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Mackenzie SC, Dickson J, Mehar S, Yusof BNM, Alselmi A, Aksi B, Baxter MS, Bickerton A, Bharaj HS, Conway N, Cumming KM, Lim LL, Lessan N, Ghouri N, Flax TT, Osei-Kwasi HA, Teo ME, Waqar S, Hassanein M, Wake DJ. Digitising diabetes education for a safer Ramadan: Design, delivery, and evaluation of massive open online courses in Ramadan-focused diabetes education. Prim Care Diabetes 2024:S1751-9918(24)00065-2. [PMID: 38493066 DOI: 10.1016/j.pcd.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/26/2024] [Accepted: 03/10/2024] [Indexed: 03/18/2024]
Abstract
AIMS Ramadan-focused diabetes education is critical to facilitate safer Ramadan fasting amongst Muslim people living with diabetes. We present the design, delivery, and evaluation of two parallel massive open online courses (MOOCs) in Ramadan-focused diabetes education for people with diabetes and HCPs. METHODS Two Ramadan-focused diabetes education MOOCs were developed and delivered for Ramadan 2023: one for HCPs in English, and another for people with diabetes in English, Arabic and Malay. A user-centred iterative design process was adopted, informed by user feedback from a 2022 pilot MOOC. Evaluation comprised a mixed-methods evaluation of pre- and post-course user surveys. RESULTS The platform was utilised by people with diabetes and their family, friends and healthcare professionals. Overall, a total of 1531 users registered for the platform from 50 countries, 809 started a course with a 48% subsequent completion rate among course starters. Qualitative analysis showed users found the course a user-friendly and authoritative information source. In the HCP MOOC, users reported improved post-MOOC Ramadan awareness, associated diabetes knowledge and ability to assess and advise patients in relation to their diabetes during Ramadan (p<0.01). CONCLUSIONS We demonstrate the potential of MOOCs to deliver culturally tailored, high-quality, scalable, multilingual Ramadan-focused diabetes education to HCPs and people with diabetes.
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Affiliation(s)
- Scott C Mackenzie
- MyWay Digital Health, Dundee, UK; Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Jane Dickson
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Salma Mehar
- Department of Diabetes, Endocrinology & Metabolism, Imperial College London, UK
| | - Barakatun Nisak Mohd Yusof
- Universiti Putra Malaysia, Department of Dietetics Faculty of Medicine and Health Sciences, Selangor, Malaysia
| | - Adhari Alselmi
- Clinical Sciences Department, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia; Dr. Soliman Fakeeh Medical Center, Jeddah, Saudi Arabia
| | | | - Mats Stage Baxter
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alex Bickerton
- Department of Diabetes & Endocrinology, Yeovil District Hospital, Somerset Foundation Trust, Yeovil, UK
| | | | - Nicholas Conway
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | | | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Nader Lessan
- Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates
| | - Nazim Ghouri
- School of Medicine, University of Glasgow, Glasgow, UK; Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Hibbah A Osei-Kwasi
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Michelle Es Teo
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Salman Waqar
- Department of Primary Care & Public Health, Imperial College London, London, UK; British Islamic Medical Association, UK
| | | | - Deborah J Wake
- MyWay Digital Health, Dundee, UK; Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK.
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Waqar S, Ghouri N, Awaad R. Chronic Disease Management During Ramadan. Am Fam Physician 2023; 107:125-126. [PMID: 36791453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Salman Waqar
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Rania Awaad
- Stanford Muslim Mental Health Lab, Stanford Diversity Clinics, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
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Iliodromiti S, McLaren J, Ghouri N, Miller MR, Dahlqvist Leinhard O, Linge J, Ballantyne S, Platt J, Foster J, Hanvey S, Gujral UP, Kanaya A, Sattar N, Lumsden MA, Gill JMR. Liver, visceral and subcutaneous fat in men and women of South Asian and white European descent: a systematic review and meta-analysis of new and published data. Diabetologia 2023; 66:44-56. [PMID: 36224274 PMCID: PMC9729139 DOI: 10.1007/s00125-022-05803-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS South Asians have a two- to fivefold higher risk of developing type 2 diabetes than those of white European descent. Greater central adiposity and storage of fat in deeper or ectopic depots are potential contributing mechanisms. We collated existing and new data on the amount of subcutaneous (SAT), visceral (VAT) and liver fat in adults of South Asian and white European descent to provide a robust assessment of potential ethnic differences in these factors. METHODS We performed a systematic review of the Embase and PubMed databases from inception to August 2021. Unpublished imaging data were also included. The weighted standardised mean difference (SMD) for each adiposity measure was estimated using random-effects models. The quality of the studies was assessed using the ROBINS-E tool for risk of bias and overall certainty of the evidence was assessed using the GRADE approach. The study was pre-registered with the OSF Registries ( https://osf.io/w5bf9 ). RESULTS We summarised imaging data on SAT, VAT and liver fat from eight published and three previously unpublished datasets, including a total of 1156 South Asian and 2891 white European men, and 697 South Asian and 2271 white European women. Despite South Asian men having a mean BMI approximately 0.5-0.7 kg/m2 lower than white European men (depending on the comparison), nine studies showed 0.34 SMD (95% CI 0.12, 0.55; I2=83%) more SAT and seven studies showed 0.56 SMD (95% CI 0.14, 0.98; I2=93%) more liver fat, but nine studies had similar VAT (-0.03 SMD; 95% CI -0.24, 0.19; I2=85%) compared with their white European counterparts. South Asian women had an approximately 0.9 kg/m2 lower BMI but 0.31 SMD (95% CI 0.14, 0.48; I2=53%) more liver fat than their white European counterparts in five studies. Subcutaneous fat levels (0.03 SMD; 95% CI -0.17, 0.23; I2=72%) and VAT levels (0.04 SMD; 95% CI -0.16, 0.24; I2=71%) did not differ significantly between ethnic groups in eight studies of women. CONCLUSIONS/INTERPRETATION South Asian men and women appear to store more ectopic fat in the liver compared with their white European counterparts with similar BMI levels. Given the emerging understanding of the importance of liver fat in diabetes pathogenesis, these findings help explain the greater diabetes risks in South Asians. FUNDING There was no primary direct funding for undertaking the systematic review and meta-analysis.
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Affiliation(s)
- Stamatina Iliodromiti
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
- School of Medicine, University of Glasgow, Glasgow, UK.
| | - James McLaren
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
| | - Nazim Ghouri
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Melissa R Miller
- Worldwide Research Development and Medical, Pfizer, Cambridge, MA, USA
| | - Olof Dahlqvist Leinhard
- AMRA Medical AB, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Jonathan Platt
- Department of Radiology, Greater Glasgow and Clyde NHS, Glasgow, UK
| | - John Foster
- Department of Clinical Physics and Bioengineering, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Scott Hanvey
- Radiotherapy Physics, Derriford Hospital, Plymouth, UK
| | - Unjali P Gujral
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Alka Kanaya
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Jason M R Gill
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Lip S, Dempster G, Jain S, Brooksbank K, Ghouri N, McCallum L, Padmanabhan S. Underrepresentation of ethnic minorities in hypertension research-a survey of enablers and barriers among South Asian and African communities in Glasgow. Trials 2022; 23:609. [PMID: 35906700 PMCID: PMC9335986 DOI: 10.1186/s13063-022-06542-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertension is the biggest contributor to the global cardiovascular burden with evidence for ethnic differences in treatment response and outcomes. Under-representation of ethnic minorities in clinical research is well known, and despite wide-ranging public engagement events by the Glasgow Blood Pressure Clinic team, there was a lack of participation of ethnic minorities in both engagement activities and clinical trials conducted by them. This study aims to explore the awareness and knowledge of hypertension and the facilitators and barriers to participation in hypertension clinical research among South Asian (SA) and African (AFR) communities in Glasgow. METHODS A survey questionnaire was co-developed with representatives from South Asian (SA) and African (AFR) patients and community members in Glasgow to understand awareness and knowledge of hypertension and enablers and barriers to participation in clinical research. The survey was distributed to adults (aged > 18) years of SA or AFR ancestry at public engagement events at venues that were frequently visited by these two communities in Glasgow. RESULTS The survey response rate was 337 (67.4%) consisting of 242 (71.8%) South Asian (SA) and 56 (16.9%) African (AFR) respondents. Thirty-nine questionnaires were excluded because of incompletion. Most of the respondents were not born in the UK and were in the 35-53-year group (AFR 29 (51%), SA 113 (47%)). The proportion living in the most deprived (SIMD 1) and least deprived (SIMD 5) was respectively 26 (12.4%) and 34 (16.2%) for SA and 20 (42.6%) and 2 (4.3%) for AFR. There was a considerable recognition that treatment needs to be ethnicity-specific (SA/AFR = 107 (48%)/23 (45.1%)) and that current cardiovascular disease treatment guidelines were not tailored for different ethnicities 84 (38.5%)/23 (45.1%). The key enablers encouraging research participation are enhanced health information, conducting aspects of their clinical research visits/appointments at a location they frequently visited and allowing a family member to accompany them. Barriers included concerns about the use of personal information and side effects of the new treatment. CONCLUSION Our survey confirmed enablers and barriers to ethnic minority participation in research. We find improving and evolving awareness and beliefs among the ethnic minority population including community leaders. Thus, continual review of researchers' beliefs and attitudes is also essential to ensure engagement activities keep up with these changing perceptions.
