Utilizing community InfoSpots for health education: perspectives and experiences in Migoli and Izazi, Tanzania

Limited access to health education can be a barrier for reaching the Sustainable Development Goals, especially in rural communities in sub-Saharan Africa. We addressed this gap by installing community information spots (InfoSpots) with access to the internet and a locally stored digital health education platform (the platform) in Migoli and Izazi, Tanzania. The objective of this case study was to explore the perspectives and experiences of InfoSpot users and non-users in these communities. We conducted 35 semi-structured interviews with participants living, working or studying in Migoli or Izazi in February 2020 and subsequently analysed the data using content analysis. The 25 InfoSpot users reported variations in use patterns. Users with more education utilized the platform for their own health education and that of others, in addition to internet surfing. High school students also used the platform for practicing English, in addition to health education. Most InfoSpot users found the platform easy to use; however, those with less education received guidance from other users. Non-users reported that they would have used the InfoSpot with the platform if they had been aware of its existence. All participants reported a positive view of the digital health messages, especially animations as a health knowledge transfer tool. In conclusion, different and unintended use of the platform shows that the communities are creative in ways of utilizing the InfoSpots and gaining knowledge. The platform could have been used by more people if it had been promoted better in the communities.

Improving Health Knowledge Through Provision of Free Digital Health Education to Rural Communities in Iringa, Tanzania: Nonrandomized Intervention Study

BACKGROUND

Community health education is one of the most effective measures to increase health literacy worldwide and can contribute to the achievement of specific targets of the Sustainable Development Goal 3. Digitalized health education materials can improve health knowledge as a dimension of health literacy and play an important role in disease prevention in rural sub-Saharan settings.

OBJECTIVE

The objective of this research is to assess the effect of a digital health education intervention on the uptake and retention of knowledge related to HIV/AIDS, tuberculosis (TB), and Taenia solium (neuro)cysticercosis and taeniosis in rural communities in Iringa, Tanzania.

METHODS

We conducted a nonrandomized intervention study of participants aged 15 to 45 years, randomly selected from 4 villages in Iringa, Tanzania. The intervention consisted of 2 parts. After the baseline assessment, we showed the participants 3 animated health videos on a tablet computer. After a period of 6 months, free access to community information spots (InfoSpots) with an integrated digital health education platform was provided to the intervention villages. Participants in the control group did not receive the intervention. The primary outcome was the difference in disease knowledge between the intervention and control groups, 12 months after baseline. Data were collected using an open-ended questionnaire, with correct or incorrect answers before and after intervention.

RESULTS

Between April and May 2019, a total of 600 participants were recruited into the intervention (n=298, 49.7%) or control (n=302, 50.3%) groups. At baseline, no statistically significant differences in knowledge of the target diseases were observed. At 12 months after intervention, knowledge about HIV/AIDS, TB, and T. solium (neuro)cysticercosis and taeniosis was 10.2% (95% CI 5.0%-15.4%), 12% (95% CI 7.7%-16.2%), and 31.5% (95% CI 26.8%-36.2%) higher in the intervention group than in the control group, respectively. In all 4 domains (transmission, symptoms, treatment, and prevention), an increase in knowledge was observed in all the 3 diseases, albeit to varying degrees. The results were adjusted for potential confounders, and the significance of the primary results was maintained in the sensitivity analysis to assess dropouts. The participants who reported using the InfoSpots in the 12-month assessment further increased their knowledge about the target diseases by 6.8% (HIV/AIDS), 7.5% (TB), and 13.9% higher mean proportion of correct answers compared with the participants who did not use the InfoSpots.

CONCLUSIONS

Digital health education based on animated health videos and the use of free InfoSpots has significant potential to improve health knowledge, especially in rural areas of low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03808597; https://clinicaltrials.gov/ct2/show/NCT03808597.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25128.

Development of Digital Health Messages for Rural Populations in Tanzania: Multi- and Interdisciplinary Approach

BACKGROUND

Health workers have traditionally delivered health promotion and education to rural communities in the Global South in paper leaflet formats or orally. With the rise of digital technologies, health promotion and education can be provided in innovative and more effective formats, which are believed to have a higher impact on disease prevention and treatment.

OBJECTIVE

The aim of this tutorial is to illustrate how a multi- and interdisciplinary approach can be applied in the design process of digital health messages for use in the Global South.

METHODS

The multi- and interdisciplinary team of the Non-discriminating access for Digital Inclusion (DigI) project digitalized and customized available government-approved paper-based health promotion messages into a screen-suitable format. The team worked closely together and used its diverse expertise to develop digital health messages with disease-specific content in Tanzania's national language (Swahili) as well as English. The development process included the following phases: a local needs assessment; identification of government-approved health promotion materials in a nondigital format; identification of key health messages; creation of a practical and engaging story, easy to understand for the general public; drafting of a storyboard for an animated video with review, feedback, and revisions; forward and backward translation; audio recording of the story in both languages; finalization and presentation of the animations; development of relevant questions related to the health messages in each domain; and development of web and mobile apps to access the digital health messages.

RESULTS

Between 2017 and 2019, we developed key health messages, quizzes, and animated health videos to address HIV/AIDS, tuberculosis, Taenia solium cysticercosis and taeniasis, and anthrax, all of which are of public health importance in Tanzania. Feedback from local stakeholders and test users was included in various phases of the process. The 4 videos and other content are available in local information spots on a digital health platform (DigI platform), established by the DigI project, in both Tanzanian Swahili and English.

CONCLUSIONS

Our methodological multi- and interdisciplinary approach ensures that the digital health messages for the public are clear, high quality, and align with the government's objectives for health promotion. It also demonstrates the diversity of scientific disciplines required when collaborating on a digital health project. We recommend this approach to be applied to the development of other digital health messages for a wide range of diseases.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25128.

