No relationship between socioeconomic status, education level and development and progression of diabetic retinopathy in type 2 diabetes: a FIELD trial substudy

In 6002 Australian adults with type 2 diabetes and a median 5-year follow-up in the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) trial, baseline socioeconomic status (SES) and self-reported education level were not related to development of on-trial sight-threatening diabetic retinopathy. Similarly, in a retinal photography substudy (n = 549), two-step diabetic retinopathy progression was not related to SES or education.

Review and comparison of retinal vessel calibre and geometry software and their application to diabetes, cardiovascular disease, and dementia

Developments in retinal imaging technologies have enabled the quantitative evaluation of the retinal vasculature. Changes in retinal calibre and/or geometry have been reported in systemic vascular diseases, including diabetes mellitus (DM), cardiovascular disease (CVD), and more recently in neurodegenerative diseases, such as dementia. Several retinal vessel analysis softwares exist, some being disease-specific, others for a broader context. In the research setting, retinal vasculature analysis using semi-automated software has identified associations between retinal vessel calibre and geometry and the presence of or risk of DM and its chronic complications, and of CVD and dementia, including in the general population. In this article, we review and compare the most widely used semi-automated retinal vessel analysis softwares and their associations with ocular imaging findings in common systemic diseases, including DM and its chronic complications, CVD, and dementia. We also provide original data comparing retinal calibre grading in people with Type 1 DM using two softwares, with good concordance.

Prevalence of diabetic retinopathy and reduced vision among indigenous Australians in the nurse-led integrated Diabetes Education and Eye Screening study in a regional primary care clinic

BACKGROUND

Nationally, Indigenous Australians are more likely to have diabetes and diabetic retinopathy (DR) than non-Indigenous Australians. However, the prevalence of DR and impaired vision in regional primary care settings is unclear.

AIM

To describe the prevalence and severity of DR and presenting vision level among Indigenous Australian adults with diabetes attending an indigenous primary care clinic in regional Australia.

METHODS

Participants underwent nurse-led retinal imaging and DR screening with offsite retinal grading in the integrated Diabetes Education and Eye Screening (iDEES) project implemented at a regional indigenous primary healthcare setting between January 2018 and March 2020.

RESULTS

Of 172 eligible adults, 135 (79%) were recruited and screened for DR and vision level. The median age was 56 (46-67) years, 130 (96%) had type 2 diabetes of median (interquartile range) duration 6 (2-12) years and 48 (36%) were male. Images from 132 (97.8%) participants were gradable. DR was present in 38 (29%) participants: mild non-proliferative in 33 (25%); moderate-severe in three (2.5%); and sight-threatening two (1.5%). Subnormal presenting vision was present in 33%.

CONCLUSIONS

A nurse-led model of care integrating diabetes eye screening and education at a single visit was successful at recruiting Indigenous Australian adults with diabetes, screening their vision and acquiring a high rate of gradable images. Even for a short duration of known diabetes, DR was present in three out of 10 patients screened.

Nurse-led vascular risk assessment in a regional Victorian Indigenous primary care diabetes clinic: An integrated Diabetes Education and Eye disease Screening [iDEES] study

AIM

The aim was to describe vascular risk factors in Australian adults with diabetes attending an Indigenous primary care nurse-led diabetes clinic.

DESIGN

This was a cross-sectional descriptive single-site study.

METHODS

Vascular risk factor data were extracted from the electronic health records of participants in the nurse-led integrated Diabetes Education and Eye disease Screening (iDEES) study at a regional Victorian Indigenous primary health-care clinic between January 2018 and March 2020.

RESULTS

Of 172 eligible adults, 135 (79%) provided data. Median (IQR) age was 56 (46-67) years; 89% were Indigenous; 95% had Type 2 diabetes of median (IQR) duration of 6 (2-12) years and 48 (36%) were male. Median HbA1c, blood pressure, cholesterol (total; LDL and HDL), triglycerides, eGFR, CRP and BMI were 8.0% (64 mmol/mol), 127/78 mm Hg, 4.2; 1.9; 1.1 mmol/L, 2.3 mmol/L, 89 ml/min/1.73 m² , 7.0 mg/L and 32.4 kg/m² . Of nine clinical risk factors, the median (IQR) number of risk factors at target was 4 (3-5) for women and 3 (2-5) for men, p_χ2  = 0.563. Clinical targets for BMI, HbA1c, blood pressure, triglycerides, total cholesterol, LDL cholesterol, urine albumin: creatinine ratio, HDL cholesterol and smoking were met by 14%, 34%, 38%, 39%, 44%, 52%, 54%, 62% and 64%, respectively.

CONCLUSION

A nurse-led model of integrated clinical risk factor assessment and diabetes education identified suboptimal levels of clinical risk factor control for avoiding diabetes chronic complications amongst Australian adults with diabetes in an Indigenous primary care setting.

