studies into potential causal mechanisms of the health effects of dairy intake are required.

The influence of adiposity on the interactions between strength, physical function and cognition among older adults in the Australian Diabetes, Obesity and Lifestyle (AusDiab) study

Background

Being overweight or obese may be associated with lower physical and cognitive function, but in late-adulthood (≥ 65 years) evidence is mixed. This study aimed to investigate how being overweight or obese affected interactions between muscle strength, function and cognition in Australians aged ≥ 50 years, and whether interactions varied according to age (i.e. ≥ 50–65 vs > 65 years).

Methods

This study included 2368 adults [mean (standard deviation) age: 63 (7) years; 56% female] from the 2011/2012 Australian Diabetes, Obesity and Lifestyle (AusDiab) follow-up. Physical function was assessed via timed up-and-go (TUG) and muscle strength from knee extensor strength (KES). Cognition was assessed using Mini-Mental-State Exam (MMSE), Spot-the-Word (STW), California Verbal Learning Test (CVLT) and Symbol–Digit-Modalities Test (SDMT). Beta binomial regression was used to evaluate how being overweight or obese influenced strength, physical and cognitive function associations.

Results

Being overweight or obese did not affect strength-cognition associations regardless of sex or age. With slower physical function; obese females showed better STW (odds ratio [OR] 95% CI]: 1.070 [1.016, 1.127], P = 0.011); obese men better MMSE (OR [95% CI]: 1.157 [1.012, 1.322], P = 0.033); and obese men aged > 65 better CVLT (OR [95% CI]: 1.122 [1.035, 1.217], P = 0.019) and MMSE (OR [95% CI]: 1.233 [1.049, 1.449], P = 0.017) compared to normal weight participants.

Conclusion

Slower physical function was associated with better performance in some cognitive domains in obese, but not in non-obese adults aged ≥ 50 years. These findings suggest some benefits of obesity to aspects of cognition when physical function is slower, but longitudinal follow-up studies are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03033-3.

Lipidomic Signatures of Changes in Adiposity: A Large Prospective Study of 5849 Adults from the Australian Diabetes, Obesity and Lifestyle Study

Lipid metabolism is tightly linked to adiposity. Comprehensive lipidomic profiling offers new insights into the dysregulation of lipid metabolism in relation to weight gain. Here, we investigated the relationship of the human plasma lipidome and changes in waist circumference (WC) and body mass index (BMI). Adults (2653 men and 3196 women), 25–95 years old who attended the baseline survey of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) and the 5-year follow-up were enrolled. A targeted lipidomic approach was used to quantify 706 distinct molecular lipid species in the plasma samples. Multiple linear regression models were used to examine the relationship between the baseline lipidomic profile and changes in WC and BMI. Metabolic scores for change in WC were generated using a ridge regression model. Alkyl-diacylglycerol such as TG(O-50:2) [NL-18:1] displayed the strongest association with change in WC (β-coefficient = 0.125 cm increment per SD increment in baseline lipid level, p = 2.78 × 10⁻¹¹. Many lipid species containing linoleate (18:2) fatty acids were negatively associated with both WC and BMI gain. Compared to traditional models, multivariate models containing lipid species identify individuals at a greater risk of gaining WC: top quintile relative to bottom quintile (odds ratio, 95% CI = 5.4, 3.8–6.6 for women and 2.3, 1.7–3.0 for men). Our findings define metabolic profiles that characterize individuals at risk of weight gain or WC increase and provide important insight into the biological role of lipids in obesity.

Seventeen-Year Associations between Diet Quality Defined by the Health Star Rating and Mortality in Australians: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)

BACKGROUND

The Health Star Rating (HSR) is the government-endorsed front-of-pack labeling system in Australia and New Zealand.

OBJECTIVES

We aimed to examine prospective associations of a dietary index (DI) based on the HSR, as an indicator of overall diet quality, with all-cause and cardiovascular disease (CVD) mortality.

METHODS

We utilized data from the national population-based Australian Diabetes, Obesity and Lifestyle Study. The HSR-DI at baseline (1999-2000) was constructed by 1) calculation of the HSR points for individual foods in the baseline FFQ, and 2) calculation of the HSR-DI for each participant based on pooled HSR points across foods, weighted by the proportion of energy contributed by each food. Vital status was ascertained by linkage to the Australian National Death Index. Associations of HSR-DI with mortality risk were assessed by Cox proportional hazards regression.

RESULTS

Among 10,025 eligible participants [baseline age: 51.6 ± 14.3 y (mean ± standard deviation)] at entry, higher HSR-DI (healthier) was associated with higher consumption of healthy foods such as fruits, vegetables, and nuts, and lower consumption of discretionary foods such as processed meats and confectionery (P-trend < 0.001 for each). During a median follow-up of 16.9 y, 1682 deaths occurred with 507 CVD deaths. In multivariable models adjusted for demographic characteristics, lifestyle factors, and medical conditions, higher HSR-DI was associated with lower risk of all-cause mortality, with a hazard ratio (95% confidence interval) of 0.80 (0.69, 0.94; P-trend < 0.001) comparing the fifth with the first HSR-DI quintile. A corresponding inverse association was observed for CVD mortality (0.71; 0.54, 0.94; P-trend = 0.008).

CONCLUSIONS

Better diet quality as defined by the HSR-DI was associated with lower risk of all-cause and CVD mortality among Australian adults. Our findings support the use of the HSR nutrient profiling algorithm as a valid tool for guiding consumer food choices.

A cluster-randomized study on the Risk Assessment and Management Program for home blood pressure monitoring in an older population with inadequate health literacy

The Risk Assessment and Management Program (RAMP) has successfully demonstrated a reduction of blood pressure (BP) and cardiovascular (CVD) risk of patients with hypertension. This study aimed to compare the blood pressure control rate of participants after attended RAMP group, with those attended RAMP individual from usual care. A prospective open cluster-randomized controlled trial was performed in five public primary care clinics. Patients with uncontrolled hypertension were recruited. RAMP group consisted of multi-disciplinary group education on knowledge of hypertension, lifestyle modification, and hands-on home blood pressure monitoring (HBPM) training. Each participant was given a branchial HBPM device. An individual face-to-face nurse follow-up was arranged 6 weeks later. Participants' office BP and clinical parameters were assessed at 6, 12, and 18 months. Three RAMP group and two RAMP-individual clusters recruited 152 and 139 participants, respectively. The mean age was 67.0 (SD 9.9) year. After 18 months of treatment, there was a significantly higher BP control rate in the RAMP-group participants than the RAMP-individual participants (78.9% vs 36.5%, P < .001). The systolic BP was reduced by 19.7 mm Hg (95% CI -22.03, -17.40, P < .001) and diastolic BP by 8.1 mm Hg (95% CI -9.66, -6.61, P < .001) in RAMP group while the RAMP individual demonstrated 9.3 mm Hg (95% CI -12.1, -6.4, P < .001) reduction in systolic BP without any significant difference in diastolic BP. The RAMP-group participants' body weight (BW) and body mass index(BMI) had no significant changes, while the RAMP-individual participants had a significant increase in BW and BMI. No adverse effect was reported.