Digital Health Intervention to Increase Health Knowledge Related to Diseases of High Public Health Concern in Iringa, Tanzania: Protocol for a Mixed Methods Study

BACKGROUND

Traditionally, health promotion and health education have been provided to communities in the global south in the form of leaflets or orally by health care workers. Digital health interventions (DHIs) such as digital health messages accessed by smartphones have the potential to reach more people at a lower cost and to contribute to strengthening of health care systems. The DHI in this study focuses on disseminating digital health education regarding 3 disease complexes of high public health concern: HIV/AIDS, tuberculosis, and Taenia solium (neuro)cysticercosis or taeniasis, a parasitic zoonotic disease that requires a One Health approach. The DHI presents the participants with animated health videos (animations) and provides access to information spots (InfoSpots) with a free-of-charge digital health platform containing messages about health to rural Tanzanian communities.

OBJECTIVE

The objective of this study is to measure the effect of the DHI on health knowledge uptake and retention over time in the rural communities.

METHODS

This is a mixed methods study including a nonrandomized controlled trial and qualitative interviews conducted in rural Tanzania. A health platform containing digital health messages for the communities was developed prior to the study. The health messages consist of text, pictures, quizzes, and animations of everyday stories, aimed at disease prevention and early treatment. The baseline and immediate postintervention assessments were completed in Iringa, Tanzania in May 2019. The participants were interviewed by enumerators and completed questionnaires regarding health knowledge. Participants in the intervention group were exposed to 3 different health animations once on a tablet device. The participants' health knowledge was assessed again immediately after the exposure. The first follow-up survey was undertaken in August 2019. The InfoSpots with the digital health platform were thereafter launched in the intervention villages in November 2019. Qualitative interviews were undertaken in February 2020. The second follow-up was completed in June 2020.

RESULTS

A total of 600 participants have been enrolled in the trial. We will assess (1) the difference in knowledge scores between baseline and the immediate postintervention assessments in the intervention group and (2) the difference in knowledge scores between the intervention and control groups at baseline, 3 and 6 months post-DHI rollout. Since a randomized design did not prove feasible, potential confounders (eg, age, gender, education, and time of exposure) may be introduced, and results will be adjusted. Data analysis for the 35 qualitative interviews is currently ongoing, and perspectives and experiences related to use and nonuse of the InfoSpots are being explored.

CONCLUSIONS

The data have been collected, and the analysis is ongoing in this digital health study, aimed at evaluating the effects of a DHI based on relevant health messages. The publications of results can be expected this year.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03808597; https://clinicaltrials.gov/ct2/show/NCT03808597.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/25128.

Alcohol and delirium tremens: effects of average number of drinks per day and beverage type

OBJECTIVE

Associations of amount of alcohol intake and beverage type with the risk of delirium tremens (DT) have not been studied. This longitudinal study investigated if the average number of drinks per day and beverage type predict DT.

METHODS

A cohort of 3 582 alcohol-dependent men and women aged 19-82 without previous DT were interviewed about alcohol intake and beverage type at baseline in 1994-2005 and followed through record linkage in Danish nationwide registers to identify incident DT. Data were analyzed by means of Cox regression models.

RESULTS

An average number of drinks per day of 20-30 or >30 was associated with hazard ratios (HRs) of 1.38 (95% CI 1.03-1.84) and 1.64 (95% CI 1.19-2.27) relative to the reference category (1-9 drinks). Independently of amount consumed and covariates (age, gender, civil status and work status), beverage type (spirits vs. mixed alcohol) was associated with a HR of 1.63 (95% CI 1.08-2.46). Male gender was robustly associated with increased risk (HR = 1.62 (95% CI 1.25-2.08).

CONCLUSIONS

In alcohol-dependent men and women, daily alcohol intake above a threshold of 20 beverages or 240 g alcohol and a preference for spirits increase the risk of developing DT.

Parental alcohol use disorder with and without other mental disorders and offspring alcohol use disorder

OBJECTIVE

To examine the association between parental alcohol use disorder (AUD) with and without other mental disorders and offspring AUD.

METHODS

Using data from Danish nationwide registers, we identified 15 477 offspring with parental AUD and 154 392 reference individuals from the general population. Parental AUD was defined as registration for AUD treatment. Parental mental disorders were identified in medical registers and comprised psychotic, mood, anxiety, personality, drug use, and other non-alcohol-related mental disorders. AUD in offspring was identified from medical, pharmacy, treatment and cause of death registers. Hazard ratios (HRs) of AUD were estimated using Cox regression models.

RESULTS

AUD in one or both parents was associated with higher risks of AUD in offspring compared with reference individuals. Paternal AUD plus other mental disorder (HR = 2.27, 95% confidence interval (CI): 2.10-2.46) and paternal AUD alone (HR = 2.21, 95% CI: 2.07-2.36) were associated with higher offspring AUD risk. Similarly, maternal AUD plus other mental disorder (HR = 3.02, 95% CI: 2.66-3.43) and maternal AUD alone (HR = 2.57, 95% CI: 2.20-3.01) were associated with higher offspring AUD risk.

CONCLUSIONS

Offspring with parental AUD are at increased risk of AUD irrespective of exposure to other parental mental disorders.

Weight and weight gain during early infancy predict childhood obesity: a case-cohort study

BACKGROUND

Infant weight and weight gain are positively associated with later obesity, but whether there is a particular critical time during infancy remains uncertain.

OBJECTIVE

The aim was to investigate when and how weight and weight gain during infancy become associated with childhood obesity.

METHODS

In a cohort representing 28 340 children born from 1959-67 and measured in Copenhagen schools, 962 obese children (2007 World Health Organization criteria), were compared with a 5% randomly selected sub-cohort of 1417 children. Information on weight at birth, 2 weeks, 1, 2, 3, 4, 6 and 9 months was retrieved from health visitors' records. Odds ratios and 95% confidence intervals (CI) for childhood obesity by tertiles of weight at each age and by change in tertiles of weight between two consecutive measurements were estimated using multivariate logistic regression with adjustment for indicators of socioeconomic status, preterm birth, and breastfeeding.