IMPACT

A nurse-led model of diabetes care integrating clinical risk factor assessment into a diabetes education service is achievable. Understanding by stakeholders, including people with diabetes, their clinicians and health services, of the importance of regular monitoring of risk factors impacting diabetes complications is important. The novel nurse-managed iDEES primary-care model of care can assist.

TRIAL REGISTRATION

This study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001204235).

Fenofibrate, which reduces risk of sight-threatening diabetic retinopathy in type 2 diabetes, is associated with early narrowing of retinal venules: a FIELD trial substudy

Retinal vessel calibre metrics were evaluated at baseline and 2 years in a FIELD substudy (n = 208). Central retinal venule calibre was significantly reduced by fenofibrate and unchanged by placebo. Arteriole metrics did not change. Larger studies relating retinal vessel calibre to future diabetes complications and response to therapy are merited.

Retinopathy risk calculators in the prediction of sight-threatening diabetic retinopathy in type 2 diabetes: A FIELD substudy

AIMS

To evaluate the risk algorithm by Aspelund et al. for predicting sight-threatening diabetic retinopathy (STDR) in Type 2 diabetes (T2D), and to develop a new STDR prediction model.

METHODS

The Aspelund et al. algorithm was used to calculate STDR risk from baseline variables in 1012 participants in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) ophthalmological substudy, compared to on-trial STDR status, and receiver operating characteristic analysis performed. Using multivariable logistic regression, traditional risk factors and fenofibrate allocation as STDR predictors were evaluated, with bootstrap-based optimism-adjusted estimates of predictive performance calculated.

RESULTS

STDR developed in 28 participants. The Aspelund et al. algorithm predicted STDR at 2- and 5-years with area under the curve (AUC) 0.86 (95% CI 0.77-0.94) and 0.86 (0.81-0.92), respectively. In the second model STDR risk factors were any DR at baseline (OR 24.0 [95% CI 5.53-104]), HbA1c (OR 1.95 [1.43-2.64]) and male sex (OR 4.34 [1.32-14.3]), while fenofibrate (OR 0.13 [0.05-0.38]) was protective. This model had excellent discriminatory ability (AUC = 0.89).

CONCLUSIONS

The algorithm by Aspelund et al. predicts STDR well in the FIELD ophthalmology substudy. Logistic regression analysis found DR at baseline, male sex, and HbA1c were predictive of STDR and, fenofibrate was protective.

Mixed diabetic retinopathy screening coverage results in Indigenous Australian primary care settings: A nurse-led model of integrated diabetes care

AIMS

To determine eye screening coverage and adherence to national eye screening recommendations of a nurse-led retinal image-based model of diabetes education and eye screening in Indigenous primary care clinics.

DESIGN

A pre-post study.

METHODS

During January 2018-March 2020 Indigenous Australians with diabetes at three regional Australian clinics were offered eye screening by a nurse-diabetes educator/retinal imager. At the main site the nurse recruited/scheduled participants, and at satellite sites local clinic staff did so. Visual acuity was tested and digital retinal images acquired and graded. Participants were offered rescreening at or before 12-months based on baseline results.

RESULTS

In total 203 adults with diabetes attending Indigenous primary care clinics were screened, with divergent results based on the recruitment methods. At the main clinic 135 of 172 eligible adults (79%) were screened. At the satellite sites, 15 of 85 (18%) and 21 of 77 (27%) diabetes patients were screened. Combined coverage 51%.

CONCLUSION

A credentialed nurse-educator implemented a model of retinal image-based diabetes education, measured eye screening coverage and adherence to national eye screening guidelines, met the 'acceptable 75% eye screening coverage' benchmark and improved patient eye screening guideline adherence at the one site where the nurse-educator had access to patient recruitment and scheduling.

IMPACT

This novel nurse-led primary care iDEES model of retinal image-based diabetes education can improve the currently low Indigenous diabetes eye screening coverage in Australia. Importantly, the nurse-managed iDEES model of integrated diabetes care is readily adaptable to other settings and populations where access to and/or uptake of eye care is suboptimal.

CLINICAL TRIAL REGISTRATION

ANZCTRN1261800120435.

Health-risk behaviours among Indigenous Australians with diabetes: A study in the integrated Diabetes Education and Eye Screening (iDEES) project

AIM

To assess the prevalence of modifiable health-risk behaviours among Indigenous Australian adults with diabetes attending a regional Victorian Indigenous primary-care clinic.

DESIGN

A cross-sectional observational single-site study.

METHODS

As part of a multi-study project we administered the Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional wellbeing (SNAPE) survey tool during the study baseline visit to methodically capture health-related behavioural data in the nurse-led integrated Diabetes Education and Eye Screening (iDEES) project in a regional Indigenous primary healthcare setting between January 2018 and March 2020. This descriptive SNAPE study helps address the lack of health behaviour data for Indigenous people with diabetes.