Screening for hypertension in adults during emergency department consultation: a systematic review

A large proportion of patients affected with hypertension go undetected. A systematic review was conducted to assess the performance of a screening strategy in adults using blood pressure measurement at the time of an emergency department consultation. A systematic literature search on Embase, CINHAL and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy. Intervention studies with adults including at least one blood pressure measurement for all participants were included. A repeat blood pressure assessment had to have been carried out to assess the validity of the elevated blood pressure value within the next few days after the emergency department initial visit. Out of 1030 articles identified, published between 1985 and 2018, 10 articles met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years. A single study reports that blood pressure screening was measured according to hypertension guidelines referred to in the study. The average follow-up rate was 61.9% (95% confidence interval 45.5-78.3). For diagnostic confirmation, four studies used a blood pressure measurement method based on the reported guidelines. Half of the patients (50.2%) with elevated blood pressure during the emergency department visit had blood pressure corresponding to uncontrolled elevated blood pressure at follow-up measurement. The contribution of emergency department to the screening for hypertension, by recognizing the presence of elevated blood pressure and then making a referral for diagnostic confirmation, could provide an opportunity to detect a large number of people with hypertension.

Untreated Relative Hypotension Measured as Perfusion Pressure Deficit During Management of Shock and New-Onset Acute Kidney Injury-A Literature Review

Maintaining an optimal blood pressure (BP) during shock is a fundamental tenet of critical care. Optimal BP targets may be different for different patients. In current practice, too often, uniform BP targets are pursued which may result in inadvertently accepting a degree of untreated relative hypotension, i.e., the deficit between patients' usual premorbid basal BP and the achieved BP, during vasopressor support. Relative hypotension is a common but an under-recognized and an under-treated sign among patients with potential shock state. From a physiological perspective, any relative reduction in the net perfusion pressure across an organ (e.g., renal) vasculature has a potential to overwhelm autoregulatory mechanisms, which are already under stress during shock. Such perfusion pressure deficit may consequently impact organs' ability to function or recover from an injured state. This review discusses such pathophysiologic mechanisms in detail with a particular focus on the risk of new-onset acute kidney injury (AKI). To review current literature, databases of Medline, Embase, and Google scholar were searched to retrieve articles that either adjusted BP targets based on patients' premorbid BP levels or considered relative hypotension as an exposure endpoint and assessed its association with clinical outcomes among acutely ill patients. There were no randomized controlled trials. Only seven studies could be identified and these were reviewed in detail. These studies indicated a significant association between the degree of relative hypotension that was inadvertently accepted in real-world practice and new-onset organ dysfunction or subsequent AKI. However, this is not a high-quality evidence. Therefore, well-designed randomized controlled trials are needed to evaluate whether adoption of individualized BP targets, which are initially guided by patient's premorbid basal BP and then tailored according to clinical response, is superior to conventional BP targets for vasopressor therapy, particularly among patients with vasodilatory shock states.

Inequalities in the prevalence of undiagnosed hypertension among Bangladeshi adults: evidence from a nationwide survey

BACKGROUND

In recent years, developing countries like Bangladesh are facing a higher burden of non-communicable diseases such as hypertension as a result of demographic transition. Prevalence of hypertension is often studied in this setting. However, evidence on undiagnosed hypertension is not widely available in the existing literature. Therefore, the current study focuses on inequalities in the prevalence of undiagnosed hypertension in Bangladesh.

METHODS

A total of 8835 participants aged 35+ years were included in this study using nationally representative Bangladesh Demographic and Health Survey 2011 (BDHS). In the survey, systolic blood pressure (SBP) and diastolic blood pressure (DBP) of these participants were measured three times with approximately 10 minutes of an interval between each measurement. Any respondent with either SBP ≥ 140 mmHg or DBP ≥ 90 mmHg was considered as patient with hypertension as per the guidelines from American Heart Association. Among the participants, undiagnosed hypertension was defined as having SBP > =140 mmHg or DBP > =90 mmHg and never taking prescribed medicine or being told by health professionals to lower/control blood pressure. Multiple logistic regression analysis was applied for identifying factors associated with undiagnosed hypertension. Further, socioeconomic inequalities in the prevalence of undiagnosed hypertension were estimated using Concentration Index (C).

RESULTS

We found 978 (59.9% of the total) were undiagnosed among 1685 hypertensive patients studied. Regression analysis showed individuals with being underweight, having poor socioeconomic conditions, and lower educational qualifications were more likely to have undiagnosed hypertension. A similar association between undiagnosed hypertension and socioeconomic quintiles was observed using concentration index (C = - 0.07). On the other hand, individuals from higher age group (50-64 or above), female sex, and Sylhet region were at lower risk of undiagnosed hypertension.

CONCLUSIONS

This study showed that a large proportion of the cases with hypertension are remained undiagnosed in Bangladesh, especially among the poor and low educated population. Screening and awareness building initiatives on hypertension should be taken for this group of population to reduce the burden of undiagnosed hypertension.

Hypertension Status and Associations with Self-Rated Health and General Practitioner Health Seeking in a Rural Australian Cohort

Hypertension is the most frequently managed condition by Australian general practitioners (GP). Knowledge of hypertension and blood pressure (BP) values may motivate individuals to seek GP management. Our study aims to determine the associations of knowledge of BP values, BP perception, GP health seeking, and self-rated health (SRH) in a rural population. Two-hundred and seventy-eight (278) residents responded to the health survey on socio-demographic profile, medical history, BP knowledge and perception, SRH, and GP visit frequency. Associations were evaluated using Chi-squared test and multivariate logistic regression. Cohort mean age was 63.6 (12.4) years with 63.3% females. Hypertension (37.8%) was the most common condition. GP visits were made at least once every month (19.1%), every 2–6 months (35.6%), >6 months (11.5%), or only when needed (29.5%). Univariate analyses showed age, education, alcohol consumption, comorbidities, hypertension status, and SRH were significantly associated with visit frequency. After adjustments, hypertension status (OR = 3.6, 95% CI [1.7, 7.9]) and poor SRH (OR = 3.1, 95% CI [1.4, 7.0]) were significantly associated with frequent monthly visits. Our cohort demonstrated that having hypertension and poor self-rated health were associated with frequent monthly GP visits. The perception of high blood pressure does not drive seeking additional GP input.