RESULTS

Compared with children in the middle weight-tertile, children with a weight in the upper tertile had a 1.36-fold (CI, 1.10-1.69) to 1.72-fold (CI, 1.36-2.18) higher risk of childhood obesity from birth through 9 months, whereas children in the lower weight-tertile had almost half the risk of obesity from 2 through 9 months. The risk of childhood obesity associated with change in weight-tertile in each interval was stable at ∼1.5-fold per weight-tertile increase throughout infancy.

CONCLUSIONS

Infant weight and weight gain are associated with obesity in childhood already during the first months of life. Determinants of weight gain shortly after birth may be a suitable target for prevention of obesity.

Predictors of weight loss maintenance and attrition during a 6-month dietary intervention period: results from the DiOGenes study

There is a need to develop tools to predict individual weight loss maintenance and attrition prognosis. We aimed to identify predictors of weight loss maintenance outcome and attrition in subjects from eight European countries in the DiOGenes project. A total of 932 overweight/obese subjects (body mass index: 27-42 kg m(-2) ) were enrolled in an 8-week low-calorie diet (LCD). The 776 subjects (83%) who achieved at least 8% reduction in their initial body weight were randomized into five dietary arms varying in protein content and glycemic index for a 6-month weight maintenance period. Baseline characteristics, weight loss at weeks 1, 3 and 8 of LCD were assessed as predictors of weight loss maintenance and attrition using multivariate regression and correlation models. The multivariate model showed that the 6-month weight loss maintenance was predicted by: 7.889 - 0.343 × weight loss at week 3 + 1.505 × weight loss at week 8 + 2.422 × gender (0 = male and 1 = female gender) (R(2)  = 51%, P = 0.0001). A greater weight loss at week 8 was associated with a lower attrition during the subsequent 6-month dietary intervention period (OR = 0.92, 95% CI: 0.88-0.97, P = 0.001). Furthermore, the men showed an increased likelihood for attrition during the dietary intervention period (OR = 1.54, 95% CI: 1.07-2.20, P = 0.02). A greater weight loss during 8 weeks of LCD and female gender predict better 6-month weight maintenance of weight loss, whereas the baseline characteristics did not predict outcome. Attrition could be strongly predicted by gender and weight loss during LCD.

The Diet, Obesity and Genes (Diogenes) Dietary Study in eight European countries - a comprehensive design for long-term intervention

Diogenes is a Pan-European, randomized, controlled dietary intervention study investigating the effects of dietary protein and glycaemic index on weight (re)gain, metabolic and cardiovascular risk factors in obese and overweight families in eight European centres. The article is methodological in character, and the presentation of 'results' will be limited to baseline characteristics of the study populations included. A total of 891 families with at least one overweight/obese parent underwent screening. The parents started an initial 8-week low-calorie diet and families with minimum one parent attaining a weight loss of > or = 8%, were randomized to one of five energy ad libitum, low-fat (25-30 E%) diets for 6 or 12 months: low protein/low glycaemic index, low protein/high glycaemic index, high protein/low glycaemic index, high protein/high glycaemic index or control (national dietary guidelines). At two centres the families were provided dietary instruction plus free foods for 6 months followed by 6-month dietary instruction only. At the remaining six centres the families received dietary instruction only for 6 months. The median weight loss during the low-calorie diet was 10.3 kg (inter-quartile range: 8.7-12.8 kg, n = 775). A total of 773 adults and 784 children were randomized to the 6-month weight (re)gain prevention phase. Despite major cultural and dietary regional differences in Europe, interventions addressing effects of dietary factors are feasible with a reasonable attrition.

Impact on weight dynamics and general growth of the common FTO rs9939609: a longitudinal Danish cohort study

OBJECTIVE AND DESIGN

We investigated the impact of the fatness-related FTO rs9939609 A-allele on cross-sectional and longitudinal measures of body mass index (BMI), height and lean body mass (LBM) in a unique cohort representing a broad range of BMI.

SUBJECTS AND MEASUREMENTS

A random sample of all men attending the Danish draft boards during 1943-1977 plus all men with a BMI>or=31.0 kg/m(2) (assuring representation of the right end of the distribution) was taken. Anthropometric measures were available at up to eight points in time from birth to adulthood in 1629 genotyped men. The odds ratio (OR) for being a carrier of FTO rs9939609 according to (1) one unit alteration in z-scores for BMI, height and LBM at given ages and (2) longitudinal changes in BMI and height z-scores were assessed by logistic regression.

RESULTS

Except at birth, the AA genotype was associated with increased BMI z-scores at all point during the monitored lifespan, starting at the age of 7 years. This effect remained stable until early adulthood, where further weight gain occurred. The AA genotype was also--mainly through the effect on fatness--associated with accelerated linear growth in childhood (age 7 years; OR, 1.36; 95% confidence interval (CI), 1.06-1.74) and increased LBM in adulthood (OR, 1.24; 95% CI, 1.14-1.35).

CONCLUSION

Fatness induced by FTO rs9939609 in early childhood is sustained until early adulthood, where further weight gain may occur. FTO rs9939609 may, however, also be associated with linear growth and LBM mainly through the effect on fat mass.

Lack of association of fatness-related FTO gene variants with energy expenditure or physical activity

CONTEXT

A common variant in the first intron of FTO (rs9939609, T/A) is associated with fatness in Caucasians.

OBJECTIVE

FTO may regulate energy homeostasis through the hypothalamus, and we hypothesized that AA-genotypes of rs9939609 FTO have lower energy expenditure and/or a lower level of physical activity.

METHODS

The study population included all obese young men (body mass index > or = 31 kg/m(2)) at the mandatory draft board examinations in the Copenhagen area from 1943 to 1977 and a randomly selected control group from this population. Subgroups of 234 obese and 323 controls were examined in 1998-2000 (median age 48 yr). Fat mass (FM), lean body mass (LBM), leisure-time physical activity (LTPA), maximum oxygen uptake (VO(2)max), resting energy expenditure (REE), and glucose-induced thermogenesis (GIT) were measured. The FTO rs9939609 variant was genotyped. A recessive transmission mode fit the data best. Logistic regression was used to assess the odds ratios of the AA-genotype in relation to LTPA, VO(2)max, REE, and GIT.