RESULTS

Of 172 eligible adults, 135 (79%) were recruited to the iDEES study, 50 (37%) male. All participated in at least one survey. Median (range) age was 56 (46-67) years; 130 (96%) had Type 2 diabetes of median [IQR] duration 6 (2-12) years. All 135 provided smoking data; 88 (65%) completed all surveys. Forty-nine (36%) and 29 (22%) were current or former smokers, respectively; 5 (6%) met vegetable intake guidelines, 22 (25%) met fruit intake guidelines; 38 [43%] drank alcohol in the past year. On average, participants walked for ≥10 min at a time 4 days/week and sat for an average of 8 h on weekdays; 35 (40%) had minimal-mild, and 30 (34%) had moderate-severe depressive symptoms.

CONCLUSION

Suboptimal modifiable health-risk behaviours and depressive symptoms are common in Indigenous Australian adults with diabetes.

IMPACT

Orderly assessment and reporting of health-risk behaviours using a single multi-component survey instrument (SNAPE tool) during a nurse-led diabetes education clinical visit is feasible and efficient. Such data may facilitate personalised interventions and improve diabetes management at both individual and health service levels.

Adherence to the Mediterranean Diet and Successful aging in Greeks living in Greece and abroad: the epidemiological Mediterranean Islands Study (MEDIS)

Background: Whether older immigrant populations from the Mediterranean region, continue to follow the MD long after they immigrated is not known. Aim: Compare adherence to the MD and successful aging levels between Greeks living in Greece (GG) and Greeks living abroad (GA). Methods: Anthropometrical, clinical, psychological, sociodemographic, dietary and lifestyle parameters were assessed in a cross-sectional manner in a sample of 252 GG and 252 GA. Mediterranean Diet Score (MedDietScore range 0-55) was used to assess adherence to the MD. Successful aging was evaluated with the validated successful aging index (SAI range 0-10). Results: GA presented higher adherence to MD (p < 0.001); they were consuming significantly more cereals, legumes, vegetables, and fruits compared to GG. GG consumed significantly more dairy (3.8 ± 2.9 vs. 1.9 ± 2.2, p < 0.001) and potatoes (2.4 ± 1.6 vs. 1.9 ± 1.5, p < 0.001) compared to GA. Meat (p = 0.27), poultry (p = 0.72), fish (p = 0.68), olive oil (p = 0.16) and alcohol consumption (p = 0.05) were comparable between the two groups (all p's > 0.05). MedDietScore was positively associated with SAI among both groups after adjusting for possible confounders (0.041 ± 0.014, p = 0.003 GG and 0.153 ± 0.035, p < 0.001 GA). Also, legumes, cereals, fruits and vegetables were found to be beneficial for successful aging. Conclusion: Adherence to the MD is associated with higher levels of successful aging among people of the same genetic background living in different environments. However, traditional dietary habits are gradually abandoned in their native countries, when, at the same time, are considered cultural heritage and preserved accordingly among immigrants.

Successful aging and lifestyle comparison of Greeks living in Greece and abroad: the epidemiological Mediterranean Islands Study (MEDIS)

OBJECTIVES

Comparing lifestyle and successful aging between Greeks living in Greece (GG) and Greeks living abroad (GA) using a multidimensional model of successful aging including both biomedical and non-medical components.

METHODS

Anthropometric, clinical, psychological, socio-demographic, dietary and lifestyle parameters were assessed in a random sample of 252 GG and 252 GA. Successful aging was evaluated using the validated successful aging index (SAI range 0-10).

RESULTS

GA had better financial and educational status and scored higher in all social activity parameters (p's < 0.05). GA were more likely to be physically active (p < 0.001), had higher adherence to the Mediterranean diet (p < 0.001) and were less likely to be smoking (p = 0.008). Depression was more evident among GG compared to GA (p < 0.001). GA was aging significantly more successfully than GG (p < 0.001). Men irrespective of location were aging significantly more successfully than women (p < 0.05).

CONCLUSION

Place of residence and personal choices significantly affect the level of healthy aging among people with similar genetic backgrounds.

Facilitating diabetic retinopathy screening using automated retinal image analysis in underresourced settings

AIM

To evaluate an automated retinal image analysis (ARIA) of indigenous retinal fundus images against a human grading comparator for the classification of diabetic retinopathy (DR) status.

METHODS

Indigenous Australian adults with type 2 diabetes (n = 410) from three remote and very remote primary-care services in the Northern Territory, Australia, underwent teleretinal DR screening. A single, central retinal fundus photograph (opportunistic mydriasis) for each eye was later regraded using a single ARIA and a UK human grader and national DR classification system. The sensitivity and specificity of ARIA were assessed relative to the comparator. Proportionate agreement and a Kappa statistic were also computed.