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Affiliation(s)
- Stefanie Lip
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Georgia Dempster
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sahil Jain
- Department of Rheumatology and General Internal Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Katriona Brooksbank
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Linsay McCallum
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
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Malik S, Hamer R, Shabir S, Youssouf S, Morsy M, Rashid R, Waqar S, Ghouri N. Effects of fasting on solid organ transplant recipients during Ramadan - a practical guide for healthcare professionals. Clin Med (Lond) 2021; 21:e492-e498. [PMID: 38594852 DOI: 10.7861/clinmed.2021-0250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Fasting in the month of Ramadan is an obligatory act for healthy adult Muslims. It requires abstinence from food and drink from dawn to sunset. Although there are exemptions from fasting, many patients are keen to fulfil what they see as a religious obligation, even if this may be against medical advice in some cases. Solid organ transplant (SOT) recipients often ask healthcare professionals for advice on fasting. Studies on the effect of fasting in transplant patients have all been done in the Middle East and North Africa where the average fasting duration is between 12 and 14 hours. In comparison, in temperate regions in the summer, fasting duration can be as long as 20 hours. Fasting when patients have to take immunosuppression 12 hours apart with little time variation poses unique challenges. In this review, current literature is reviewed, and a decision-making tool has been developed to assist clinicians in discussing the risks of fasting in transplant recipients, with consideration also given to circumstances such as the COVID-19 pandemic. Our review highlights that SOT recipients wishing to fast should undergo a thorough risk assessment, ideally 3 months before Ramadan. They may require medication changes and a plan for regular monitoring of graft function and electrolytes in order to fast safely. Recommendations have been based on risk tiers (very high risk, high risk and low/moderate risk) established by the International Diabetes Federation and the Diabetes and Ramadan International Alliance. Patients in the 'very high risk' and 'high risk' categories should be encouraged to explore alternative options to fasting such as winter fasting or Fidyah. Those in the 'low/moderate' category may be able to cautiously fast with guidance from their clinician. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick-day rules, instructions on when to terminate their fast or abstain from fasting.
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Affiliation(s)
- Shafi Malik
- University Hospitals Coventry and Warwickshire NHS Trust, UK, and honorary clinical lecturer, University of Leicester, Leicester, UK.
| | - Rizwan Hamer
- University Hospitals Coventry and Warwickshire NHS Trust, UK
| | | | | | - Mohamed Morsy
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Nazim Ghouri
- University of Glasgow, Glasgow, UK, and consultant physician in diabetes, endocrinology and general medicine, Queen Elizabeth University Hospital, Glasgow, UK
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Deen M, Moothadeth A, Waqar S, Awad E, Ghouri N. Fasting during Ramadan and fitness for work implications. Occup Med (Lond) 2021; 72:154-156. [PMID: 34401918 DOI: 10.1093/occmed/kqab079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nazim Ghouri
- Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Musbahi A, Khan Z, Welsh P, Ghouri N, Durrani A. Understanding the stigma: a novel quantitative study comparing mental health attitudes and perceptions between young British Muslims and their non-Muslims peers. J Ment Health 2021; 31:92-98. [PMID: 34304663 DOI: 10.1080/09638237.2021.1952951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A significant proportion of young British Muslims identify themselves by religious identity rather than ethnicity however very few mental health studies have focused on this cohort. AIMS To explore whether young British Muslims' knowledge, awareness and perceptions of mental illness differ to their non-Muslim peers. METHOD Population based survey of second generation Muslims (n = 83) and non-Muslims (n = 76) aged 18-35. Anonymised 38-item questionnaire on mental health attitudes, perceptions and help seeking behaviours. RESULTS Muslims were less likely to correctly identify symptoms of mental illness compared to their non-Muslim peers. Stigma and awareness remains a major issue. A third of Muslims would consider stopping medication on advice of a religious leader. Nearly half of Muslims were more likely to attend a dedicated ethnic/religious mental health service. CONCLUSIONS British Muslim views and attitudes of mental health differ from their non-Muslim counterparts. Services should ensure they are religiously sensitive.
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Affiliation(s)
- Aya Musbahi
- South Tees NHS Trust, James Cook Hospital, Middlesbrough, UK
| | - Zainib Khan
- Greater Manchester Mental Health Foundation Trust, Manchester, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Nazim Ghouri
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Akhtar AM, Ghouri N, Chahal CAA, Patel R, Ricci F, Sattar N, Waqar S, Khanji MY. Ramadan fasting: recommendations for patients with cardiovascular disease. Heart 2021; 108:258-265. [PMID: 33990414 PMCID: PMC8819657 DOI: 10.1136/heartjnl-2021-319273] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 12/28/2022] Open
Abstract
Ramadan fasting is observed by most of the 1.8 billion Muslims around the world. It lasts for 1 month per the lunar calendar year and is the abstention from any food and drink from dawn to sunset. While recommendations on ‘safe’ fasting exist for patients with some chronic conditions, such as diabetes mellitus, guidance for patients with cardiovascular disease is lacking. We reviewed the literature to help healthcare professionals educate, discuss and manage patients with cardiovascular conditions, who are considering fasting. Studies on the safety of Ramadan fasting in patients with cardiac disease are sparse, observational, of small sample size and have short follow-up. Using expert consensus and a recognised framework, we risk stratified patients into ‘low or moderate risk’, for example, stable angina or non-severe heart failure; ‘high risk’, for example, poorly controlled arrhythmias or recent myocardial infarction; and ‘very high risk’, for example, advanced heart failure. The ‘low-moderate risk’ group may fast, provided their medications and clinical conditions allow. The ‘high’ or ‘very high risk’ groups should not fast and may consider safe alternatives such as non-consecutive fasts or fasting shorter days, for example, during winter. All patients who are fasting should be educated before Ramadan on their risk and management (including the risk of dehydration, fluid overload and terminating the fast if they become unwell) and reviewed after Ramadan to reassess their risk status and condition. Further studies to clarify the benefits and risks of fasting on the cardiovascular system in patients with different cardiovascular conditions should help refine these recommendations.
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Affiliation(s)
- Abid Mohammed Akhtar
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
| | - C Anwar A Chahal
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Department of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Riyaz Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, University of Gabriele d'Annunzio Chieti and Pescara, Chieti Scalo, Abruzzo, Italy.,Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Casa di Cura Villa Serena, Pescara, Italy
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Salman Waqar
- Nuffield Department of Primary care Health Sciences, University of Oxford, Oxford, UK
| | - Mohammed Yunus Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK .,NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK.,Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, UK.,Department of Cardiovascular Disease Prevention and Proactive Care, UCLPartners, London, UK
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Lee MMY, Ghouri N, McGuire DK, Rutter MK, Sattar N. Meta-analyses of Results From Randomized Outcome Trials Comparing Cardiovascular Effects of SGLT2is and GLP-1RAs in Asian Versus White Patients With and Without Type 2 Diabetes. Diabetes Care 2021; 44:1236-1241. [PMID: 33707305 DOI: 10.2337/dc20-3007] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Results of cardiovascular outcome trials (CVOTs) suggest Asians may derive greater benefit than Whites from newer classes of antihyperglycemic medications. PURPOSE To provide summary hazard ratio (HR) estimates for cardiovascular efficacy of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) stratified by race (Asian vs. White). DATA SOURCES A systematic review performed in PubMed from 1 January 2015 to 8 December 2020. STUDY SELECTION Randomized placebo-controlled CVOTs of SGLT2is and GLP-1RAs that reported HRs (95% CIs) for 1) major adverse cardiovascular event (MACE) in patients with diabetes and 2) cardiovascular (CV) death/hospitalization for heart failure (HHF) in patients with HF and reduced ejection fraction (HFrEF). DATA EXTRACTION AND SYNTHESIS HRs (95% CIs) for selected outcomes in Asians and Whites were extracted from each trial, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random-effects meta-analyses were performed to examine differences between the selected outcomes in Asians versus Whites. RESULTS In four SGLT2i trials in type 2 diabetes, the MACE outcome HR (95% CI) in 3,298 Asians versus 20,258 Whites was 0.81 (0.57, 1.04) vs. 0.90 (0.80, 1.00), respectively (P interaction = 0.46). In two SGLT2i trials in patients with HFrEF, the CV death/HHF outcome HR in 1,788 Asians versus 5,962 Whites was 0.60 (0.47, 0.74) vs. 0.82 (0.73, 0.92), respectively (P interaction = 0.01). In six GLP-1RA trials, the MACE outcome HR in 4,195 Asians versus 37,530 Whites was 0.68 (0.53, 0.84) vs. 0.87 (0.81, 0.94), respectively (P interaction = 0.03). LIMITATIONS Lack of individual patient-level data, relatively short duration of trial observation, and lack of granular categorization of race within broadly defined Asian subgroups. CONCLUSIONS Compared with Whites, Asians may derive greater CV death/HHF benefit from SGLT2is in patients with HFrEF, and MACE benefit from GLP-1RAs in patients with type 2 diabetes.