RESULTS

The AA-genotype of FTO rs9939609 had higher REE in the age-adjusted model, but the association was eliminated when adjusting for FM and LBM. The AA-genotype was not associated with LTPA, VO(2)max, or GIT. This was not influenced by adjustment for age, FM, or LBM. The AA-genotype had increased FM, even with adjustment for age, LBM, REE, GIT, VO(2)max, and LTPA. Results were similar for FTO rs8050136 and rs7193144.

CONCLUSIONS

Homozygous carriers of the A-allele of rs9939609 FTO do not have lower REE, GIT, VO(2)max, or LTPA but higher FM, irrespective of LBM, REE, GIT, VO(2)max, and LTPA.

Total adiponectin and adiponectin multimeric complexes in relation to weight loss-induced improvements in insulin sensitivity in obese women: the NUGENOB study

AIM

Adiponectin increases insulin sensitivity, protects arterial walls against atherosclerosis, and regulates glucose metabolism, and is decreased in obese, insulin resistant, and type 2 diabetic patients. Adiponectin circulates in plasma as high, medium, and low molecular weight forms (HMW, MMW, and LMW). The HMW form was suggested to be closely associated with insulin sensitivity. This study investigated whether diet-induced changes in insulin sensitivity were associated with changes in adiponectin multimeric complexes.

SUBJECTS

Twenty obese women with highest and twenty obese women with lowest diet induced changes in insulin sensitivity (responders and non-responders respectively), matched for weight loss (body mass index (BMI)=34.5 (s.d. 2.9) resp. 36.5 kg/m(2) (s.d. 4.0) for responders and non-responders), were selected from 292 women who underwent a 10-week low-caloric diet (LCD; 600 kcal/d less than energy requirements). Plasma HMW, MMW, and LMW forms of adiponectin were quantified using Western blot method.

RESULTS

LCD induced comparable weight reduction in responders and non-responders by 8.2 and 7.6 kg. Homeostasis model assessment insulin resistance index decreased by 48.1% in responders and remained unchanged in non-responders. Total plasma adiponectin and the quantity of HMW and MMW remained unchanged in both groups, while LMW increased by 16.3% in non-responders. No differences between both groups were observed at baseline and after the study. Total plasma adiponectin, MMW, and LMW were negatively associated with fasting insulin levels at baseline.

CONCLUSION

No differences in total plasma adiponectin, HMW, MMW, and LMW forms were observed between responders and non-responders following 10-week LCD, suggesting that adiponectin is not a major determinant of weight loss-induced improvements in insulin sensitivity.

High social class and suicide in persons at risk for schizophrenia

OBJECTIVE

The relationship between suicide and social class has been equivocal. While some authors have reported that higher social class is related to higher rates of suicide, most other studies report that lower social class is associated with higher rates of suicide. Our study attempted to resolve these inconsistencies by using a High Risk for schizophrenia method.

METHOD

Children of women with severe schizophrenia were assessed in 1962. In 2005, when subjects were a mean age of 58 years, we identified those who had committed suicide.

RESULTS

A higher rate of suicide was associated with risk for schizophrenia in the High-Risk sample. Higher social class origin was associated with suicide in persons at risk for mental illness.

CONCLUSION

Higher social class origin was associated with suicide in subjects at genetic risk for schizophrenia (but not those without risk).

[Experiences with the FAMACHA-Eye-Colour-Chart for identifying sheep and goats for targeted anthelmintic treatment]

The bloodsuckling abomasal parasite Haemonchus contortus is the most pathogenic worm in sheep and goats. High prevalences of anthelmintic-resistant isolates make H. contortus difficult to control. Detecting the most anaemic animals could support a targeted selective treatment approach. Leaving the rest of the flock untreated would generate a refuge for anthelmintic-sensitive parasites. South-African researchers tried the FAMACHA-Eye-Colour-Chart for anaemic sheep and goats with good success. Field studies, carried out in Northern Germany on naturally infected sheep and goats showed, that at a comparatively low prevalence of H. contortus the FAMACHA-test proved not being sufficient in detecting all animals with high fecal egg counts. Under these conditions there was no satisfying reliability to identify small ruminants for selective deworming only based on the FAMACHAEye-Colour-Test. But if not working hours are the limiting factor, the repeated score could support the selection of pale animals in need to be treated.

Possible role of adiponectin and insulin sensitivity in mediating the favorable effects of lower body fat mass on blood lipids

AIMS

The objective of this study was to investigate the role of insulin sensitivity and serum adiponectin concentration as determinants, in middle-aged men, of the relationship between lower body fat and blood lipids after truncal fat has been accounted for.

METHODS

Men (443) aged 39-65 yr, body mass index 18-43 kg/m(2), participated in the study. The following variables were measured: regional body fat distribution as assessed by dual-energy x-ray absorptiometry, maximal oxygen uptake, physical activity, fasting levels of serum adiponectin, triglycerides, and high-density lipoprotein- and total cholesterol. Plasma glucose and serum insulin were measured in the fasting state and after an oral glucose load.

RESULTS

Lower body fat mass was inversely associated with serum triglycerides and total cholesterol and positively with serum high-density lipoprotein-cholesterol after adjustment for age, lean tissue mass, truncal fat mass, weight history, maximal oxygen uptake, and the level of physical activity (P < 0.0005). Serum adiponectin level and Matsudas insulin sensitivity index were positively intercorrelated, and both were positively correlated to lower body fat mass. When including adiponectin and insulin sensitivity in the analyses, the relationships between lower body fat mass and serum lipids were partly explained.

CONCLUSION

For a given level of truncal fat mass, a large lower body fat mass is associated with an advantageous blood lipid profile, which may be partially mediated by the relationships to both insulin sensitivity and serum adiponectin level.

Randomized, multi-center trial of two hypo-energetic diets in obese subjects: high- versus low-fat content

OBJECTIVE

To investigate whether a hypo-energetic low-fat diet is superior to a hypo-energetic high-fat diet for the treatment of obesity.