RESULTS

Retinal images from 391 and 393 participants were gradable for 'Any DR' by the human grader and ARIA grader, respectively. 'Any DR' was detected by the human grader in 185 (47.3%) participants and by ARIA in 202 (48.6%) participants (agreement =88.0%, Kappa = 0.76,), whereas proliferative DR was detected in 31 (7.9%) and 37 (9.4%) participants (agreement = 98.2%, Kappa = 0.89,), respectively. The ARIA software had 91.4 (95% CI, 86.3-95.0) sensitivity and 85.0 (95% CI, 79.3-89.5) specificity for detecting 'Any DR' and 96.8 (95% CI, 83.3-99.9) sensitivity and 98.3 (95% CI, 96.4-99.4) specificity for detecting proliferative DR.

CONCLUSIONS

This ARIA software has high sensitivity for detecting 'Any DR', hence could be used as a triage tool for human graders. High sensitivity was also found for detection of proliferative DR by ARIA. Future versions of this ARIA should include maculopathy and referable DR (CSME and/or PDR). Such ARIA software may benefit diabetes care in less-resourced regions.

Associations with sight-threatening diabetic macular oedema among Indigenous adults with type 2 diabetes attending an Indigenous primary care clinic in remote Australia: a Centre of Research Excellence in Diabetic Retinopathy and Telehealth Eye and Associated Medical Services Network study

Objective

To identify factors associated with sight-threatening diabetic macular oedema (STDM) in Indigenous Australians attending an Indigenous primary care clinic in remote Australia.

Methods and analysis

A cross-sectional study design of retinopathy screening data and routinely-collected clinical data among 236 adult Indigenous participants with type 2 diabetes (35.6% men) set in one Indigenous primary care clinic in remote Australia. The primary outcome variable was STDM assessed from retinal images.

Results

Age (median (range)) was 48 (21–86) years, and known diabetes duration (median (range)) was 8.0 (0–24) years. Prevalence of STDM was high (14.8%) and similar in men and women. STDM was associated with longer diabetes duration (11.7 vs 7.9 years, respectively; p<0.001) and markers of renal impairment: abnormal estimated Glomerular Filtration Rate (eGFR) (62.9 vs 38.3%, respectively; p=0.007), severe macroalbuminuria (>300 mg/mmol) (20.6 vs 5.7%, respectively; p=0.014) and chronic kidney disease (25.7 vs 12.2%, respectively; p=0.035). Some clinical factors differed by sex: anaemia was more prevalent in women. A higher proportion of men were smokers, prescribed statins and had increased albuminuria. Men had higher blood pressure, but lower glycated Haemoglobin A1c (HbA1c) levels and body mass index, than women.

Conclusion

STDM prevalence was high and similar in men and women. Markers of renal impairment and longer diabetes duration were associated with STDM in this Indigenous primary care population. Embedded teleretinal screening, known diabetes duration-based risk stratification and targeted interventions may lower the prevalence of STDM in remote Indigenous primary care services.

Trial registration number

Australia and New Zealand Clinical Trials Register: ACTRN 12616000370404.

Imaging the eye and its relevance to diabetes care

Diabetes is a major cause of vision loss globally, yet this devastating complication is largely preventable. Early detection and treatment of diabetic retinopathy necessitates screening. Ocular imaging is widely used clinically, both for the screening and management of diabetic retinopathy. Common eye conditions, such as glaucoma, cataracts and retinal vessel thrombosis, and signs of systemic conditions, such as hypertension, are frequently revealed. As well as imaging by a skilled clinician during an eye examination, non-ophthalmic clinicians, such as general practitioners, endocrinologists, nurses and trained health workers, can also can carry out diabetic eye screening. This process usually comprises local imaging with remote grading, mostly human grading. However, grading incorporating artificial intelligence is emerging. In a clinical research context, retinal vasculature analyses using semi-automated software in many populations have identified associations between retinal vessel geometry, such as vessel caliber, and the risk of diabetic retinopathy and other chronic complications of type 1 and type 2 diabetes. Similarly, evaluation of corneal nerves by corneal confocal microscopy is revealing diabetes-related abnormalities, and associations with and predictive power for other chronic diabetes complications. As yet, the value of retinal vessel geometry and corneal confocal microscopy measures at an individual level is uncertain. In this article, targeting non-ocular clinicians and researchers, we review existent and emerging ocular imaging and grading tools, including artificial intelligence, and their associations between ocular imaging findings and diabetes and its chronic complications.

A model of culturally-informed integrated diabetes education and eye screening in indigenous primary care services and specialist diabetes clinics: Study protocol

AIMS

To improve diabetes management in Indigenous Australians using an integrated nurse-led model of diabetes education and eye screening in indigenous primary care and specialist diabetes clinics.