Impact of Clinical Factors on the Achievement of Target Blood Pressure in Hypertensive Patients from Ivanovo Region of Russia: Data of 2015

INTRODUCTION

In Russia, blood pressure (BP) control is below the optimal. The little is known about regional features and barriers to adequate BP control in Russian primary care.

AIM

To evaluate the impact of clinical factors on achieving the target BP in hypertensive patients in one region of Russia.

METHODS

Retrospective medical data of 2015 on 11,129 patients (31.4% male) with hypertension (Htn) from Ivanovo region of Russia were examined. Achievement of target BP was assessed in all patients. We study association between BP control and clinical factors.

RESULTS

45.9% of studied patients with Htn had controlled BP. The frequency of achieving the target BP in subsets of hypertensive patients was 37.8% in patients with diabetes, 39.5% in patients with coronary artery disease, and 29.9% in patients with chronic heart failure. The main clinical factors associated with achieving the target BP in studied hypertensive patients were the advice on alcohol consumption, advice on smoking cessation, and advice on weight reduction. Therapy with main antihypertensive drugs (in particular, beta-blockers and thiazide diuretics) were also factors of optimal BP control in these patients. Comorbidities (chronic heart failure and cardiovascular diseases requiring the prescription of aspirin and statins) and family history of coronary artery disease were associated with inadequate BP control. A negative effect of some antihypertensive drugs (potassium sparing diuretics, ARBs, ACE-Is, and dihydropyridine CCBs) on BP control that was found out in our study requires further investigation. Other studied factors had no influence on BP control in patients with Htn from Ivanovo region.

CONCLUSION

We identified regional factors of BP control in hypertensive patients from Ivanovo region of Russia. It is shown that individual medical education (in particular, medical advices) is the most important factor of optimal BP control. The intervention with antihypertensive therapy (beta-blockers and thiazide diuretics) facilitates the achievement of target BP. Comorbidity and age reduce the frequency of achieving the target BP.

Home blood pressure monitoring: Australian Expert Consensus Statement

Measurement of blood pressure (BP) by a doctor in the clinic has limitations that may result in an unrepresentative measure of underlying BP which can impact on the appropriate assessment and management of high BP. Home BP monitoring is the self-measurement of BP in the home setting (usually in the morning and evening) over a defined period (e.g. 7 days) under the direction of a healthcare provider. When it may not be feasible to measure 24-h ambulatory BP, home BP may be offered as a method to diagnose and manage patients with high BP. Home BP has good reproducibility, is well tolerated, is relatively inexpensive and is superior to clinic BP for prognosis of cardiovascular morbidity and mortality. Home BP can be used in combination with clinic BP to identify 'white coat' and 'masked' hypertension. An average home BP of at least 135/85 mmHg is an appropriate threshold for the diagnosis of hypertension. Home BP may also offer the advantage of empowering patients with their BP management, with benefits including increased adherence to therapy and lower achieved BP levels. It is recommended that, when feasible, home BP should be considered for routine use in the clinical management of hypertension.

Garlic Lowers Blood Pressure in Hypertensive Individuals, Regulates Serum Cholesterol, and Stimulates Immunity: An Updated Meta-analysis and Review

BACKGROUND

Garlic has been shown to have cardiovascular protective and immunomodulatory properties.

OBJECTIVES

We updated a previous meta-analysis on the effect of garlic on blood pressure and reviewed the effect of garlic on cholesterol and immunity.

METHODS

We searched the Medline database for randomized controlled trials (RCTs) published between 1955 and December 2013 on the effect of garlic preparations on blood pressure. In addition, we reviewed the effect of garlic on cholesterol and immunity.

RESULTS

Our updated meta-analysis on the effect of garlic on blood pressure, which included 20 trials with 970 participants, showed a mean ± SE decrease in systolic blood pressure (SBP) of 5.1 ± 2.2 mm Hg (P < 0.001) and a mean ± SE decrease in diastolic blood pressure (DBP) of 2.5 ± 1.6 mm Hg (P < 0.002) compared with placebo. Subgroup analysis of trials in hypertensive subjects (SBP/DBP ≥140/90 mm Hg) at baseline revealed a larger significant reduction in SBP of 8.7 ± 2.2 mm Hg (P < 0.001; n = 10) and in DBP of 6.1 ± 1.3 mm Hg (P < 0.001; n = 6). A previously published meta-analysis on the effect of garlic on blood lipids, which included 39 primary RCTs and 2300 adults treated for a minimum of 2 wk, suggested garlic to be effective in reducing total and LDL cholesterol by 10% if taken for >2 mo by individuals with slightly elevated concentrations [e.g., total cholesterol >200 mg/dL (>5.5 mmol/L)]. Garlic has immunomodulating effects by increasing macrophage activity, natural killer cells, and the production of T and B cells. Clinical trials have shown garlic to significantly reduce the number, duration, and severity of upper respiratory infections.

CONCLUSIONS

Our review suggests that garlic supplements have the potential to lower blood pressure in hypertensive individuals, to regulate slightly elevated cholesterol concentrations, and to stimulate the immune system. Garlic supplements are highly tolerated and may be considered as a complementary treatment option for hypertension, slightly elevated cholesterol, and stimulation of immunity. Future long-term trials are needed to elucidate the effect of garlic on cardiovascular morbidity and mortality.

Estimating the proportion of metabolic health outcomes attributable to obesity: a cross-sectional exploration of body mass index and waist circumference combinations

BACKGROUND

Recent evidence suggests that a substantial subgroup of the population who have a high-risk waist circumference (WC) do not have an obese body mass index (BMI). This study aimed to explore whether including those with a non-obese BMI but high risk WC as 'obese' improves prediction of adiposity-related metabolic outcomes.