DESIGN

Open-label, 10-week dietary intervention comparing two hypo-energetic (-600 kcal/day) diets with a fat energy percent of 20-25 or 40-45.

SUBJECTS

Obese (BMI >or=30 kg/m(2)) adult subjects (n = 771), from eight European centers.

MEASUREMENTS

Body weight loss, dropout rates, proportion of subjects who lost more than 10% of initial body weight, blood lipid profile, insulin and glucose.

RESULTS

The dietary fat energy percent was 25% in the low-fat group and 40% in the high-fat group (mean difference: 16 (95% confidence interval (CI) 15-17)%). Average weight loss was 6.9 kg in the low-fat group and 6.6 kg in the high-fat group (mean difference: 0.3 (95% CI -0.2 to 0.8) kg). Dropout was 13.6% (n = 53) in the low-fat group and 18.3% (n = 70) in the high-fat group (P=0.001). Among completers, more subjects lost >10% in the low-fat group than in the high-fat group ((20.8%, n = 70) versus (14.7%, n = 46), P = 0.02). Fasting plasma total, low-density lipoprotein- and high-density lipoprotein-cholesterol decreased in both groups, but more so in the low-fat group than in the high-fat group. Fasting plasma insulin and glucose were lowered equally by both diets.

CONCLUSIONS

The low-fat diet produced similar mean weight loss as the high-fat diet, but resulted in more subjects losing >10% of initial body weight and fewer dropouts. Both diets produced favorable changes in fasting blood lipids, insulin and glucose.

Lower-body fat mass as an independent marker of insulin sensitivity--the role of adiponectin

AIMS

To study the association between lower-body fat and estimates of whole-body insulin sensitivity in middle-aged men with and without a history of juvenile onset obesity, and to determine the possible mediating role of fasting serum adiponectin level as an insulin-sensitizing peptide.

METHODS

A total of 401 men aged 39-65 y, body mass index 18-54 kg/m2, participated in the study. The following variables were measured on the study participants: regional body fat distribution as assessed by dual energy X-ray absorptiometry, abdominal sagittal diameter, maximal oxygen uptake (VO2max), physical activity, fasting and post-glucose load levels of plasma glucose, serum insulin, and blood non-esterified fatty acid plus fasting levels of serum adiponectin and HbA1c.

RESULTS

Lower-body fat mass was positively associated with insulin sensitivity as estimated by Matsudas index also after adjusting for age, lean tissue mass, trunkal fat mass, weight changes since draft board examination, VO2max and the level of physical activity. In a subgroup of men selected for a large lower-body fat mass, fasting serum insulin concentration was 24% lower (P<0.01) and fasting serum adiponectin 33% higher (P<0.005) compared to a subgroup of men with a small lower-body fat mass but with similar trunkal fat mass.

CONCLUSION

Lower-body fat mass is positively associated with an estimate of insulin sensitivity independently of trunkal fat mass in both lean and obese middle-aged men and this effect could partly be statistically explained by variations in serum adiponectin levels.

Long-term influences of body-weight changes, independent of the attained weight, on risk of impaired glucose tolerance and Type 2 diabetes

AIM

To investigate if weight gain during adulthood has effects on the risk of developing impaired glucose tolerance (IGT) or Type 2 diabetes beyond effect of attained weight.

RESEARCH DESIGN AND METHODS

Data were obtained from a longitudinal study of two cohorts: one of juvenile-onset obese (n = 248) and one of randomly selected control (n = 320) men, weighed at average ages of 20, 33, 44 and 51 years, respectively.

RESULTS

For any given BMI, the risk of IGT was higher the greater the weight gain since age 20 (odds ratio of 1.10 per unit kg/m2 of BMI gain, confidence interval 1.03-1.17, P = 0.004), and weight gain during both the early and later ages contributed to the increased risk. Obese men, maintaining weight since age 20, had lower risk of IGT than non-obese men who became similarly obese by age 51. The risk of Type 2 diabetes increased by weight gain in early adult life, but not by more recent weight gain in the later periods, probably because of the development of Type 2 diabetes leading to weight loss.

CONCLUSIONS

Independent of attained level of body weight in middle-aged men, weight gain is associated with increased risk of IGT, and is greater in those not overweight in childhood.

Adipose tissue gene expression in obese subjects during low-fat and high-fat hypocaloric diets

AIMS/HYPOTHESIS

Adaptation to energy restriction is associated with changes in gene expression in adipose tissue. However, it is unknown to what extent these changes are dependent on the energy restriction as such or on the macronutrient composition of the diet.

METHODS

We determined the levels of transcripts for 38 genes that are expressed in adipose tissue and encode transcription factors, enzymes, transporters and receptors known to play critical roles in the regulation of adipogenesis, mitochondrial respiration, and lipid and carbohydrate metabolism. Two groups of 25 obese subjects following 10-week hypocaloric diet programmes with either 20-25 or 40-45% of total energy derived from fat were investigated. Levels of mRNA were measured by performing real-time RT-PCR on subcutaneous fat samples obtained from the subjects before and after the diets.

RESULTS

The two groups of subjects lost 7 kg over the duration of the diets. Ten genes were regulated by energy restriction; however, none of the genes showed a significantly different response to the diets. Levels of peroxisome proliferator-activated receptor gamma co-activator 1alpha mRNA were increased, while the expression of the genes encoding leptin, osteonectin, phosphodiesterase 3B, hormone-sensitive lipase, receptor A for natriuretic peptide, fatty acid translocase, lipoprotein lipase, uncoupling protein 2 and peroxisome proliferator-activated receptor gamma was decreased. Clustering analysis revealed new potential coregulation of genes. For example, the expression of the genes encoding the adiponectin receptors may be regulated by liver X receptor alpha.

CONCLUSIONS/INTERPRETATION

In accordance with the comparable loss of fat mass produced by the two diets, this study shows that energy restriction and/or weight loss rather than the ratio of fat: carbohydrate in a low-energy diet is of importance in modifying the expression of genes in the human adipose tissue.