DESIGN

A pre-post study.

METHODS

This study will be implemented in indigenous primary care and specialist diabetes clinics in Victoria, Australia. Participants recruited to the study will be existing adult patient with diagnosed diabetes attending study sites. A nurse-credentialled diabetes educator and certified retinal imager will deliver three study components: (a) retinal photography as a diabetic retinopathy screening and patient engagement tool; (b) lifestyle and behaviour surveys, administered at baseline and at the final visit, in 12 months. Findings from the surveys and participants' retinal images will be used to guide; and (c) personalized diabetes education. The primary outcomes are participant adherence to diabetic eye screening recommendations and health service diabetic retinopathy screening coverage. Secondary outcomes are baseline DR prevalence and changes in clinical and lifestyle risk factor levels, diabetes knowledge and satisfaction with diabetes care.

DISCUSSION

Compared with non-indigenous Australians, Indigenous Australians have a high prevalence of diabetic retinopathy and blindness, low adherence to eye screening recommendations and suboptimal health literacy. Nurse-credentialled diabetes educators can be trained to incorporate retinal imaging and eye screening into their clinical practice to give image-based diabetes education to facilitate diabetic retinopathy management.

IMPACT

Credentialled nurse diabetes educators who integrate eye screening and diabetes education can facilitate timelier diabetic retinopathy screening, referral pathways and treatment of sight-threatening retinopathy. We believe that this model of integrated diabetes education and eye screening will also improve adherence to eye screening recommendations, population screening coverage, health literacy, risk factor levels and diabetes self-care.

CLINICAL TRIAL REGISTRATION

ANZCTRN1261800120435.

Screening for diabetic retinopathy and reduced vision among Indigenous Australians in Top End primary care health services: a TEAMSnet sub-study

BACKGROUND

Diabetic retinopathy (DR) prevalence is higher in Indigenous Australians than in other Australians and is a major cause of vision loss. Consequently, timely screening and treatment is paramount, and annual eye screening is recommended for Indigenous Australians.

AIMS

To assess the prevalence of DR, reduced vision and DR treatment coverage among Indigenous Australian adults with diabetes attending Top End indigenous primary care health services.

METHODS

A cross-sectional DR screening study conducted from November 2013 to December 2015 in two very remote Northern Territory Aboriginal primary healthcare services.

RESULTS

In 287 subjects, the prevalence of non-proliferative DR, proliferative DR and clinically significant diabetic macular oedema was 37.3%, 5.4% and 9.0% respectively. Treatment coverage for PDR was 60% (of 10 patients) and for CSMO was 17% (of 23 patients). Vision data were available from 122 participants at one site. The proportion with normal vision, reduced vision, impaired vision and blindness was 31.1%, 52.5%, 15.6% and 0.8% respectively. Overall, ungradable monocular image sets (46%) were associated with poorer quality images and missing protocol images (both P < 0.001). Ungradable images for DR were associated with presence of small pupils/media opacities (P < 0.001). Ungradable images for diabetic macular oedema were associated with poorer image quality (P < 0.001), cataracts (P < 0.001) and small pupils (P = 0.04).

CONCLUSIONS

A high prevalence of DR, CSMO and impaired vision was noted in Indigenous Australians with diabetes. Screening in primary care is feasible, but more effective screening methods are needed.

Visual Outcomes in the Management of Diabetic Maculopathy in Central Australia

PURPOSE

In major urban centres and high-resource settings, treatment of diabetic maculopathy with anti-Vascular Endothelial Growth Factor (VEGF) injections has largely displaced laser treatment. However, intravitreal therapy alone requires frequent follow-up, a barrier to adherence in remote Australia. We report vision outcomes of phased diabetic maculopathy treatment in remote Central Australia for maculopathy using laser and, in a subset, supplementary injection treatment.

METHODS

We audited clinical records of patients undergoing laser treatment for diabetic maculopathy between 2001 and 2013 at an ophthalmology service based at Alice Springs Hospital, a regional hub in remote Australia. All patients receiving macular laser treatment were included, and some required supplementary injection(s). The primary outcome measure was change in best-corrected visual acuity [BCVA] from baseline treatment.

RESULTS

Of 338 maculopathy-treated patients, 88% were indigenous and 39% were male. Of 554 maculopathy laser-treated eyes, 118 (21%) received supplementary injection/s. In the laser treatment phase, median BCVA was 78 letters at baseline (interquartile range 62-80) and decreased by a median of two letters at final visit. In the subset who underwent subsequentinjection treatment, BCVA was 60 letters at first injection, with a median five-letter increase by final visit. Overall outcomes were similar in Indigenous and non-Indigenous Australians. Predictors of reduction in BCVA in the macular laser treatment phase were better baseline BCVA, older age, and PRP treatment (all p < .005).