METHODS

Eleven thousand, two hundred forty-seven participants were recruited. Height, weight and WC were measured. Ten thousand, six hundred fifty-nine participants with complete data were included. Adiposity categories were defined as: BMI(N)/WC(N), BMI(N)/WC(O), BMI(O)/WC(N), and BMI(O)/WC(O) (N = non-obese and O = obese). Population attributable fraction, area under the receiver operating characteristic curve (AUC), and odds ratios (OR) were calculated.

RESULTS

Participants were on average 48 years old and 50 % were men. The proportions of BMI(N)/WC(N), BMI(N)/WC(O), BMI(O)/WC(N) and BMI(O)/WC(O) were 68, 12, 2 and 18 %, respectively. A lower proportion of diabetes was attributable to obesity defined using BMI alone compared to BMI and WC combined (32 % vs 47 %). AUC for diabetes was also lower when obesity was defined using BMI alone (0.62 vs 0.66). Similar results were observed for all outcomes. The odds for hypertension, dyslipidaemia, diabetes and CVD were increased for those with BMI(N)/WC(O) (OR range 1.8-2.7) and BMI(O)/WC(O) (OR 1.9-4.9) compared to those with BMI(N)/WC(N).

CONCLUSIONS

Current population monitoring, assessing obesity by BMI only, misses a proportion of the population who are at increased health risk through excess adiposity. Improved identification of those at increased health risk needs to be considered for better prioritisation of policy and resources.

The performance of diabetes risk prediction models in new populations: the role of ethnicity of the development cohort

It is believed that diabetes risk scores need to be ethnic specific. However, this prerequisite has not been tested. We examined the performance of several risk models, developed in various populations, in a Europid and a South Asian population. The performance of 14 published risk prediction models were tested in two prospective studies: the Australian Diabetes, Obesity and Lifestyle (AusDiab) study and the Mauritius non-communicable diseases survey. Eight models were developed in Europid populations; the remainder in various non-Europid populations. Model performance was assessed using area under the receiver operating characteristic curves (discrimination), Hosmer-Lemeshow tests (goodness-of-fit) and Brier scores (accuracy). In both AusDiab and Mauritius, discrimination was highest for a model developed in a mixed population (non-Hispanic white and African American) and lowest for a model developed in a Europid population. Discrimination for all scores was higher in AusDiab than in Mauritius. For almost all models, goodness-of-fit was poor irrespective of the ethnicity of the development cohort, and accuracy was higher in AusDiab compared to Mauritius. Our results suggest that similarity of ethnicity or similarity of diabetes risk may not be the best way of identifying models that will perform well in another population. Differences in study methodology likely account for much of the difference in the performance. Thus, identifying models which use measurements that are clearly described and easily reproducible for both research and clinical settings may be more important.

Evaluating the guideline enhancement tool (GET): an innovative clinical training tool to enhance the use of hypertension guidelines in general practice

BACKGROUND

This project aims to evaluate the effectiveness of an innovative educational intervention in enhancing clinical decision making related to the management of hypertension in general practice. The relatively low level of uptake of clinical practice guidelines by clinicians is widely recognised as a problem that impacts on clinical outcomes. This project addresses this problem with a focus on hypertension guidelines. Hypertension is the most frequently managed problem in general practice but evidence suggests that management of Hypertension in general practice is sub-optimal.

METHODS/DESIGN

This study will explore the effectiveness of an educational intervention named the 'Guideline Enhancement Tool (GET)'. The intervention is designed to guide clinicians through a systematic process of considering key decision points related to the management of hypertension and provides a mechanism for clinicians to engage with the hypertension clinical guidelines. The intervention will be administered within the Australian General Practice Training program, via one of the regional training providers. Two cohorts of trainees will participate as the intervention and delayed intervention groups. This process is expected to improve clinicians' engagement with the hypertension guidelines in particular, and enhance their clinical reasoning abilities in general. The effectiveness of the intervention in improving clinical reasoning will be evaluated using the 'Script Concordance Test'.

DISCUSSION

The study design presented in this protocol aims to achieve two major outcomes. Firstly, the trial and evaluation of the educational intervention can lead to the development of a validated clinical education strategy that can be used in GP training to enhance the decision-making processes related to the management of hypertension. This has the potential to be adapted to other clinical conditions and training programs and can benefit clinicians in their clinical decision-making. Secondly, the study explores features that influence the effective use of clinical practice guidelines. The study thus addresses a significant problem in clinical education.

Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes

BACKGROUND

A significant proportion of individuals taking antihypertensive therapies fail to achieve blood pressures <140/90 mmHg. In order to develop strategies for improved treatment of blood pressure, we examined the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors in a cohort of adults at increased cardiovascular risk.

METHODS

A cross-sectional study of 3994 adults from Melbourne and Shepparton, Australia enrolled in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN-HF) study. Inclusion criteria were age ≥60 years with one or more of self-reported ischaemic or other heart disease, atrial fibrillation, cerebrovascular disease, renal impairment or treatment for hypertension or diabetes for ≥2 years. Exclusion criteria were known heart failure or cardiac abnormality on echocardiography or other imaging. The main outcome measures were the proportion of participants receiving antihypertensive therapy with blood pressures ≥140/90 mmHg and the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors.

RESULTS

Of 3623 participants (1975 men and 1648 women) receiving antihypertensive therapy, 1867 (52%) had blood pressures ≥140/90 mmHg. Of these 1867 participants, 1483 (79%) were receiving only one or two antihypertensive drug classes. Blood pressures ≥140/90 mmHg were associated with increased age, male sex, waist circumference and log amino-terminal-pro-B-type natriuretic peptide levels.

CONCLUSIONS

Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes. Prescribing additional antihypertensive drug classes and lifestyle modification may improve blood pressure control in this population of individuals at increased cardiovascular risk.

Mean perfusion pressure deficit during the initial management of shock--an observational cohort study

PURPOSE

It is unclear if blood pressure targets for patients with shock should be adjusted to pre-morbid levels. We aimed to investigate mean deficit between the achieved mean perfusion pressure (MPP) in vasopressor-treated patients and their estimated basal (resting) MPP, and assess whether MPP deficit has any association with subsequent acute kidney injury (AKI).

MATERIALS AND METHODS

Fifty-one consecutive, non-trauma patients, aged ≥40 years, with ≥2 organ dysfunction and requiring vasopressor≥4 hours were observed at an academic intensive care unit. Mean MPP deficit [=%(basal MPP-achieved MPP)/basal MPP] and % time spent with >20% MPP deficit were assessed during initial 72 vasopressor hours (T0-T72) for each patient.