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Affiliation(s)
- Matthew M Y Lee
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
- Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, U.K
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX
| | - Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, U.K
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K.
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Ghouri N, Hussain S, Ahmed SH, Beshyah SA, Rashid R, Al-Ozairi E, Waqar S, Dabhad A, Mohammed R. Changing how we risk-categorise in Ramadan: Does the IDF-DAR scoring system achieve the requirements for people with diabetes internationally? Diabetes Res Clin Pract 2021; 175:108835. [PMID: 33901626 DOI: 10.1016/j.diabres.2021.108835] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/20/2021] [Indexed: 01/12/2023]
Abstract
The IDF-DAR guidance was most recently updated this year. The most notable change is the moving to a scoring system from a tabulated risk categorization to determine and classify the risk of harm from fasting derived from an online survey. This change may be appealing and is welcomed. However, such a system and the methodology underpinning it is not without limitations. This commentary highlights some of these limitations and the associated limited safe options available to individuals with diabetes desiring to fast during Ramadan. Overlooked clinical considerations that deserve formal recognition include the role of technology (aspects relating to glucose monitoring and/or insulin delivery) and previous experience of safe Ramadan fasting. Further, duration of fast (which can almost double in temperate regions from winter to summer) needs greater emphasis. We also advocate separate scoring systems for people with type 1 diabetes and complex type 2 diabetes. The guidance acknowledges fasting is an individual's decision, however the general message needs to be more person-centred and currently only presents a binary approach to fasting - all or nothing choices. We propose and discuss addition options including, trial fasting of voluntary fasts, starting the fast and terminating due to health and/or safety, intermittent fasting and winter fasting.
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Affiliation(s)
- Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Sufyan Hussain
- Department of Diabetes & Endocrinology, St Thomas' Hospital, London, UK; Department of Diabetes & Endocrinology, King' s College London, UK
| | - Syed H Ahmed
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK; School of Medicine, University of Liverpool, Liverpool, UK
| | - Salem A Beshyah
- Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates; Dubai Medical College for Girls, Dubai, United Arab Emirates
| | | | - Ebaa Al-Ozairi
- Clinical Research Unit, Dasman Diabetes Institute, Kuwait; Department of Medicine, Faculty of Medicine, Kuwait
| | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Affiliation(s)
- Salman Waqar
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Queen Elizabeth University Hospital, Glasgow, UK
| | - Mehrunisha Suleman
- The Health Foundation and Center of Islamic Studies, University of Cambridge, Cambridge, UK
| | | | - Michael Marmot
- Institute of Health Equity, Department of Epidemiology and Public Health, UCL, London, UK
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12
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Malik S, Bhanji A, Abuleiss H, Hamer R, Shah SH, Rashad R, Junglee N, Waqar S, Ghouri N. Effects of fasting on patients with chronic kidney disease during Ramadan and practical guidance for healthcare professionals. Clin Kidney J 2021; 14:1524-1534. [PMID: 34079617 PMCID: PMC7929006 DOI: 10.1093/ckj/sfab032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/11/2021] [Indexed: 12/30/2022] Open
Abstract
There are an estimated 1.8 billion Muslims worldwide, with the majority of them choosing to fast during the month of Ramadan. Fasting, which requires abstinence from food and drink from dawn to sunset can be up to 20 h per day during the summer months in temperate regions. Fasting can be especially challenging in patients on haemodialysis and peritoneal dialysis. Moreover, there is concern that those with chronic kidney disease (CKD) can experience electrolyte imbalance and worsening of renal function. In this article, current literature is reviewed and a decision-making management tool has been developed to assist clinicians in discussing the risks of fasting in patients with CKD, with consideration also given to circumstances such as the coronavirus disease 2019 pandemic. Our review highlights that patients with CKD wishing to fast should undergo a thorough risk assessment ideally within a month before Ramadan, as they may require medication changes and a plan for regular monitoring of renal function and electrolytes in order to fast safely. Recommendations have been based on risk tiers (very high risk, high risk and low-moderate risk) established by the International Diabetes Federation and the Diabetes and Ramadan International Alliance. Patients in the very high risk and high risk categories should be encouraged to explore alternative options to fasting, while those in the low-moderate category may be able to fast safely with guidance from their clinician. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick-day rules and instructions on when to terminate their fast or abstain from fasting.
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Affiliation(s)
- Shafi Malik
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.,University of Leicester, Leicester, UK
| | - Amir Bhanji
- Wessex Kidney Centre, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | - Rizwan Hamer
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | - Naushad Junglee
- University Hospital Llandough, Cardiff and Vale, University Health Board, Cardiff, Wales
| | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nazim Ghouri
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, Scotland.,Department of Diabetes and Endocrinology, Queen, Elizabeth University Hospital, Glasgow, Scotland
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13
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Ghouri N, Javed H, Sattar N. Pharmacological Management of Diabetes for Reducing Glucose Levels and Cardiovascular Disease Risk: What Evidence in South Asians? Curr Diabetes Rev 2021; 17:e122820189511. [PMID: 33371853 DOI: 10.2174/1573399817666201228120725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION South Asians experience more type 2 diabetes, which is earlier in onset and with more rapid glycaemic deterioration, although average body mass indices are lower than in whites. Cardiovascular outcomes from diabetes drug trials are now reported as standard, with data from newer therapies influencing patient management. However, less is known of the effect of such therapies in South Asians. The aim of this narrative review was to extract, wherever possible, the glucose-lowering efficacy and cardiovascular and renal outcome data for these therapies in South Asians. DISCUSSION Despite the higher prevalence and global burden of type 2 diabetes and adverse outcomes in South Asians, they remain underrepresented in global trials. Even when recruited, the current method of classifying ethnicity does not commonly allow South Asian data to be extracted and reported separately from all Asians. Interrogation of available trial data suggests broadly comparable effects on glycaemia and weight in Asians to other ethnicities with use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs), but a potentially early, albeit marginally, greater glycaemia benefit with Dipeptidyl peptidase-4 inhibitors (DPP4is) which may not be sustained. Furthermore, there appears a potentially greater glycaemia benefit with use of sodium-glucose transport protein 2 inhibitors (SGLT2is) in Asians compared to whites. Whether such findings are true in all Asians subgroups requires further direct study. For cardiovascular outcomes, available data suggest at least comparable and potentially greater outcome benefits in Asians; point estimates were more favourable for Asians in the vast majority of GLP-1 RAs and SGLT2is outcome trials. It was, however, impossible to determine whether the effects were similar across all Asian subgroups. CONCLUSION We conclude that trialists should be encouraged to record ethnicity with better granularity to allow differing ethnic groups data to be better interrogated. In the meantime, doctors should, where possible, confidently follow newer guidelines for the use of newer glucose lowering agents for treating glycaemia and for the prevention of cardiovascular and cardiorenal complications in South Asian people with type 2 diabetes.
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Affiliation(s)
- Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Hareem Javed
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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14
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Affiliation(s)
| | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Syed H Ahmed
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Ateeq Syed
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ali Karamat
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ahmed Helmy
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
- Department of Diabetes and Endocrinology, Elizabeth University Hospital, Glasgow, Queen, UK.