CONCLUSION

Laser treatment for diabetic maculopathy preserved vision in Central Australia, where barriers to follow-up can preclude regular injections. Supplementary injections stabilized vision in the laser-resistant subset.

Integrating diabetic retinopathy screening within diabetes education services in Australia's diabetes and indigenous primary care clinics

As diabetes occurs in all ethnicities and regions it is essential that retinopathy screening be widely available. Screening rates are lower in Indigenous than in non-Indigenous Australians. Technological advances and Medicare rebates should facilitate improved outcomes. Use of non-ophthalmic clinicians, (general practitioners, diabetes educators, health-workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists would extend retinopathy screening capacity. Diabetes educators are an integral part of diabetes management. Integrating ocular screening and diabetes education in primary care settings has potential to improve synergistically retinopathy screening coverage, patient self-management, risk factor control, care satisfaction, health economics and sustainability of under-resourced services.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project

AIM

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes.

METHODS

We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs.

RESULTS

At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P < 0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P = 0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10 min or more at a time 6.0 days a week and spent 4.8 h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms.

CONCLUSIONS

Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

The SMILES trial: an important first step

The SMILES trial was the first intervention study to test dietary improvement as a treatment strategy for depression. Molendijk et al. propose that expectation bias and difficulties with blinding might account for the large effect size. While we acknowledge the issue of expectation bias in lifestyle intervention trials and indeed discuss this as a key limitation in our paper, we observed a strong correlation between dietary change and change in depression scores, which we argue is consistent with a causal effect and we believe unlikely to be an artefact of inadequate blinding. Since its publication, our results have been largely replicated and our recent economic evaluation of SMILES suggests that the benefits of our approach extend beyond depression. We argue that the SMILES trial should be considered an important, albeit preliminary, first step in the field of nutritional psychiatry research.

The AUStralian MEDiterranean Diet Heart Trial (AUSMED Heart Trial): A randomized clinical trial in secondary prevention of coronary heart disease in a multiethnic Australian population: Study protocol

The Mediterranean diet was first characterized as a heart-protective diet in the 1960s. The significant cardioprotective effects of the Mediterranean diet in comparison to the standard-care low-fat diet have been established in the primary prevention of cardiovascular disease (CVD); however, there is insufficient evidence in secondary prevention research to influence the current standard of care. Opportunity exists to assess the Mediterranean diet as a therapeutic target for secondary CVD prevention within Australia's ethnoculturally diverse communities. The AUSMED Heart Trial is a multisite randomized controlled trial that will evaluate the efficacy of the Mediterranean diet for secondary prevention of CVD in the Australian health care setting. This trial aims to evaluate the effect of a 6-month Mediterranean diet intervention (delivered by dietitians) versus a "standard-care" low-fat diet in reducing the composite incidence of cardiovascular events at 12 months and at trial end in participants with documented evidence of a previous acute myocardial infarction at trial entry. The quality of the diet at baseline and follow-up will be assessed using comprehensive dietary questionnaires and diaries as well as relevant dietary biomarkers (such as urinary polyphenols and erythrocyte fatty acids). Cardiovascular risk markers, including novel measures of immune and inflammatory status, endothelial function, vascular compliance, platelet activity, and body composition, will be collected to explore possible mechanisms for treatment effect. Cost-effectiveness will also be estimated to support policy translation. We plan to recruit 1,032 participants (516 per arm) from cardiology clinics in major Australian hospitals in Melbourne, Adelaide, and Brisbane.

Economic evaluation of a dietary intervention for adults with major depression (the "SMILES" trial)

Background

Recently, the efficacy of dietary improvement as a therapeutic intervention for moderate to severe depression was evaluated in a randomised controlled trial. The SMILES trial demonstrated a significant improvement in Montgomery–Åsberg Depression Rating Scale scores favouring the dietary support group compared with a control group over 12 weeks. We used data collected within the trial to evaluate the cost-effectiveness of this novel intervention.

Methods

In this prospective economic evaluation, sixty-seven adults meeting DSM-IV criteria for a major depressive episode and reporting poor dietary quality were randomised to either seven sessions with a dietitian for dietary support or to an intensity matched social support (befriending) control condition. The primary outcome was Quality Adjusted Life Years (QALYs) as measured by the AQoL-8D, completed at baseline and 12 week follow-up (endpoint) assessment. Costs were evaluated from health sector and societal perspectives. The time required for intervention delivery was costed using hourly wage rates applied to the time in counselling sessions. Food and travel costs were also included in the societal perspective. Data on medications, medical services, workplace absenteeism and presenteesim (paid and unpaid) were collected from study participants using a resource-use questionnaire. Standard Australian unit costs for 2013/2014 were applied. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in average costs between groups divided by the difference in average QALYs. Confidence intervals were calculated using a non-parametric bootstrap procedure.