RESULTS

Achieved MPP was unrelated to basal MPP (P=.99). Mean MPP deficit was 18% (95% CI 15-21). Patients spent 48% (95% CI 39-57) time with >20% MPP deficit. Despite similar risk scores at T0, subsequent AKI (≥2 RIFLE class increase from T0) occurred more frequently in patients with higher (>median) MPP deficit compared to patients with lower MPP deficit (56% vs 28%; P=.045). Incidence of subsequent AKI was also higher among patients who spent greater % time with >20% MPP deficit (P=.04).

CONCLUSIONS

Achieved blood pressure during vasopressor therapy had no relationship to the pre-morbid basal level. This resulted in significant and varying degree of relative hypotension (MPP deficit), which could be a modifiable risk factor for AKI in patients with shock.

Higher heart rate increases risk of diabetes among men: The Australian Diabetes Obesity and Lifestyle (AusDiab) Study

AIMS

A very limited number of prospective studies have reported conflicting data on the relation between heart rate and diabetes risk. Our aim therefore was to determine in a large, national, population-based cohort if heart rate predicts the development of diabetes.

METHODS

The Australian Diabetes Obesity and Lifestyle study followed up 6537 people over 5 years. Baseline measurements included questionnaires, anthropometrics and blood and urine collection. Heart rate was recorded in beats per min (Dinamap). An oral glucose tolerance test was performed at baseline and follow-up, and diabetes was defined using World Health Organization criteria.

RESULTS

A total of 5817 participants were eligible for analysis, 221 of whom developed diabetes. Compared with participants with a heart rate < 60 b min(-1), those with a heart rate ≥ 80 b min(-1) were more likely to develop diabetes (odds ratio 1.89, 95% CI 1.07-3.35) over 5 years, independent of traditional risk factors. This relationship was highly significant, particularly in non-obese men (odds ratio 5.61, 95% CI 1.75-17.98), but not in their obese counterparts or in women.

CONCLUSIONS

Resting heart rate is associated with an increased risk of diabetes over a 5-year period, particularly among non-obese men. This suggests that sympathetic overactivity may be a contributing factor to the development of diabetes, and that resting heart rate may be useful in predicting risk of Type 2 diabetes in non-obese men.

Feasibility and outcomes of screening for cardiovascular risk factors in the emergency department

OBJECTIVES

The present study aimed to determine the prevalence of undiagnosed and undertreated hypercholesterolaemia and hypertension (HT) among ED patients and to evaluate the effects of a formal referral back to the general practitioner (GP) for further management.

METHODS

This was a cross-sectional study of ED patients with follow up, if indicated. Patients aged ≥35 years, without substantial illness or communication difficulties, were enrolled. Data were collected using a researcher-administered questionnaire, a point-of-care Accutrend® Plus System machine (Roche Diagnostic Australia Pty Ltd, Castle Hill, NSW, Australia) and digital sphygmomanometer. Patients with total cholesterol (TC) ≥6.0 mmol/L and/or BP ≥140/90 were given a referral letter and advised to consult their GP. The investigators made follow-up telephone calls 5 weeks later.

RESULTS

Of 827 presentations, 534 patients were enrolled (mean age 56.7 ± 13.3 years, 300 [56.2%] male). One hundred and eleven patients (20.7%, 95% CI 17.5-24.5) had TC ≥6.0 mmol/L. Patients with/without elevated TC differed significantly (P < 0.05) in regard to age, gender, GP ownership and attendance, and previous screening. Sixty-six patients consulted with their GP. Thirty had their TC levels retested, 18 received dietary/lifestyle advice and four had lipid-lowering medication prescribed or adjusted. Ninety-six patients (18.0%, 95% CI 14.9-21.6) had HT. Whereas 53 consulted their GP, no action was taken in 43 cases. Investigations were ordered for three and nine had antihypertensive medication prescribed or adjusted.

CONCLUSION

Substantial proportions of ED patients have undiagnosed and undertreated hypercholesterolaemia and/or HT. GP referral initiated interventions for many patients with hypercholesterolaemia, but fewer with HT. The ED has potential as a useful venue for the opportunistic screening of hypercholesterolaemia.

The Know Your Numbers (KYN) program 2008 to 2010: impact on knowledge and health promotion behavior among participants

BACKGROUND

Since 2007, the National Stroke Foundation in Australia has undertaken a community-based 'Know Your Numbers' program on blood pressure and other stroke risk factors.

AIMS

The aims of this study are to assess, in a sample of registrants participating in a three-month follow-up survey, retention of knowledge of risk factors and health conditions associated with hypertension, and whether those who were advised to see their doctor sought treatment or performed other health promotion actions.

METHODS

Various organizations (mainly pharmacies) were recruited to offer a 'free' standardized blood pressure check and educational resources for one-week/year between 2008 and 2010. Data collection was done thru registration log and detailed questionnaires for a sample of registrants at baseline and three-months. Descriptive statistics were used for comparison of baseline and three-month data.

RESULTS

There were 59 817 registrants over three-years. A total of 2044/2283 (90%) registrants completed a baseline survey (66% female, 50% aged >55 years); 43% had blood pressure ≥140/90 mmHg whereby 32% were unaware of their blood pressure status. Follow-up surveys were obtained from 510/805 (63%) baseline participants who provided consent. At three-months, improved knowledge was found for 9 of 11 risk factors for hypertension (e.g. lack of exercise baseline 73%; three-months 85%, P < 0·001). Knowledge for all the health conditions assessed that are associated with hypertension improved (e.g. stroke baseline 72%; three-months 87%, P < 0·001, heart attack baseline 69%; three-months 84%, P < 0·001). All respondents reported at least one health promotion action. Among 141/510 advised to visit their doctor, 114 (81%) did.

CONCLUSION

Know Your Numbers is a successful health promotion program and encourages people to be reviewed by their doctor.