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15
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Mahmood A, Abbasi HN, Ghouri N, Mohammed R, Leach JP. Managing epilepsy in Ramadan: Guidance for healthcare providers and patients. Epilepsy Behav 2020; 111:107117. [PMID: 32599428 DOI: 10.1016/j.yebeh.2020.107117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 11/16/2022]
Abstract
Ramadan is a regularly recurring period of fasting that takes place in the ninth month of the Islamic calendar. For this period, adult Muslims refrain from eating and drinking between dawn and sunset. The variation in summer daylight hours means that at temperate latitudes, fasting can last up to 20 h. It is already recognized that epilepsy control can deteriorate during Ramadan, and this may be explained by fasting-related changes to adherence to antiseizure drug regimes. This article provides specific advice to help Muslim patients prepare for Ramadan and reduce chances of exacerbation in epilepsy. In addition to advice around sleep hygiene, it explores the use of drugs or preparations of drugs that will demonstrate reduced variation during periods of fasting.
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Affiliation(s)
- Ammad Mahmood
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
| | - Hina Naz Abbasi
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
| | - Nazim Ghouri
- Department of Medicine, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
| | | | - John Paul Leach
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK; School of Medicine, Wolfson Medical School Building, University of Glasgow, Glasgow G12 8QQ, UK.
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16
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Ahmed SH, Chowdhury TA, Hussain S, Syed A, Karamat A, Helmy A, Waqar S, Ali S, Dabhad A, Seal ST, Hodgkinson A, Azmi S, Ghouri N. Ramadan and Diabetes: A Narrative Review and Practice Update. Diabetes Ther 2020; 11:1-44. [PMID: 32922560 PMCID: PMC7480213 DOI: 10.1007/s13300-020-00886-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Indexed: 02/06/2023] Open
Abstract
Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Syed H. Ahmed
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
- School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
- Department of Diabetes, School of Life Course Sciences, King’s College London, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London, UK
| | - Ateeq Syed
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ali Karamat
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ahmed Helmy
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Salman Waqar
- Nuffield Department of Primary Care Health Sciences, University Oxford, Oxford, UK
| | - Samina Ali
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - Susan T. Seal
- Department of Endocrinology and Metabolic Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Anna Hodgkinson
- Department of Diabetes and Endocrinology, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
- NHS South East London Clinical Commissioning Group, London, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
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17
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Sattar N, Ho FK, Gill JM, Ghouri N, Gray SR, Celis-Morales CA, Katikireddi SV, Berry C, Pell JP, McMurray JJ, Welsh P. BMI and future risk for COVID-19 infection and death across sex, age and ethnicity: Preliminary findings from UK biobank. Diabetes Metab Syndr 2020; 14:1149-1151. [PMID: 32668401 PMCID: PMC7326434 DOI: 10.1016/j.dsx.2020.06.060] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 11/16/2022]
Abstract
AIMS We examined the link between BMI and risk of a positive test for SARS-CoV-2 and risk of COVID-19-related death among UK Biobank participants. METHODS Among 4855 participants tested for SARS-CoV-2 in hospital, 839 were positive and of these 189 died from COVID-19. Poisson models with penalised thin plate splines were run relating exposures of interest to test positivity and case-fatality, adjusting for confounding factors. RESULTS BMI was associated strongly with positive test, and risk of death related to COVID-19. The gradient of risk in relation to BMI was steeper in those under 70, compared with those aged 70 years or older for COVID-19 related death (Pinteraction = 0.03). BMI was more strongly related to test positivity (Pinteraction = 0.010) and death (Pinteraction = 0.002) in non-whites (predominantly South Asians and Afro-Caribbeans), compared with whites. CONCLUSIONS These data add support for adiposity being more strongly linked to COVID-19-related deaths in younger people and non-white ethnicities. If future studies confirm causality, lifestyle interventions to improve adiposity status may be important to reduce the risk of COVID-19 in all, but perhaps particularly, non-white communities.
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Affiliation(s)
- Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom.
| | - Frederick K Ho
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
| | - Jason Mr Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - Carlos A Celis-Morales
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - S Vittal Katikireddi
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
| | - John Jv McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow, G12 8TA, United Kingdom
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18
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Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N. Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan. Clin Endocrinol (Oxf) 2020; 93:87-96. [PMID: 32419166 DOI: 10.1111/cen.14250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/24/2023]
Abstract
There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.
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Affiliation(s)
- Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital NHS Trust, London, UK
- Department of Diabetes and Endocrinology, King's College London, London, UK
| | - Shazia Hussain
- Department of Diabetes and Endocrinology, Barts Health NHS Trust, London, UK
| | | | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College London NHS Trust, London, UK
| | - Nazim Ghouri
- Department of Diabetes and Endocrinology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Queen Elizabeth University Hospital, Glasgow, UK
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19
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Affiliation(s)
| | - Salman Waqar
- General Practitioner and Research Fellow, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nazim Ghouri
- Honorary Clinical Senior Lecturer, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Consultant Physician, Queen Elizabeth University Hospital, Glasgow, UK
| | - Zahid Iqbal
- Consultant in Occupational Medicine, London, UK
| | - Junaid Alam
- Consultant in Occupational Medicine, Al-Khobar, Saudi Arabia
| | - Sohail Ahmed
- General Practitioner and Occupational Health Physician, Glasgow, UK
| | - Syed Zakir Abbas
- Occupational Health Physician and Chief Medical Officer, Sunderland City Council, Sunderland, UK
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20
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Welsh C, Welsh P, Celis-Morales CA, Mark PB, Mackay D, Ghouri N, Ho FK, Ferguson LD, Brown R, Lewsey J, Cleland JG, Gray SR, Lyall DM, Anderson JJ, Jhund PS, Pell JP, McGuire DK, Gill JMR, Sattar N. Glycated Hemoglobin, Prediabetes, and the Links to Cardiovascular Disease: Data From UK Biobank. Diabetes Care 2020; 43:440-445. [PMID: 31852727 DOI: 10.2337/dc19-1683] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/27/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE HbA1c levels are increasingly measured in screening for diabetes; we investigated whether HbA1c may simultaneously improve cardiovascular disease (CVD) risk assessment, using QRISK3, American College of Cardiology/American Heart Association (ACC/AHA), and Systematic COronary Risk Evaluation (SCORE) scoring systems. RESEARCH DESIGN AND METHODS UK Biobank participants without baseline CVD or known diabetes (n = 357,833) were included. Associations of HbA1c with CVD was assessed using Cox models adjusting for classical risk factors. Predictive utility was determined by the C-index and net reclassification index (NRI). A separate analysis was conducted in 16,596 participants with known baseline diabetes. RESULTS Incident fatal or nonfatal CVD, as defined in the QRISK3 prediction model, occurred in 12,877 participants over 8.9 years. Of participants, 3.3% (n = 11,665) had prediabetes (42.0-47.9 mmol/mol [6.0-6.4%]) and 0.7% (n = 2,573) had undiagnosed diabetes (≥48.0 mmol/mol [≥6.5%]). In unadjusted models, compared with the reference group (<42.0 mmol/mol [<6.0%]), those with prediabetes and undiagnosed diabetes were at higher CVD risk: hazard ratio (HR) 1.83 (95% CI 1.69-1.97) and 2.26 (95% CI 1.96-2.60), respectively. After adjustment for classical risk factors, these attenuated to HR 1.11 (95% CI 1.03-1.20) and 1.20 (1.04-1.38), respectively. Adding HbA1c to the QRISK3 CVD risk prediction model (C-index 0.7392) yielded a small improvement in discrimination (C-index increase of 0.0004 [95% CI 0.0001-0.0007]). The NRI showed no improvement. Results were similar for models based on the ACC/AHA and SCORE risk models. CONCLUSIONS The near twofold higher unadjusted risk for CVD in people with prediabetes is driven mainly by abnormal levels of conventional CVD risk factors. While HbA1c adds minimally to cardiovascular risk prediction, those with prediabetes should have their conventional cardiovascular risk factors appropriately measured and managed.
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Affiliation(s)
- Claire Welsh
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Paul Welsh
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | | | - Patrick B Mark
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Daniel Mackay
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - Nazim Ghouri
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Fredrick K Ho
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - Lyn D Ferguson
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Rosemary Brown
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - James Lewsey
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - John G Cleland
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - Stuart R Gray
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Donald M Lyall
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - Jana J Anderson
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | - Pardeep S Jhund
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Jill P Pell
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, U.K
| | | | - Jason M R Gill
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, U.K.