Results

Compared with the social support condition, average total health sector costs were $856 lower (95% CI -1247 to − 160) and average societal costs were $2591 lower (95% CI -3591 to − 198) for those receiving dietary support. These differences were driven by lower costs arising from fewer allied and other health professional visits and lower costs of unpaid productivity. Significant differences in mean QALYs were not found between groups. However, 68 and 69% of bootstrap iterations showed the dietary support intervention was dominant (additional QALYs at less cost) from the health sector and societal perspectives.

Conclusions

This novel dietary support intervention was found to be likely cost-effective as an adjunctive treatment for depression from both health sector and societal perspectives.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820. Registered on 29 February 2012.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5504-8) contains supplementary material, which is available to authorized users.

Diabetic retinopathy in a remote Indigenous primary healthcare population: a Central Australian diabetic retinopathy screening study in the Telehealth Eye and Associated Medical Services Network project

AIM

To determine diabetic retinopathy prevalence and severity among remote Indigenous Australians.

METHODS

A cross-sectional diabetic retinopathy screening study of Indigenous adults with Type 2 diabetes was conducted by locally trained non-ophthalmic retinal imagers in a remote Aboriginal community-controlled primary healthcare clinic in Central Australia and certified non-ophthalmic graders in a retinal grading centre in Melbourne, Australia. The main outcome measure was prevalence of any diabetic retinopathy and sight-threatening diabetic retinopathy.

RESULTS

Among 301 participants (33% male), gradable image rates were 78.7% (n = 237) for diabetic retinopathy and 83.1% (n = 250) for diabetic macular oedema, and 77.7% (n = 234) were gradable for both diabetic retinopathy and diabetic macular oedema. For the gradable subset, the median (range) age was 48 (19-86) years and known diabetes duration 9.0 (0-24) years. The prevalence of diabetic retinopathy was 47% (n = 110) and for diabetic macular oedema it was 14.4% (n = 36). In the fully gradable imaging studies, sight-threatening diabetic retinopathy prevalence was 16.2% (n = 38): 14.1% (n = 33) for clinically significant macular oedema, 1.3% (n = 3) for proliferative diabetic retinopathy and 0.9% (n = 2) for both. Sight-threatening diabetic retinopathy had been treated in 78% of detected cases.

CONCLUSIONS

A novel telemedicine diabetic retinopathy screening service detected a higher prevalence of 'any' diabetic retinopathy and sight-threatening diabetic retinopathy in a remote primary care setting than reported in earlier surveys among Indigenous and non-Indigenous populations. Whether the observed high prevalence of diabetic retinopathy was attributable to greater detection, increasing diabetic retinopathy prevalence, local factors, or a combination of these requires further investigation and, potentially, specific primary care guidelines for diabetic retinopathy management in remote Australia. Clinical Trials registration number: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404.

Observational study of adherence to a traditional Mediterranean diet, sociocultural characteristics and cardiovascular disease risk factors of older Greek Australians from MEDiterranean ISlands (MEDIS-Australia Study): Protocol and rationale

AIM

To describe the study protocol of the MEDiterranean ISlands-Australia (MEDIS-Australia) Study modelled on the MEDIS Study conducted in Greece. The present study aims to explore adherence to the traditional Mediterranean diet pattern, determine enablers and barriers to adherence, explore the definition of Greek cuisine, and associations between adherence to the diet pattern and risk factors for cardiovascular disease (CVD) and metabolic syndrome in older Greek Australians originally from Greek islands and Cyprus. Now long-term immigrants, with at least 50 years in Australia, characteristics and risk factor profiles of older Greek islander-born Australians will be compared and contrasted to their counterparts living on Greek islands to evaluate the influence of migration on adherence.

METHODS

The present study is an observational study of cross-sectional design using a modified lifestyle and semi-quantitative food frequency questionnaire to capture sociodemographic, health, psychosocial and dietary characteristics, including cuisine, of 150 older Greek islander-born Australians. Anthropometric measures and medical history will be collected. Participants will be aged over 65 years, live independently, are originally from a Greek island and are free from CVD.

RESULTS

Data collection is underway.

CONCLUSIONS

Characteristics and behaviours associated with adherence, if identified, could be evaluated in future studies. For example, exploration of enablers or barriers to adherence to a Mediterranean dietary pattern in an Australian population.

Retinal Vascular Caliber and Kidney Function in Children and Adolescents with Type 1 Diabetes

PURPOSE

To evaluate the relationship between retinal vascular caliber and kidney function in a cohort of Australian children and adolescents with type 1 diabetes.

METHODS

This was a cross-sectional study of 483 children and adolescents with type 1 diabetes, aged 7-18 years. An audit of medical files of participants who attended the Royal Children's Hospital, Melbourne, between January 2009 and March 2014 was performed. Albumin to creatinine ratio (ACR) was acquired through spot urine samples and microalbuminuria was classified as ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males. Retinal vascular caliber was measured using a standardized protocol and later summarized as central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE).