Barriers to lifestyle risk factor assessment and management in hypertension: a qualitative study of Australian general practitioners

Hypertension is a leading cause of mortality and disease burden worldwide, yet its management remains suboptimal. Identification and management of lifestyle risk factors should be a clinical priority in all patients because of the beneficial effects of lifestyle intervention on blood pressure. The objective of this qualitative focus group study was to identify barriers to lifestyle management in hypertension in Australian general practice. Purposeful sampling was used to select large group practices. Six focus groups (n=30) were audio recorded and transcribed. An iterative thematic analysis was conducted. Overall participants felt they had the required knowledge to provide broad lifestyle advice. However, cynicism dominated due to an overwhelming lack of success in practice. Patient reluctance and ambivalence were identified as major barriers but participants were willing to share the responsibility. Other barriers included time, reduced access to allied health and broader determinants of health. General practitioners need to be empowered to allow continuation of valuable lifestyle advice and counselling. The results emphasise the importance of ongoing lifestyle assessment and tailoring of management to the complex interplay of factors that impact on a patient's ability to adopt and maintain lifestyle change. System issues need to be addressed to provide better streamlined care.

General practitioners' hypertension knowledge and training needs: a survey in Xuhui district, Shanghai

Background

Hypertension prevalence is high in China, while patients’ levels of hypertension awareness, treatment and control are low. General practitioners’ knowledge and training relating to hypertension prevention may be an important related factor. We aimed to investigate general practitioners’ knowledge of hypertension prevention and potential training needs.

Methods

A questionnaire survey was conducted among all general practitioners at five community health service centers selected by convenience sampling. A total of 160 questionnaires were distributed and 147 were returned (response rate 91.9%) The questionnaire included general information; 12 subjective questions on health promotion, education and training needs; and 19 objective questions in 5 domains (epidemiology, diagnosis, treatment, referral and community management) measuring knowledge of hypertension prevention and treatment.

Results

The major difficulties in health education practice for general practitioners were poor patient compliance (77.6%) and lack of medical consultation time (49.0%). The average accuracy rate of hypertension prevention knowledge was 49.2%, ranging from 10.5% to 94.7%. The factors associated with accuracy rate were physician’s education level (medical university vs. professional school, β = 13.3, P = 0.003), and type of center (training base vs. community healthcare center, β = 12.3, P < 0.0001). Most physicians (87.8%) reported being willing to attend training courses regularly and the preferred frequency was once every 2 ~ 3 months (53.5%). The preferred course was medical treatment of hypertension (82.3%) and the most favored training approach was expert lectures (80.3%).

Conclusions

The knowledge level of hypertension prevention is low among general practitioners in urban settings. Physicians working in community clinics where they participate in a series of teaching, assessing and evaluating systems for hypertension prevention perform better than those in general healthcare centers who lack specific training. Continuing hypertension education is urgently needed to ensure that physicians in general practice are aware of and adhere to the national hypertension prevention guidelines.

Untreated hypertension: prevalence and patient factors and beliefs associated with under-treatment in a population sample

Identifying barriers to hypertension management may facilitate cardiovascular risk reduction. Therefore, our objective, was to determine the prevalence of hypertension not managed with medication ('untreated') in a representative adult sample and identify patient factors/beliefs, and aspects of the patient-general practitioner (GP) relationship associated with untreated hypertension. The North West Adelaide Health Study, a biomedical cohort study over three stages from 2000-2009, assesses hypertension (systolic > or =140 mm Hg and/or > or =90 mm Hg or current treatment with anti-hypertensive medication), chronic disease and associated risk factors and health-care experiences, including risk perception, decision-making preferences, GP/primary care provider affiliation and satisfaction with care (n=2425). The prevalence of hypertension was 32.1% (n=781) comprised of treated (19.0%, n=462) and untreated (13.1%, n=319) hypertension. Thus, 40.8% of hypertension was untreated. Among hypertensive subjects, non-treatment was significantly associated with male sex, age <45 years, workforce participation, infrequent GP visits, dissatisfaction with recent medical care, high total cholesterol, moderate-level physical activity and lower body weights. Compared with participants without hypertension (and no treatment), untreated subjects demonstrated significant (15%) 10-year Framingham general cardiovascular risk (odds ratio=6.44, 95% confidence interval=4.52-9.17). Novel screening strategies and public health messages to address beliefs and perceptions of both patients and the health system are required to identify untreated, at-risk hypertensive individuals.

Aged garlic extract reduces blood pressure in hypertensives: a dose-response trial

BACKGROUND/OBJECTIVES

Hypertension affects about 30% of adults worldwide. Garlic has blood pressure-lowering properties and the mechanism of action is biologically plausible. Our trial assessed the effect, dose-response, tolerability and acceptability of different doses of aged garlic extract as an adjunct treatment to existing antihypertensive medication in patients with uncontrolled hypertension.

SUBJECTS/METHODS

A total of 79 general practice patients with uncontrolled systolic hypertension participated in a double-blind randomised placebo-controlled dose-response trial of 12 weeks. Participants were allocated to one of three garlic groups with either of one, two or four capsules daily of aged garlic extract (240/480/960 mg containing 0.6/1.2/2.4 mg of S-allylcysteine) or placebo. Blood pressure was assessed at 4, 8 and 12 weeks and compared with baseline using a mixed-model approach. Tolerability was monitored throughout the trial and acceptability was assessed at 12 weeks by questionnaire.

RESULTS

Mean systolic blood pressure was significantly reduced by 11.8±5.4 mm Hg in the garlic-2-capsule group over 12 weeks compared with placebo (P=0.006), and reached borderline significant reduction in the garlic-4-capsule group at 8 weeks (-7.4±4.1 mm Hg, P=0.07). Changes in systolic blood pressure in the garlic-1-capsule group and diastolic blood pressure were not significantly different to placebo. Tolerability, compliance and acceptability were high in all garlic groups (93%) and highest in the groups taking one or two capsules daily.

CONCLUSIONS

Our trial suggests aged garlic extract to be an effective and tolerable treatment in uncontrolled hypertension, and may be considered as a safe adjunct treatment to conventional antihypertensive therapy.

Prescribing Data in General Practice Demonstration (PDGPD) project--a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

BACKGROUND

Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner's drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.

METHODS

A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a "control" for the other two groups.De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.

DISCUSSION

This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.

The association between dairy food intake and the incidence of diabetes in Australia: the Australian Diabetes Obesity and Lifestyle Study (AusDiab)

OBJECTIVE

Several studies have suggested that dairy food may reduce the risk of obesity and metabolic abnormalities but few have been able to conclusively demonstrate that it reduces the risk of diabetes. The aim of the present analysis was to investigate if dairy food intake independently reduces the risk of diabetes.

DESIGN

The Australian Diabetes Obesity and Lifestyle Study (AusDiab) is a national, population-based, prospective survey conducted over 5 years. Baseline measurements included a 121-item FFQ, anthropometrics and an oral glucose tolerance test.