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21
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Beshyah SA, Chowdhury TA, Ghouri N, Lakhdar AA. Risk of diabetic ketoacidosis during Ramadan fasting: A critical reappraisal. Diabetes Res Clin Pract 2019; 151:290-298. [PMID: 30836132 DOI: 10.1016/j.diabres.2019.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/27/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To evaluate the validity of the perceived increased risk and the actual occurrence of DKA observed during fasting in Ramadan. METHODS This is a non-systematic narrative review of the literature on the occurrence of DKA during Ramadan. Online databases (PubMed, Google Scholar, Cochrane Database, Medline OVID and CINAHL EBSCO) were searched. Three research questions are addressed 1. What is the basis of the expert opinion on the risk for DKA? 2. What is the likelihood that DKA is precipitated by Ramadan fast? and 3. What is the frequency of observed DKA during Ramadan? RESULTS The expert opinion suggesting a risk of DKA during Ramadan fasting was proposed with no evidence in the early writing on Ramadan fasting and has been reiterated and propagated since then. However, from first principles, DKA is not readily precipitated by the usual stress-free metabolic environment induced by Ramadan fasting with the exception of cases involved in the usual risk factors for metabolic decompensation. Furthermore, recent studies could not document any increase in observed DKA during Ramadan fasting in retrospective, prospective and database studies. CONCLUSIONS The current state of knowledge and evidence suggests the risk of DKA is not increased during Ramadan fasting.
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Affiliation(s)
- Salem A Beshyah
- Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; Dubai Medical College, Dubai, United Arab Emirates.
| | - Tahseen A Chowdhury
- The Royal London Hospital Whitechapel, Barts Health NHS Trust, London, United Kingdom
| | - Nazim Ghouri
- Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom; Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
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Ghouri A, Boachie C, McDowall S, Parle J, Ditchfield CA, McConnachie A, Walters MR, Ghouri N. Response to: Response to: Gaining an advantage by sitting an OSCE after your peers: A retrospective study. Med Teach 2018; 40:1194-1195. [PMID: 30444172 DOI: 10.1080/0142159x.2018.1500909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Asim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Charles Boachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow , Glasgow , UK
| | - Suzanne McDowall
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Jim Parle
- c Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Carol A Ditchfield
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Alex McConnachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow , Glasgow , UK
| | - Matthew R Walters
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Nazim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
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23
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Ghouri A, Boachie C, McDowall S, Parle J, Ditchfield CA, McConnachie A, Walters MR, Ghouri N. Response to: Is there such a thing as a fair OSCE? Med Teach 2018; 40:1192-1193. [PMID: 30422024 DOI: 10.1080/0142159x.2018.1500949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Asim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Charles Boachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow , Glasgow , UK
| | - Suzanne McDowall
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Jim Parle
- c Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Carol A Ditchfield
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Alex McConnachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow , Glasgow , UK
| | - Matthew R Walters
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
| | - Nazim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow , Glasgow , UK
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Ghouri A, Boachie C, McDowall S, Parle J, Ditchfield CA, McConnachie A, Walters MR, Ghouri N. Gaining an advantage by sitting an OSCE after your peers: A retrospective study. Med Teach 2018; 40:1136-1142. [PMID: 29687736 DOI: 10.1080/0142159x.2018.1458085] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Purpose: To investigate if final year medical students undertaking an OSCE station at a later stage during examination diet were advantaged over their peers who undertook the same station at an earlier stage, and whether any such effect varies by the student's relative academic standing. Methods: OSCE data from six consecutive final year cohorts totaling 1505 students was analyzed. Mixed effects logistic regression was used to model factors associated with the probability of passing each individual station (random effects for students and circuits; and fixed effects to assess the association with day of examination, time of day, gender and year). Results: Weaker students were more likely to pass if they took their OSCE later in the examination period. The odds of passing a station increased daily by 20%. Overall, the mean number of stations passed by each student increased over the 5 days. Conclusions: Students undertaking the same OSCE stations later in examination period statistically had higher chances of passing compared to their peers, and the weaker students appear to be particularly advantaged. These findings have major implications for OSCE design, to ensure students are not advantaged by examination timing, and weaker students are not "passing in error".
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Affiliation(s)
- Asim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
| | - Charles Boachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing , University of Glasgow , Glasgow , UK
| | - Suzanne McDowall
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
| | - Jim Parle
- c Institute of Clinical Sciences, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Carol A Ditchfield
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
| | - Alex McConnachie
- b Robertson Centre for Biostatistics, Institute of Health and Wellbeing , University of Glasgow , Glasgow , UK
| | - Matthew R Walters
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
| | - Nazim Ghouri
- a School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences , University of Glasgow , Glasgow , UK
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Ghouri N, Hussain S, Mohammed R, Beshyah SA, Chowdhury TA, Sattar N, Sheikh A. Diabetes, driving and fasting during Ramadan: the interplay between secular and religious law. BMJ Open Diabetes Res Care 2018; 6:e000520. [PMID: 29892339 PMCID: PMC5992469 DOI: 10.1136/bmjdrc-2018-000520] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/25/2018] [Indexed: 11/03/2022] Open
Abstract
A large proportion of the Muslim population fasts during Ramadan. The risk of hypoglycemia is increased with fasting during Ramadan in people with diabetes who are on insulin and insulin secretagogues. Therefore, the combination of fasting with diabetes and driving presents a challenging situation, with legal implications for such individuals and their healthcare professionals. This novel, narrative, non-systematic review discusses the importance of addressing hypoglycemia in fasting with reference to secular legal guidance on driving with diabetes. We discuss religious aspects relating to fasting and driving in Islam. While there is no clear guidance or legal position on diabetes and driving for individuals who are fasting, Islamic law provides a logical framework to address this. Healthcare professionals need to raise and facilitate discussions on this often-overlooked topic with people with diabetes who are planning on fasting to minimize the potential for public harm. For some individuals fasting perhaps should be avoided when driving and that this religiously compatible position would best be adopted when one is dependent on driving for livelihood. Ultimately further research on glycemic control and management when fasting and driving, as well as a formal legal guidance on this topic, is required to safeguard healthcare professionals and the public from the potential dangers of driving with diabetes and fasting.
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Affiliation(s)
- Nazim Ghouri
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | | | - Salem Arifi Beshyah
- Institute of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | | | - Naveed Sattar
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Abstract
The impact of exercise interventions on south Asians with type 2 diabetes (T2DM), who have a higher T2DM incidence rate compared to other ethnic groups, is inconclusive. This study aimed to systematically review the effect of exercise interventions in south Asians with T2DM. Five electronic databases were searched up to April 2017 for controlled trials investigating the impact of exercise interventions on south Asian adults with T2DM. The PEDro scale was used to assess the quality of the included studies. Eighteen trials examining the effect of aerobic, resistance, balance or combined exercise programs met the eligibility criteria. All types of exercise were associated with improvements in glycemic control, blood pressure, waist circumference, blood lipids, muscle strength, functional mobility, quality of life or neuropathy progression. The majority of included studies were of poor methodological quality. Few studies compared different types or dose of exercise. In conclusion, this review supports the benefits of exercise for south Asians with T2DM, although it was not possible to identify the most effective exercise prescription. Further studies of good methodological quality are required to determine the most effective dosage and type of exercise to manage T2DM in this population.