Blood pressure in relation to relative weight at birth through childhood and youth in obese and non-obese adult men

OBJECTIVE

To determine the influence on blood pressure of relative weight from birth through adulthood in non-obese and juvenile obese men.

DESIGN

Case-cohort study of obesity in Danish men, identified at age (mean+/-s.d.) 19.8+/-1.6 y at draft board examination, who participated in at least one of two follow-up studies in adulthood (age 36.8+/-6.7 and 47.9+/-6.8 y at first and second follow-up, respectively). Birth weight and weight and height from the age of 7-13 y were collected from school health records.

SUBJECTS

Three hundred and twenty-seven non-obese men (controls) selected as 0.5% of the draft board population and 285 obese men with body mass index (BMI)> or =31 kg/m(2) at draft board examination.

MAIN OUTCOME MEASURES

Systolic and diastolic blood pressure measured twice in adulthood adjusted for current age.

RESULTS

Birth weight was inversely related to systolic blood pressure at first and second follow-up, but only significantly so when adjusted for current BMI (regression coefficients in mmHg per unit Z-score (95% confidence interval (CI))-1.2 (-2.3, -0.1) and -1.6 (-3.1, 0.0)). Change in Z-score from birth weight to BMI at the age of 7 y was significantly positively related to systolic blood pressure, but the relationship weakened by adjustment for current BMI (0.8 (0.1, 1.6) and 0.6 (-0.4, 1.6), respectively). If both birth weight and change until 7 y were included in the same model, their effects were both positive and significant, but they weakened and became not significant when adjusted for current BMI. BMI since the age of 7 y had no significant effect on blood pressure beyond that of current BMI.

CONCLUSION

In a wide range of adult BMI in men, the birth weight was inversely related to systolic blood pressure, even when controlled for BMI since the age of 7 y. However, the effect may reflect the weight change between birth and 7 y of age. After that age BMI had no additional effect on blood pressure beyond the effect of current BMI.

Influence of genes and family environment on adult smoking behavior assessed in an adoption study

Twin studies suggest that genetic factors influence smoking behavior. However, in these studies, genetic and environmental influences may be confounded. We examined whether smoking behavior of adoptees is associated with smoking behavior in adoptive and biological relatives in a design in which this confounding is minimized. Data on smoking status were collected using a mailed questionnaire in a sample of 840 adoptive families from the Danish Adoption Register including all non-familial adoptions from 1924 through 1947. Smoking data were available for 706 adoptees, 451 biological fathers, 580 biological mothers, 641 adoptive fathers, 693 adoptive mothers, 199 biological full-siblings, 684 maternal half-siblings, and 576 paternal half-siblings. Adoptees' status as ever, current, heavy, or former (ex-)smokers was related to their relatives' smoking status. Adoptees ever smoking was associated with their full-siblings' status as ever smokers (OR = 3.6 [1.5-8.7]). Adoptees' current smoking was also associated with their full-siblings' ever (OR = 3.2 [1.5-7.7]) and current (OR = 2.6 [1.3-5.0]) smoking, whereas adoptees' heavy smoking was associated with their full-siblings ever (OR = 5.5 [2.1-14.3]), current (OR = 4.0[1.9-8.6]) and heavy (OR = 2.0[1.0-4.2]) smoking. Compared with current smokers, adoptee ex-smokers had full-siblings who were ex-smokers more often (OR = 3.5 [1.0-11.6]), current (OR = 0.4 [0.2-0.8]), and heavy (OR = 0.3 [0.1-0.9]) smokers less often. Adoptees' smoking behavior was not associated with adoptive or biological parents' status as current smokers. This study of smoking behavior in adult adoptees and their biological and adoptee family supports the finding in twin studies of a genetic influence on smoking within the same generation.

Enaminone substitutents attached to cyclopentadienes: 3E/3Z stereochemistry of 1-metalla-1,3,5-hexatriene intermediates (M = Cr, W) as a functional criterion for the formation of cyclopentadienes and six-membered heterocycles, respectively

Reactions of NH-enaminones 2 with [2-(1-cycloalkenyl)ethynyl]carbene complexes 7 (M=W, Cr) gave tetrahydropentalenes, tetrahydroindenes, and hexahydroazulenes 8a-i, in which the NH-enaminone moiety is attached to the cyclopentadiene unit. The reaction involved formation of (3E)-1-metalla-1,3,5-hexatriene intermediates, which underwent pi cyclization faster than 3E/3Z isomerization. Tungsten complexes 12 and 13 were characterized as reaction intermediates. Compounds 8 are potentially bidentate ligands with respect to coordination both of the cyclopentadienyl and the enaminone moieties.

Alternative medicine among college students

The use of "alternative" medicine has become increasingly popular in the United States. Books devoted to alternative medicine, e.g., Spontaneous Healing and 8 Weeks to Optimum Health, have become best sellers. Nevertheless, relatively few research studies have focused on the subject. This study examined the role of alternative medicine among college students. Issues addressed included students' familiarity with, use of, and perceptions regarding unconventional health therapies. The study substantiated a phenomenon health care providers across the country are discovering: a growing number of Americans with interest and financial resources support the development of "mainstream" alternative medicine programs. Results of the study also suggest that well-respected traditional health care organizations would not suffer reputation damage if they were to offer such programs.

Adoption study of environmental modifications of the genetic influences on obesity

BACKGROUND

Adult body mass index (BMI weight (kg)/height2 (m2)) usually shows familial correlations below 0.3, which are almost entirely due to genetic influences. The considerable remaining non-familial individual variation may be due to non-shared environmental influences which, however, may interact with or modify the genetic influence.

OBJECTIVE

To investigate whether the genetic influence on adult BMI is modified by various obesity-related environmental conditions during childhood and adulthood.

DESIGN

Adoption study, in which the genetic influence is assessed by the correlations in adult BMI between adoptees and their biological fathers, mothers and full siblings. These correlations were compared between groups of families characterized by differences in rearing or adult environment of the adoptees and/or their biological relatives.