SETTING

Forty-two randomly selected clusters across Australia.

SUBJECTS

Adults aged ≥25 years who participated in the baseline survey and returned to follow-up 5 years later.

RESULTS

A total of 5582 participants with complete data were eligible for analysis, 209 of whom had incident diabetes. Compared with men in the first tertile of dairy food intake, men in the third tertile had a significantly reduced risk of developing diabetes after adjustment for age, sex, total energy intake, family history of diabetes, education, physical activity, smoking status, fasting serum TAG and HDL cholesterol, systolic blood pressure, waist circumference and hip circumference (OR = 0·53, 95 % CI 0·29, 0·96; P = 0·033). A similar non-significant association was observed in women.

CONCLUSIONS

Dietary patterns that incorporate high intakes of dairy food may reduce the risk of diabetes among men. Further investigation into the relationship between dairy food intake and diabetes needs to be undertaken to fully understand the potential mechanism of this observation.

Risk of cardiovascular and all-cause mortality: impact of impaired health-related functioning and diabetes: the Australian Diabetes, Obesity and Lifestyle (AusDiab) study

OBJECTIVE

There is an established link between health-related functioning (HRF) and cardiovascular disease (CVD) mortality, and it is known that those with diabetes predominantly die of CVD. However, few studies have determined the combined impact of diabetes and impaired HRF on CVD mortality. We investigated whether this combination carries a higher CVD risk than either component alone.

RESEARCH DESIGN AND METHODS

The Australian Diabetes, Obesity and Lifestyle (AusDiab) study included 11,247 adults aged ≥ 25 years from 42 randomly selected areas of Australia. At baseline (1999-2000), diabetes status was defined using the World Health Organization criteria and HRF was assessed using the SF-36 questionnaire.

RESULTS

Overall, after 7.4 years of follow-up, 57 persons with diabetes and 105 without diabetes had died from CVD. In individuals with and without diabetes, HRF measures were significant predictors of increased CVD mortality. The CVD mortality risks among those with diabetes or impaired physical health component summary (PCS) alone were similar (diabetes only: hazard ratio 1.4 [95% CI 0.7-2.7]; impaired PCS alone: 1.5 [1.0-2.4]), while those with both diabetes and impaired PCS had a much higher CVD mortality (2.8 [1.6-4.7]) compared with those without diabetes and normal PCS (after adjustment for multiple covariates). Similar results were found for the mental health component summary.

CONCLUSIONS

This study demonstrates that the combination of diabetes and impaired HRF is associated with substantially higher CVD mortality. This suggests that, among those with diabetes, impaired HRF is likely to be important in the identification of individuals at increased risk of CVD mortality.

Antihypertensives for combating dementia? A perspective on candidate molecular mechanisms and population-based prevention

Age-related increases in prevalent dementia over the next 30-40 years risk collapsing medical resources or radically altering the way we treat patients. Better prevention of dementia therefore needs to be one of our highest medical priorities. We propose a perspective on the pathological basis of dementia based on a cerebrovascular-Alzheimer disease spectrum that provides a more powerful explanatory framework when considering the impact of possible public health interventions. With this in mind, a synthesis of evidence from basic, clinical and epidemiological studies indeed suggests that the enhanced treatment of hypertension could be effective for the primary prevention of dementia of either Alzheimer or vascular etiology. In particular, we focus on candidate preventative mechanisms, including reduced cerebrovascular disease, disruption of hypoxia-dependent amyloidogenesis and the potential neuroprotective properties of calcium channel blockers. Following the successful translation of large, long-term and resource-intense trials in cardiology into improved vascular health outcomes in many countries, new multinational prevention trials with dementia-related primary outcomes are now urgently required.

Satisfaction with referral relationships between general practice and allied health professionals in Australian primary health care

Chronic diseases require a multidisciplinary approach to provide patients with optimal care in general practice. This often involves general practitioners (GPs) referring their patients to allied health professionals (AHPs). The Team-link study explored the impact of an intervention to enhance working relationships between GPs and AHPs in general practice regarding the management of two chronic diseases: diabetes and ischaemic heart disease (IHD) or hypertension. The Measure of Multidisciplinary Linkages (MoML) questionnaire was developed to assess professional interactions and satisfaction with various aspects of the multidisciplinary relationship. Questionnaires were completed at baseline and 6 months by GPs (n=29) participating in the Team-link project and by AHPs (n=39) who had a current working relationship with these GPs. The Chronic Care Team Profile (CCTP) and Clinical Linkages Questionnaire (CLQ) were also completed by GPs. There were significant changes from baseline to 6 months after the intervention measures for individual items and overall MoML scores for GPs, especially items assessing 'contact', 'shared care' and 'satisfaction with communication'. The comparable item in the CLQ, 'Shared Care', also showed significant improvement. However, there were no statistically significant correlations between the change in overall 'Referral Satisfaction' scores in the GP MoML and the CLQ. The CCTP also improved and was a weak negative correlation between the GP MoML and two of the subscores of this instrument. There were no changes in AHP measure. This study demonstrates that the instrument is sensitive to differences between providers and conditions and is sensitive to change over time following an intervention. There were few associations with the other measures suggesting that the MoML might assess other aspects of teamwork involving practitioners who are not collocated or in the same organisation.

High incidence of obesity co-morbidities in young children: a cross-sectional study

AIM

The prevalence of overweight and obesity in children is a public health problem because of future morbidity. However, the prevalence of medical complications in overweight and obese primary school children in Australia is not well documented. As part of the larger, prospective cohort Growth and Development Study, this report aimed to identify the medical complications of obesity in a population-based community sample of primary school-aged children.

METHODS

Two groups of primary school children were studied: a random community sample of overweight/obese children (not seeking treatment) and a matched community sample of normal weight children. Demographics, medical history, family history and symptoms of complications of overweight were collected. Children had a physical examination, oral glucose tolerance tests with insulins, fasting lipid profiles and liver function tests.

RESULTS

Data from 283 children are presented (6.1-13.4 years, mean 9.8 years). There were no differences in birth data, family composition, parental age or socio-economic status between groups. Overweight and obese children were more likely to complain of musculoskeletal pain, depression, anxiety and bullying, and had more adverse examination findings than control children. They also had more abnormal investigations: overweight children: impaired glucose tolerance (IGT) 1.3%, hyperinsulinism 19.5%, dyslipidaemia 63.8%, raised alanine transaminase (ALT) 9.0%; obese children: IGT 5.3%, hyperinsulinism 38.9%, dyslipidaemia 73.7%, raised ALT 31.6%.