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Affiliation(s)
- Hani Albalawi
- a School of Medicine, Dentistry and Nursing , University of Glasgow , Glasgow , UK.,b College of Applied Medical Sciences , University of Tabuk , Tabuk , KSA
| | - Elaine Coulter
- c School of Health Sciences , Queen Margaret University , Edinburgh , UK
| | - Nazim Ghouri
- d Institute of Cardiovascular and Medical Sciences , University of Glasgow , Glasgow , UK
| | - Lorna Paul
- e School of Health and Life Sciences , Glasgow Caledonian University , Glasgow , UK
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O'Donovan G, Bakrania K, Ghouri N, Yates T, Gray LJ, Hamer M, Stamatakis E, Khunti K, Davies M, Sattar N, Gill JMR. Nonexercise Equations to Estimate Fitness in White European and South Asian Men. Med Sci Sports Exerc 2017; 48:854-9. [PMID: 26694847 DOI: 10.1249/mss.0000000000000836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Cardiorespiratory fitness is a strong, independent predictor of health, whether it is measured in an exercise test or estimated in an equation. The purpose of this study was to develop and validate equations to estimate fitness in middle-age white European and South Asian men. METHODS Multiple linear regression models (n = 168, including 83 white European and 85 South Asian men) were created using variables that are thought to be important in predicting fitness (V˙O2max, mL·kg⁻¹·min⁻¹): age (yr), body mass index (kg·m⁻²), resting HR (bpm); smoking status (0, never smoked; 1, ex or current smoker), physical activity expressed as quintiles (0, quintile 1; 1, quintile 2; 2, quintile 3; 3, quintile 4; 4, quintile 5), categories of moderate- to-vigorous intensity physical activity (MVPA) (0, <75 min·wk⁻¹; 1, 75-150 min·wk⁻¹; 2, >150-225 min·wk⁻¹; 3, >225-300 min·wk⁻¹; 4, >300 min·wk⁻¹), or minutes of MVPA (min·wk⁻¹); and, ethnicity (0, South Asian; 1, white). The leave-one-out cross-validation procedure was used to assess the generalizability, and the bootstrap and jackknife resampling techniques were used to estimate the variance and bias of the models. RESULTS Around 70% of the variance in fitness was explained in models with an ethnicity variable, such as: V˙O2max = 77.409 - (age × 0.374) - (body mass index × 0.906) - (ex or current smoker × 1.976) + (physical activity quintile coefficient) - (resting HR × 0.066) + (white ethnicity × 8.032), where physical activity quintile 1 is 0, 2 is 1.127, 3 is 1.869, 4 is 3.793, and 5 is 3.029. Only around 50% of the variance was explained in models without an ethnicity variable. All models with an ethnicity variable were generalizable and had low variance and bias. CONCLUSION These data demonstrate the importance of incorporating ethnicity in nonexercise equations to estimate cardiorespiratory fitness in multiethnic populations.
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Affiliation(s)
- Gary O'Donovan
- 1Diabetes Research Centre, Leicester Diabetes Centre, Leicester General Hospital, University of Leicester, Leicester, UNITED KINGDOM; 2BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UNITED KINGDOM; 3Department of Health Sciences, University of Leicester, Leicester, UNITED KINGDOM; 4National Centre for Sport & Exercise Medicine, East Midlands, Loughborough University, Loughborough, UNITED KINGDOM; and 5Faculty of Health Sciences, Charles Perkins Centre, University of Sydney, Sydney, AUSTRALIA
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Iliodromiti S, Ghouri N, Celis-Morales CA, Sattar N, Lumsden MA, Gill JMR. Should Physical Activity Recommendations for South Asian Adults Be Ethnicity-Specific? Evidence from a Cross-Sectional Study of South Asian and White European Men and Women. PLoS One 2016; 11:e0160024. [PMID: 27529339 PMCID: PMC4987009 DOI: 10.1371/journal.pone.0160024] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 07/12/2016] [Indexed: 11/19/2022] Open
Abstract
International public health guidelines recommend that adults undertake at least 150 min.week−1 of moderate-intensity physical activity. However, the underpinning evidence has largely been obtained from studies of populations of white European descent. It is unclear whether these recommendations are appropriate for other ethnic groups, particularly South Asians, who have greater cardio-metabolic risk than white Europeans. The objective of our study was to determine the level of moderate-intensity physical activity required in South Asians adults to confer a similar cardio-metabolic risk profile to that observed in Europeans of similar age and body mass index (BMI) undertaking the currently recommended levels of 150 min.week−1. 148 South Asians and 163 white Europeans aged 18 to 70 years were recruited. Physical activity was measured objectively via vertical axis accelerations from hip-worn accelerometers. Factor analysis was used to summarize the measured risk biomarkers into a single underlying latent “factor” describing overall cardio-metabolic risk. Sex did not modify the association between physical activity and the cardio-metabolic risk factor, so data for both sexes were combined and models adjusted for age, sex, BMI and accelerometer wear time. We estimated that South Asian adults needed to undertake 232 (95% Confidence interval: 200 to 268) min.week−1 in order to obtain the same cardio-metabolic risk factor score as a white European undertaking 150 minutes of moderate-equivalent physical activity per week. The present findings suggest that South Asian men and women need to undertake ~230 minutes of moderate intensity physical activity per week. This equates to South Asians undertaking an extra 10–15 minutes of moderate intensity physical activity per day on top of existing recommendations.
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Affiliation(s)
- Stamatina Iliodromiti
- Department of Obstetrics and Gynaecology, School of Medicine, University of Glasgow, Glasgow, United Kingdom
- * E-mail:
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Carlos A. Celis-Morales
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mary Ann Lumsden
- Department of Obstetrics and Gynaecology, School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Jason M. R. Gill
- Department of Obstetrics and Gynaecology, School of Medicine, University of Glasgow, Glasgow, United Kingdom
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Ghouri N, Purves D, Deans KA, Logan G, McConnachie A, Wilson J, Gill JMR, Sattar N. An investigation of two-dimensional ultrasound carotid plaque presence and intima media thickness in middle-aged South Asian and European men living in the United kingdom. PLoS One 2015; 10:e0123317. [PMID: 25884221 PMCID: PMC4401566 DOI: 10.1371/journal.pone.0123317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 03/02/2015] [Indexed: 01/09/2023] Open
Abstract
Objectives Ultrasound studies of carotid intima media thickness (cIMT) and plaques are limited in South Asians, a group at elevated cardiovascular disease (CVD) risk. We determined whether South Asians have a difference in these ultrasound markers compared to Europeans living in the United Kingdom and whether measured risk factor(s) could account for any such differences. Methods One hundred South Asian men, aged 40 to 70 years and 100 European men of similar age and BMI, without diagnosed CVD or diabetes, underwent carotid ultrasound for measurement of cIMT and carotid plaque presence. Physical activity, cardiorespiratory fitness, anthropometry and blood pressure were assessed, fasted blood taken for measurement of cardiometabolic risk factors and demographic and lifestyle factors recorded. Results Age-adjusted mean (SD) cIMT was similar in South Asians and Europeans (0.64 (0.16) mm v 0.65 (0.12) mm, p = 0.64). Plaque was present in 48 South Asians and 37 Europeans and overall, there was no age-adjusted difference between South Asian and Europeans for plaque score(odds ratio 1.49, 95% CI, 0.86-2.80, p = 0.16), however, South Asians appeared to have more plaques at a younger age than Europeans; at age 40-50 years the odds of South Asians having plaques was 2.63 (95% CI, 1.16-5.93) times that for Europeans. Conclusions cIMT is similar between healthy South Asian and European men. Whilst there was no overall difference in plaque presence in South Asians, there is an indication of greater plaque prevalence at younger ages - an observation requiring further investigation. Prospective studies linking plaques to CVD outcomes in South Asians are needed to investigate whether these measures help improve CVD risk prediction.
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Affiliation(s)
- Nazim Ghouri
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, United Kingdom
- * E-mail: (NG); (NS)
| | - David Purves
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QA, United Kingdom
| | - Kevin A. Deans
- Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, United Kingdom
| | - Greig Logan
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, United Kingdom
- Human Potential Centre, AUT University, Auckland, 1142, New Zealand
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QA, United Kingdom
| | - John Wilson
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, United Kingdom
| | - Jason M. R. Gill
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, United Kingdom
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, United Kingdom
- * E-mail: (NG); (NS)
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Malik MO, Govan L, Petrie JR, Ghouri N, Leese G, Fischbacher C, Colhoun H, Philip S, Wild S, McCrimmon R, Sattar N, Lindsay RS. Ethnicity and risk of cardiovascular disease (CVD): 4.8 year follow-up of patients with type 2 diabetes living in Scotland. Diabetologia 2015; 58:716-25. [PMID: 25669630 DOI: 10.1007/s00125-015-3492-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/22/2014] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Potential differences in cardiovascular risk by ethnicity remain uncertain. We evaluated the association of ethnicity with cardiovascular disease (CVD) incidence in a large cohort of people with type 2 diabetes living in Scotland. METHODS Data from Scottish Care Information-Diabetes (SCI-Diabetes) were linked to Scottish Morbidity Records (SMR01) and National Records of Scotland data for mortality for dates between 2005 and 2011. Of 156,991 people with type 2 diabetes with coded ethnicity, 121,535 (77.4%) had no CVD at baseline (White: 114,461; Multiple Ethnic: 2,554; Indian: 797; Other Asian: 319; Pakistani: 2,250; Chinese: 387; African-Caribbean: 301 and Other: 466) and were followed up (mean ± SD: 4.8 ± 2.3 years) for the development of fatal and non-fatal CVD. RESULTS During follow-up, 16,265 (13.4%) patients developed CVD (ischaemic heart or cerebrovascular diseases). At baseline, Pakistanis were younger and had developed diabetes earlier, had higher HbA1c and longer duration of diabetes, but had lower BP, BMI, creatinine, proportion of smokers and proportion on antihypertensive therapy than whites. The age and sex adjusted HRs for CVD were HR 1.31 (CI 1.17, 1.47), p < 0.001 in Pakistanis and HR 0.66 (CI 0.47, 0.92), p = 0.014 in Chinese compared with whites. Adjusting additionally for an area measure of deprivation, duration of diabetes, conventional CVD and other risk factors, the HR for Pakistanis (HR 1.45 [CI 1.14, 1.85], p = 0.002) was significantly higher, and that for Chinese (HR = 0.58 [CI 0.24, 1.40], p = 0.228) lower, compared with whites. CONCLUSIONS/INTERPRETATION Compared with whites with type 2 diabetes, those of Pakistani ethnicity in Scotland were at increased risk of CVD, whereas Chinese were at lower risk, with these differences unexplained by known risk factors.