SUBJECTS

Height, current weight and greatest weight ever, were obtained in 3651 subjects, who were adopted by non-related families in Copenhagen between 1924 and 1947. Groups representing thin, medium weight, overweight and obese proband adoptees were selected by current BMI (n = 540) and by maximum BMI (n = 524). The members of the biological and adoptive families of the proband adoptees were identified and their BMI was computed from height and weight obtained by mailed questionnaires.

MAIN VARIABLES

Indicators related to the rearing environment of the adoptees were age of the adoptee at transfer to the adoptive family, region of residence, presence of adoptive siblings and, for the adoptive parents, year of birth, age at time of adoption, occupational rating, smoking habits and BMI. Indicators of the environment of both the adoptee and the biological relatives were: year of birth; occupational rating and smoking habits, and, of the environment of the biological parents, age and parity at birth of the adoptee.

RESULTS

The correlations in BMI between adoptees and the biological fathers, mothers and siblings were 0.11, 0.15 and 0.26 for adoptees selected by current BMI, and 0.13, 0.16, and 0.27 for adoptees selected by maximum BMI, respectively (all P < 0.001), demonstrating the previously reported genetic influence. None of the environmental indicators showed consistent and significant effects on these six correlations. The same negative results were obtained in analysis of environmental indicators applied to the two adoptive parents together or to the adoptee and the biological relatives together.

CONCLUSION

The genetic influence on BMI was unaffected by several different environmental conditions otherwise associated with obesity.

The human zinc finger protein EGR-4 acts as autoregulatory transcriptional repressor

The human EGR-4 (AT133) gene represents one member of a family of four related zinc finger proteins, that are simultaneously and coordinately induced in resting cells upon growth stimulation. In order to characterise the function of the EGR-4 zinc finger protein, we have expressed the protein in the eukaryotic baculovirus system. The recombinant EGR-4 protein has a molecular mass of 78 kDa, as demonstrated by SDS-PAGE and Western blotting. DNA binding studies revealed that the EGR-4 protein binds to the EGR consensus motif GCGTGGGCG, but not to the G-rich regulatory ZIP-element of the human IL-2 gene, that is a binding site for EGR-1. EGR-4 functions as transcriptional repressor. Overexpression of EGR-4 mediates repression of a minimal c-fos promoter through a threefold EGR consensus site. Furthermore the EGR-4 protein displays autoregulatory activities. This protein downregulates expression of its own gene promoter in a dose dependent manner. A G-rich region in the EGR-4 promoter, located at position -106 to -82, could be identified as binding site for the recombinant EGR-4 protein. A comparison of the two related zinc finger proteins EGR-4 and EGR-1 revealed for each protein distinct and specific DNA binding- and transcriptional regulatory activities.

Characterization of revertants of unc-93(e1500) in Caenorhabditis elegans induced by N-ethyl-N-nitrosourea

Phenotypic reversion of the rubber-band, muscle-defective phenotype conferred by unc-93(e1500) was used to determine the utility of N-ethyl-N-nitrosourea (ENU) as a mutagen for genetic research in Caenorhabditis elegans. In this system, ENU produces revertants at a frequency of 3 x 10(-4), equivalent to that of the commonly used mutagen, EMS. The gene identity of 154 ENU-induced revertants shows that the distribution of alleles between three possible suppressor genes differs from induced by EMS. A higher percentage of revertants are alleles of unc-93 and many fewer are alleles of sup-9 and sup-10. Three revertants complement the three known suppressor genes; they may therefore identify a new gene product(s) involved in this system of excitation-contraction coupling in C. elegans. Molecular characterization of putative unc-93 null alleles reveals that the base changes induced by ENU are quite different from those induced by EMS; specifically we see an increased frequency of A/T-->G/C transitions. The frequency of ENU-induced intragenic deletions is found to be 13%. We suggest that ENU, at concentrations below 5 mM, will be a superior mutagen for studies of protein function in C. elegans.

A zinc finger gene from Onchocerca volvulus encodes a protein with a functional signal peptide and an unusual Ser-His finger motif

The filarial parasite Onchocerca volvulus is the causative agent of river blindness. In order to identify genes potentially involved in parasite development we cloned a zinc finger-encoding gene from this species. The ovzf-1 gene represents one member of a family of related zinc finger genes. The predicted ovzf-1 translation product of 447 amino acids includes a hydrophobic signal peptide, which is followed by 13 contiguous finger motifs. The domains of fingers II-XIII display several conserved amino acids and a typical Krüppel-like Cys2-His2 motif. The first finger domain has the two conserved Cys residues replaced with Ser residues; however, it includes all additional amino acids typical of zinc finger domains. The N-terminal domain functions as a signal peptide, as it directs secretion of a reporter protein and a truncated Ovzf protein. Expression of an Ovzf protein via the secretory pathway was also confirmed by demonstrating attachment of N-linked carbohydrates to the recombinant protein. Although the recombinant Ovzf protein also includes a signal peptide, immunofluorescence analyses localize it inside a specific compartment of the infected insect cell. Expression of ovzf mRNA is developmentally regulated; no specific transcript is detected in adult female worms but in the infective L3. Identification of a secreted protein that might function in modulating gene expression of host cells provides an interesting tool for the study of parasite-host interaction on a biochemical and molecular level.

Identification of a zinc finger encoding gene in Onchocerca volvulus

Eukaryotic transcription factors can be identified and classified according to conserved DNA-binding motifs and conserved regulatory domains. The functional and structural analysis, and the conservation of these genes among metazoans emphasizes the importance of these DNA-binding proteins in development and differentiation. In order to identify genes with common DNA-binding motifs in the genome of Onchocerca volvulus we have cloned a zinc finger encoding gene of the structure C2-H2. Using the Caenorhabditis elegans sex determining tra-1 gene as a probe we have identified two tra-1 related genes in the genome of O. volvulus. The zinc finger region of one of these genes (OvZf1) was subcloned and sequenced. The predicted protein has at least eight consecutive zinc fingers and each finger possesses the characteristic paired cysteine- and histidine residues and the proper spacing of the amino acids between the conserved residues.