CONCLUSION

Overweight and obese primary school-aged children have significant medical complications of their weight status. Overweight children, in addition to obese children, should be screened for complications. A secondary finding is a high proportion of normal weight children with lipid levels outside desirable healthy ranges.

Moving from viral suppression to comprehensive patient-centered care: the high prevalence of comorbid conditions and health risk factors in HIV-1-infected patients in Australia

HIV clinicians today need to move from focusing on viral suppression to a chronic disease model in which comorbid conditions and risk factors are comprehensively identified and addressed to reduce rates of serious non-AIDS-related morbidity and mortality. This study aimed to determine the prevalence of comorbid conditions in an Australian HIV-positive population. Of 180 patients included, there was a median CD4 count of 0.520 cells/mm(3). The majority (88%) of patients were currently receiving highly active antiretroviral therapy (HAART). There were high rates of failure to attend clinical appointments (30%), current smoking (42%), hypertension (16%), and dyslipidemia (17%). Significant rates of dipstick-positive proteinuria (16%) and elevated blood glucose (15%) were recorded. Risk factors were commonly not addressed by the treating clinician. There is an urgent need to systematize detection and management of high-prevalence comorbid conditions to prevent premature mortality associated with serious non-AIDS events.

Type 2 diabetes strengthens the association between pulse pressure and chronic kidney disease: the AusDiab study

OBJECTIVE

Chronic kidney disease (CKD) is a serious disorder with significant public health impact. Identification of factors associated with risk of progression of kidney disease may help in earlier intervention in high-risk groups. We investigated whether brachial pulse pressure (PP) was associated with 5-year changes in estimated glomerular filtration rate (eGFR) and incident CKD and whether type 2 diabetes modified these associations.

METHODS

In the population-based Australian Diabetes, Obesity and Lifestyle Study (AusDiab) 5554 individuals (5.8% with type 2 diabetes) who took part in the 5-year follow-up and had no CKD or microalbuminuria at baseline were included.

RESULTS

After adjusting for baseline age, sex, eGFR and use of blood pressure-lowering medication, each baseline SD higher PP was associated with a decline in eGFR of 0.32 ml/min (P=0.006) and an odds ratio (OR) for CKD of 1.29 [95% confidence interval (CI) 1.09-1.53] in individuals without type 2 diabetes. In individuals with type 2 diabetes, eGFR declined by 1.10 ml/min (P=0.011) and the OR for incident CKD was 1.94 (1.14-3.29). Similar associations with eGFR decline were observed with systolic blood pressure and incident CKD in individuals without type 2 diabetes. In individuals with type 2 diabetes, higher systolic blood pressure was only significantly associated with eGFR decline if the diastolic blood pressure was 70 mmHg or less (P for interaction between systolic and diastolic blood pressure: 0.033).

CONCLUSIONS

PP is an important risk factor for eGFR decline and incident CKD over a 5-year period, especially in individuals with type 2 diabetes.

Optimising management of hypertension in primary care: the Valsartan Intensified Primary Care Reduction of Blood Pressure (Viper-Bp) study

BACKGROUND

The Valstartan Intensified Primary CarE Reduction of Blood Pressure Study (VIPER-BP) Study is an open-label, randomised controlled trial comparing usual primary care management with an intensive BP management strategy using three forms of valsartan-based therapy (mono-therapy, thiazide diuretic or calcium channel blocker combinations) to achieve individualised BP control.

METHODS

To identify the features of General Practitioner (GP) management of hypertension in Australia, we analyse the response to a case scenario-based survey of 500 GPs. We subsequently recruited a national cohort of GP Investigators to enrol up to 2500 patients into the VIPER-BP Study.

RESULTS

GP responses clearly demonstrated that, compared to the VIPER-BP intervention, a heterogeneous approach to the primary care management of hypertension persists in Australia. By November 2010, 2157 hypertensive patients from 272 actively recruiting GP Investigators were enrolled into the study. Of these, 1965 (91%) patients were entered into a standardised "run-in" phase of 28 days of valsartan 80 mg/day. Subsequently, 1285 patients were randomised to usual care (n=435) or the VIPER-BP intervention (n=850). There was a predominance of males (62%), whilst 55% had pre-existing diabetes or cardiovascular disease and 63% had been previously treated for hypertension. Mean systolic and diastolic BP on randomisation for men and women, respectively, was 148 ± 15/88 ± 11 and 148 ± 18/87 ± 10 mm Hg.

CONCLUSIONS

In contrast to typical primary care management of hypertension, VIPER-BP combines more intensive and aggressive therapies with structured management to more rapidly attain and sustain individualised BP targets in hypertensive patients.

Feasibility of a pilot programme to increase awareness of blood pressure as an important risk factor for stroke in Australia

BACKGROUND

Reduction of blood pressure represents one of the most effective means of reducing stroke risk. However, lack of community awareness and uncontrolled blood pressure remain a significant problem. In 2007, the National Stroke Foundation (Australia) conducted the 'Know Your Numbers' pilot programme to improve community knowledge, based on a similar UK programme developed by the Blood Pressure Association. We aimed to determine the success of the pilot in improving knowledge and in identifying factors to improve the programme.

METHODS

Pharmacy Guild of Australia and Rotary International recruited volunteers to provide a 'free' blood pressure check and educational resources between 25 and 27 October 2007 via 'pressure stations'. evaluation methods: registration log and a survey of a 'one in 10 sample' at baseline and 3 months. Data were analysed using descriptive statistics.

RESULTS

77 out of 104 pressure stations returned data. The median tested per pressure station: 29 (interquartile range 19, 50), 66% tested by pharmacy and 32% by Rotary. Of the 2834 registrants (58% female, 55% aged >55 years), 46% had 'high' readings (>140/90 mmHg). Of those with high readings, 45% reported no history of high blood pressure and one-third of the registrants were unaware of their blood pressure level. There was evidence of improved knowledge at the 3-month follow-up, with most participants with high blood pressure (85%, n=22) being reviewed by their doctor.

CONCLUSION

The 'Know Your Numbers' pilot programme was a successful model for improving knowledge of blood pressure as an important stroke risk factor and encouraging individuals with high blood pressure to be reviewed by their doctor. Further programmes with evaluation are being planned.