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Affiliation(s)
- Muhammad Omar Malik
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow, Cardiovascular Research Centre, University of Glasgow, 126 University Place, G12 8TA, Glasgow, UK
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Ghouri N, Fisher M. Diabetes mellitus and incident cardiovascular disease: does one risk fit all? Practical Diabetes 2014. [DOI: 10.1002/pdi.1830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gill JM, Celis-Morales CA, Ghouri N. Physical activity, ethnicity and cardio-metabolic health: Does one size fit all? Atherosclerosis 2014; 232:319-33. [DOI: 10.1016/j.atherosclerosis.2013.11.039] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/07/2013] [Accepted: 11/08/2013] [Indexed: 12/24/2022]
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Negandhi PH, Ghouri N, Colhoun HM, Fischbacher CM, Lindsay RS, McKnight JA, Petrie J, Philip S, Sattar N, Wild SH. Ethnic differences in glycaemic control in people with type 2 diabetes mellitus living in Scotland. PLoS One 2013; 8:e83292. [PMID: 24358273 PMCID: PMC3865180 DOI: 10.1371/journal.pone.0083292] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 11/12/2013] [Indexed: 11/19/2022] Open
Abstract
Background and Aims Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland Methods We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes. Results Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p<0.05) greater proportions of people with suboptimal glycaemic control (HbA1c >58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively. Conclusions Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.
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Affiliation(s)
- Preeti H. Negandhi
- Indian Institute of Public Health, Public Health Foundation of India, Gurgaon, Haryana, India
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Helen M. Colhoun
- Biomedical Research Institute, Mackenzie Building, University of Dundee, Dundee, Scotland, United Kingdom
| | - Colin M. Fischbacher
- Information Services Division, NHS National Services Scotland, Edinburgh, Scotland, United Kingdom
| | - Robert S. Lindsay
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - John A. McKnight
- Metabolic Unit, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - John Petrie
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Sam Philip
- Department of Diabetes and Endocrinology, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Sarah H. Wild
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, Scotland, United Kingdom
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Celis-Morales CA, Ghouri N, Bailey MES, Sattar N, Gill JMR. Should physical activity recommendations be ethnicity-specific? Evidence from a cross-sectional study of South Asian and European men. PLoS One 2013; 8:e82568. [PMID: 24349313 PMCID: PMC3859604 DOI: 10.1371/journal.pone.0082568] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 11/04/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Expert bodies and health organisations recommend that adults undertake at least 150 min.week(-1) of moderate-intensity physical activity (MPA). However, the underpinning data largely emanate from studies of populations of European descent. It is unclear whether this level of activity is appropriate for other ethnic groups, particularly South Asians, who have increased cardio-metabolic disease risk compared to Europeans. The aim of this study was to explore the level of MPA required in South Asians to confer a similar cardio-metabolic risk profile to that observed in Europeans undertaking the currently recommended MPA level of 150 min.week(-1). METHODS Seventy-five South Asian and 83 European men, aged 40-70, without cardiovascular disease or diabetes had fasted blood taken, blood pressure measured, physical activity assessed objectively (using accelerometry), and anthropometric measures made. Factor analysis was used to summarise measured risk biomarkers into underlying latent 'factors' for glycaemia, insulin resistance, lipid metabolism, blood pressure, and overall cardio-metabolic risk. Age-adjusted regression models were used to determine the equivalent level of MPA (in bouts of ≥ 10 minutes) in South Asians needed to elicit the same value in each factor as Europeans undertaking 150 min.week(-1) MPA. FINDINGS For all factors, except blood pressure, equivalent MPA values in South Asians were significantly higher than 150 min.week(-1); the equivalent MPA value for the overall cardio-metabolic risk factor was 266 (95% CI 185-347) min.week(-1). CONCLUSIONS South Asian men may need to undertake greater levels of MPA than Europeans to exhibit a similar cardio-metabolic risk profile, suggesting that a conceptual case can be made for ethnicity-specific physical activity guidance. Further study is needed to extend these findings to women and to replicate them prospectively in a larger cohort.
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Affiliation(s)
- Carlos A. Celis-Morales
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
- Human Nutrition Research Centre, Institute for Ageing and Health, Newcastle University, Newcastle on Tyne, United Kingdom
| | - Nazim Ghouri
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark E. S. Bailey
- School of Life Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Jason M. R. Gill
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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Ghouri N, Purves D, McConnachie A, Wilson J, Gill JMR, Sattar N. Lower cardiorespiratory fitness contributes to increased insulin resistance and fasting glycaemia in middle-aged South Asian compared with European men living in the UK. Diabetologia 2013; 56:2238-49. [PMID: 23811809 PMCID: PMC3764328 DOI: 10.1007/s00125-013-2969-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 05/17/2013] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS This study aimed to determine the extent to which increased insulin resistance and fasting glycaemia in South Asian men, compared with white European men, living in the UK, was due to lower cardiorespiratory fitness (maximal oxygen uptake [VO(2max)]) and physical activity. METHODS One hundred South Asian and 100 age- and BMI-matched European men without diagnosed diabetes, aged 40-70 years, had fasted blood taken for measurement of glucose concentration, HOMA-estimated insulin resistance (HOMA(IR)), plus other risk factors, and underwent assessment of physical activity (using accelerometry), VO(2max), body size and composition, and demographic and other lifestyle factors. For 13 South Asian and one European man, HbA1c levels were >6.5% (>48 mmol/mol), indicating potential undiagnosed diabetes; these men were excluded from the analyses. Linear regression models were used to determine the extent to which body size and composition, fitness and physical activity variables explained differences in HOMA(IR) and fasting glucose between South Asian and European men. RESULTS HOMA(IR) and fasting glucose were 67% (p < 0.001) and 3% (p < 0.018) higher, respectively, in South Asians than Europeans. Lower VO(2max), lower physical activity and greater total adiposity in South Asians individually explained 68% (95% CI 45%, 91%), 29% (11%, 46%) and 52% (30%, 80%), respectively, and together explained 83% (50%, 119%) (all p < 0.001) of the ethnic difference in HOMA(IR). Lower VO(2max) and greater total adiposity, respectively, explained 61% (9%, 111%) and 39% (9%, 76%) (combined effect 63% [8%, 115%]; all p < 0.05) of the ethnic difference in fasting glucose. CONCLUSIONS/INTERPRETATION Lower cardiorespiratory fitness is a key factor associated with the excess insulin resistance and fasting glycaemia in middle-aged South Asian, compared with European, men living in the UK.