Genomic organization, chromosomal localization and promoter function of the human zinc-finger gene pAT133

We report the genomic structure and chromosomal localization of the human zinc-finger gene pAT133. This gene belongs to a family of four human immediate-early genes (pAT133, pAT225/EGR1, pAT591/EGR2 and EGR3), which have almost identical zinc-finger domains, but distinct flanking regions. The human pAT133 gene is organized in two exons, and has been mapped to human chromosome 2p13. We determined the transcription start site by primer extension analysis and identified several regulatory elements in the upstream regulatory sequence. The pAT133-promoter functions as an inducible promoter in human T cells and in fibroblasts, as constructs containing the bacterial chloramphenicol acetyl transferase (CAT) gene driven by a 943 bp pAT133-promoter fragment were induced in these cells by stimulation with PHA/PMA or by serum, respectively. The serum inducible pAT133-promoter lacks consensus serum response elements. However, we could demonstrate that two CArG-like motifs with a single base exchange confer serum inducibility to a reporter construct. Due to their serum responsiveness, these elements may serve as a high affinity binding sites for the recently described human serum response factor-related proteins.

Childhood body mass index--genetic and familial environmental influences assessed in a longitudinal adoption study

Studies of twins and adoptees have shown that the resemblance of adult family members in body mass index (weight/height2) is due more to shared genes than to shared rearing environment. In the present adoption study we assessed the genetic and environmental influences on body mass index in childhood. Among 3651 adult Danish adoptees we selected 840, comprising thin, medium weight, overweight, and obese groups, and for 269 of them we obtained height and weight measured at school health examinations at ages 7-13 years. The correlation in body mass index between the adoptees at these ages and their biological and adoptive relatives as well as among these relatives were estimated. The correlations were stable across the ages 7-13 years. The average correlation of adoptees with biological mothers was 0.17 (95% confidence limits: 0.03, 0.31), with biological fathers, 0.16 (0.00, 0.32), and with biological full siblings at same ages, 0.59 (0.28, 0.90). These correlations were comparable to the correlations within the biological families and comparable to the previously reported correlations for adult adoptees. The correlations with members of the adoptive families were lower--with adoptive mothers, 0.10 (-0.03, 0.23), with adoptive fathers, 0.03 (-0.11, 0.17), and with adoptive siblings, 0.14 (-0.13, 0.41). In conclusion, a genetic influence on body mass index as strong as that in adult life is already expressed by age 7 years. The rearing environment shared by the family has a weak influence during childhood.

Longitudinal study of influence of Helicobacter pylori on current risk of duodenal ulcer relapse. The Hvidovre Ulcer Project Group

Seventy-four patients with duodenal ulcer were followed up longitudinally for 2 years after initial ulcer healing. Endoscopy including biopsy of the antral mucosa was performed every 3rd month and whenever clinical symptoms of relapse occurred. The presence of Helicobacter pylori in the biopsy specimens was scored as 0 (none), 1 (sporadic occurrence), 2 (clusters), and 3 (numerous bacteria found diffusely in the mucus layer). The incidence rates of ulcer relapse per patient-month, grouped in accordance with these scores, were (with 95% confidence intervals) 0.073 (0.048-0.111), 0.083 (0.052-0.133), 0.123 (0.096-0.157), and 0.069 (0.041-0.116), respectively. No significant differences in incidence rates across H. pylori scores were observed when taking into account the observation period after healing of the first ulcer, number of ulcer recurrence (1st, 2nd, 3rd), sex, age, smoking habits, peak acid output, time of healing of the preceding ulcer, treatment of the present ulcer (cimetidine, antacids, or no treatment), or type and degree of gastritis. Thus, although H. pylori is prevalent in patients with duodenal ulcer disease, the present study indicates that H. pylori does not have a substantial note in the precipitation of active duodenal ulcer.

Correlations of body mass index of adult adoptees and their biological and adoptive relatives

Adult family members resemble each other in body mass index (weight/height2). Our aim was to assess the extent to which the genetic relationship can account for the resemblance in natural families. We estimated the correlations in body mass index between adult adoptees, their adoptive parents, and their biological parents and siblings and compared the correlations to those between the biological relatives. Height, current weight, and greatest ever weight were obtained for 3651 adoptees. Groups representing thin, medium weight, overweight and obese subjects were selected by current body mass index (n = 540) and similarly selected by maximum body mass index (n = 524). The heights and weights of their biological and adoptive family members were assessed. The correlation in current body mass index between the adoptees and biological mothers, fathers, and full siblings were 0.15, 0.11, and 0.23, respectively (all P less than 0.001). These correlations were compatible with those found among the biological relatives living together. The correlations exhibited no consistent gender-related pattern. There was no correlation in body mass index between the adoptees and their adoptive parents. Similar results were obtained for maximum body mass index. Moreover, the correlations between the adoptees and their biological relatives are very similar to those found in large population studies of natural families. This study suggests that the genetic relationship fully accounts for the familial resemblance in body mass index among adults.

Retrospective estimation of diabetes incidence from information in a prevalent population and historical mortality

If the distribution of onset age of disease in a well-defined prevalent (cross-sectional) population of patients is known, disease incidence rates specific for age and calendar time period may be estimated, assuming known mortality rates and a closed population. This paper develops a method of estimation, illustrates this method on Danish diabetes data, and discusses its general applicability. The prevalent population of diabetic subjects in Fyn County on July 1, 1973 was ascertained from prescriptions, and information on disease onset was obtained from the patients' medical records. In this study only patients with onset of disease before or at age 30 years were studied. The mortality of diabetic subjects in Denmark was estimated from retrospective hospital data covering the period since 1933, and historical age-specific population sizes of Fyn County were obtained from census data. The incidence of diabetes increases with calendar time and with age for most cohorts. The variation with age for a fixed calendar year is more complicated, however, usually displaying a local maximum at about the age of puberty and a higher incidence at the upper end of the studied age range.