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Affiliation(s)
- N. Ghouri
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA UK
| | - D. Purves
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - A. McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - J. Wilson
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA UK
| | - J. M. R. Gill
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA UK
| | - N. Sattar
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA UK
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Affiliation(s)
- N Ghouri
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Walsall, UK
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Shyangdan D, Clar C, Ghouri N, Henderson R, Gurung T, Preiss D, Sattar N, Fraser A, Waugh N. Insulin sensitisers in the treatment of non-alcoholic fatty liver disease: a systematic review. Health Technol Assess 2011; 15:1-110. [PMID: 22059955 PMCID: PMC4781160 DOI: 10.3310/hta15380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is closely linked with obesity and the prevalence of NAFLD is about 17% to 33% in the Western world. There is a strong association of NAFLD with insulin resistance and, hence, insulin sensitisers have been tried. This systematic review examined the clinical effectiveness of insulin sensitisers in patients with NAFLD, to help decide whether or not a trial or trials of the insulin sensitisers was necessary and also to explore whether or not non-invasive alternatives to liver biopsy were available that could be used in a large trial of the insulin sensitisers. OBJECTIVE To review the use of insulin sensitisers in the treatment of NAFLD. REVIEW METHODS A systematic review of the clinical effectiveness of metformin, rosiglitazone and pioglitazone was carried out, including reviews and randomised controlled trials (RCTs). Databases searched were MEDLINE, 1950 to June 2010; EMBASE, 1980 to June 2010; Science Citation Index Expanded, June 2010; Conference Proceedings Citation Index - Science June 2010; The Cochrane Library 2005-10. Abstracts were screened independently by two researchers. A narrative review of diagnostic methods was conducted. RESULTS Clinical effectiveness. We identified 15 RCTs (one available as abstract). Four papers explored efficacy of pioglitazone, one rosiglitazone, eight metformin; two compared metformin and rosiglitazone, although one used both metformin and rosiglitazone. The duration of most trials was between 6 and 12 months. Many trials had a small number of participants and the quality of the studies was mixed. Pioglitazone improved all parameters of liver histology. Metformin showed mixed results, with ultrasound changes in two studies showing some improvement in steatosis, whereas there were no changes in the other two. Metformin, however, showed no improvement in non-alcoholic steatohepatitis (NASH) stages. Metformin showed greater reduction in glycosylated haemoglobin (-0.23% to -1.2% vs -0.2% to -0.7%) and fasting plasma glucose (+0.05 to -3.19 mmol/l vs -0.17 to -1.11 mmol/l) compared with pioglitazone. Metformin led to weight reduction (-4.3 to -6.7 kg), whereas participants on pioglitazone gained weight (+2.5 to +4.7 kg). Alanine aminotransferase levels were reduced with both metformin and pioglitazone; however, the reduction in levels with pioglitazone was not different to that caused by vitamin E. Most studies suggested that metformin led to a significant reduction in insulin resistance. Diagnosis. Non-invasive methods of diagnosing NAFLD without liver biopsy, using combinations of clinical history, laboratory tests and ultrasound, have been explored, but so far liver biopsy is the only proven method of distinguishing simple steatosis from NASH. Transient elastography appears useful, but less so in obese individuals. Magnetic resonance spectroscopy shows promise, but is expensive and not readily available. LIMITATIONS Mixed quality of trials, with lack of detail as to how some trials were conducted. Many trials had small numbers of patients. CONCLUSIONS The main need for drug trials is at the NASH stage. However, at present, any trial in the more advanced forms of NAFLD would have to use liver biopsy. The highest priority for research may, therefore, be in the diagnosis of NAFLD, and the differentiation between steatosis and NASH. The newer agents, the glucagon-like peptide-1 analogues such as liraglutide, may be more worthy of a trial. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- D Shyangdan
- Warwick Evidence, Health Sciences Research Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Ghouri N, Preiss D, Sattar N. Liver enzymes, nonalcoholic fatty liver disease, and incident cardiovascular disease: a narrative review and clinical perspective of prospective data. Hepatology 2010; 52:1156-61. [PMID: 20658466 DOI: 10.1002/hep.23789] [Citation(s) in RCA: 198] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED In recent years, a strong link has been established between nonalcoholic fatty liver disease (NAFLD) and the pathogenesis of type 2 diabetes mellitus. The potential role of NAFLD in cardiovascular disease (CVD) has also attracted interest. Published studies have tended to use biochemical and imaging surrogate markers of NAFLD, such as elevated gamma glutamyl transpeptidase (GGT) and alanine aminotransferase (ALT) and fatty liver on ultrasound, when investigating associations with incident CVD events. Positive associations between both baseline GGT and temporal change in GGT, as well as cardiovascular events and cardiovascular mortality independent of alcohol intake, have been reported in several prospective studies. However, adjustment for confounders is often incomplete, and there is scant evidence of improvement in cardiovascular risk prediction beyond established risk scores when incorporating such data. There also appears to be a strong and underrecognized age interaction, with associations between GGT and incident coronary heart disease (CHD) being strong in young individuals but relatively weak in the elderly. By contrast, ALT appears to be only weakly associated with incident CHD and may exhibit a U-shaped association with total mortality. Finally, although some studies have linked imaging-defined and biopsy-confirmed NAFLD with CVD risk, the evidence is inconsistent, with few incident events and/or insufficient potential confounders. CONCLUSION A diagnosis of NAFLD is insufficient to consider patients as being at high risk for CVD. The presence of NAFLD should be a clear indication for diabetes screening, but cardiovascular risk screening should be performed with the use of existing risk calculators and should be guided by established cardiovascular risk factors.
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Affiliation(s)
- Nazim Ghouri
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Ghouri N, Hippisley-Cox J, Newton J, Sheikh A. Trends in the epidemiology and prescribing of medication for allergic rhinitis in England. J R Soc Med 2008; 101:466-72. [PMID: 18779249 DOI: 10.1258/jrsm.2008.080096] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate recent trends in the recorded incidence, lifetime prevalence and prescribing of symptom relief medication for allergic rhinitis in England. DESIGN Analysis of primary healthcare datasets. SETTING The UK prevalence of allergic rhinitis has increased very significantly over recent decades. Analysis of primary healthcare datasets offers the possibility to advance understanding about the changing epidemiology and management of allergic rhinitis. QRESEARCH is one of the world's largest national aggregated health databases containing the records of over nine million patients. We extracted data on all patients with a recorded diagnosis of allergic rhinitis and calculated annual age-sex standardized incidence and lifetime period prevalence rates for each year from 2001-2005. We also analysed prescribing trends for antihistamines and drugs used in nasal allergy in those with a recorded diagnosis of allergic rhinitis. MAIN OUTCOME MEASURES Age-sex standardized incidence, lifetime prevalence rates and prescribing trends for symptom relief medication for allergic rhinitis in England. RESULTS The age-sex standardized incidence of allergic rhinitis was 5.57 per 1000 person-years in 2001 and increased by 33.0% to 7.41 per 1000 person-years in 2005 (P<0.001). Lifetime age-sex standardized prevalence of a recorded diagnosis of allergic rhinitis increased by 43.2% from 46.35 per 1000 in 2001 to 66.37 per 1000 in 2005 (P<0.001). Over this period a 41.7% overall increase in prescriptions for antihistamines and drugs used in nasal allergy was observed (antihistamines 45.5%, drugs used in nasal allergies 35.5%). CONCLUSIONS Recorded incidence and lifetime prevalence of allergic rhinitis have increased substantially in recent years. A similar increase in prescriptions for antihistamines and drugs used in nasal allergy in patients with allergic rhinitis is also observed.
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Abstract
Smoking prevalence is generally high among Muslims. An awareness of their religious beliefs and rulings might increase the effectiveness of antismoking campaigns
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Affiliation(s)
- Nazim Ghouri
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU
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Abstract
BACKGROUND Towards the end of 2001, the Scottish Executive Health Department published a unique report, 'Fair for All', on the issue of addressing the health needs of ethnic minorities. One of the recommendations contained within the report was that different groups and organizations within communities should work together to provide services to minority groups. This descriptive paper is an illustration of how a settled community, in this case a Muslim community, was encouraged to become involved in its own health care by holding a health fair at its mosque. PLANNING The health fair was organized by the Minority Ethnic Health Inclusion Project, in collaboration with the Local Health Care Co-operative, and in co-operation with Edinburgh Central Mosque. The health fair was held over two consecutive Fridays in May 2003 and focused primarily on diabetes, high blood pressure, healthy eating and oral hygiene, as well as providing information on cancer and local community services. OUTCOMES The health fair was well received on both days, with around 200 men and 120 women participating. In total, there were 99 recorded blood pressure measurements and 81 blood glucose checks, and the community dental service was very well received. EVALUATION Strong participation by the community shows that people from ethnic minorities are interested in their health and will participate in health-related activities arranged for them. The success of this health fair shows that, as proposed by the Scottish Executive, different groups and organizations within the community can work together to provide services to minority ethnic groups.
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Affiliation(s)
- Nazim Ghouri
- University of Edinburgh College of Medicine and Veterinary Medicine, Teviot Place, Edinburgh EH9 8AG, UK.
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Affiliation(s)
- T. R. Romer
- ; Ralston Purina Company; Checkerboard Square St. Louis 63188 MO
| | - N. Ghouri
- ; Ralston Purina Company; Checkerboard Square St. Louis 63188 MO
| | - T. M. Boling
- ; Ralston Purina Company; Checkerboard Square St. Louis 63188 MO
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