RESULTS

CRAE was significantly narrower in participants with microalbuminuria compared to those with normo-albuminuria in crude analysis (mean ± standard deviation 159.07 ± 9.90µm vs 164.49 ± 12.45 µm; p = 0.006). After adjustment for key confounders and known or potential mediators of microalbuminuria (age, sex, ethnicity, hemoglobin A1c, systolic blood pressure, total cholesterol, body mass index, duration of diabetes and CRVE) the association between narrower CRAE and microalbuminuria was attenuated and was no longer significant (95% confidence interval 0.94-1.02, p = 0.222). No significant associations between CRVE or arteriole-to-venule ratio and microalbuminuria were observed in univariate or multivariate models.

CONCLUSIONS

After adjustment for potential confounding variables, retinal vascular caliber was not significantly associated with microalbuminuria in this sample of children and adolescents with type 1 diabetes. Future prospective longitudinal research is warranted to further evaluate these findings.

Vascular risk factors are associated with retinal arteriolar narrowing and venular widening in children and adolescents with type 1 diabetes

BACKGROUND

The aim of the study was to describe the relationship of retinal arteriolar and venular calibre with vascular risk factors in children and adolescents with type 1 diabetes.

METHODS

In this hospital-based cross-sectional study, the medical files of 483 children and adolescents with type 1 diabetes were audited to collect retinal images and relevant clinical data. Retinal vascular calibre was measured using standardised protocols.

RESULTS

After multivariable adjustments, a vascular risk profile that included: older age, higher serum creatinine, higher systolic blood pressure (SBP), higher body mass index (BMI), abnormal estimated glomerular filtration rate (eGFR), lower high-density lipoproteins (HDL) cholesterol, longer duration of diabetes and higher serum sodium was associated with narrower central retinal artery equivalent (CRAE) (95% CI=-4.10/-0.76, p=0.004). A specific risk profile, including higher total cholesterol level, higher BMI, lower physical activity level, higher HbA1c, higher triglyceride levels, female gender and lower socio-economic status, was associated with wider central retinal vein equivalent (CRVE) (95% CI=1.14/5.62, p=0.003).

CONCLUSIONS

In summary, these findings support evidence that cardiovascular disease may have its origins early in life. Prospective and/or intervention studies are required to confirm whether the observed associations are involved in the causal pathway for retinal vascular calibre.

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial)

BACKGROUND

The possible therapeutic impact of dietary changes on existing mental illness is largely unknown. Using a randomised controlled trial design, we aimed to investigate the efficacy of a dietary improvement program for the treatment of major depressive episodes.

METHODS

'SMILES' was a 12-week, parallel-group, single blind, randomised controlled trial of an adjunctive dietary intervention in the treatment of moderate to severe depression. The intervention consisted of seven individual nutritional consulting sessions delivered by a clinical dietician. The control condition comprised a social support protocol to the same visit schedule and length. Depression symptomatology was the primary endpoint, assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) at 12 weeks. Secondary outcomes included remission and change of symptoms, mood and anxiety. Analyses utilised a likelihood-based mixed-effects model repeated measures (MMRM) approach. The robustness of estimates was investigated through sensitivity analyses.

RESULTS

We assessed 166 individuals for eligibility, of whom 67 were enrolled (diet intervention, n = 33; control, n = 34). Of these, 55 were utilising some form of therapy: 21 were using psychotherapy and pharmacotherapy combined; 9 were using exclusively psychotherapy; and 25 were using only pharmacotherapy. There were 31 in the diet support group and 25 in the social support control group who had complete data at 12 weeks. The dietary support group demonstrated significantly greater improvement between baseline and 12 weeks on the MADRS than the social support control group, t(60.7) = 4.38, p < 0.001, Cohen's d = -1.16. Remission, defined as a MADRS score <10, was achieved for 32.3% (n = 10) and 8.0% (n = 2) of the intervention and control groups, respectively (χ 2 (1) = 4.84, p = 0.028); number needed to treat (NNT) based on remission scores was 4.1 (95% CI of NNT 2.3-27.8). A sensitivity analysis, testing departures from the missing at random (MAR) assumption for dropouts, indicated that the impact of the intervention was robust to violations of MAR assumptions.

CONCLUSIONS

These results indicate that dietary improvement may provide an efficacious and accessible treatment strategy for the management of this highly prevalent mental disorder, the benefits of which could extend to the management of common co-morbidities.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820 . Registered on 29 February 2012.

An evaluation of the telehealth facilitation of diabetes and cardiovascular care in remote Australian Indigenous communities: - protocol for the telehealth eye and associated medical services network [TEAMSnet] project, a pre-post study design

Background

Despite substantial investment in detection, early intervention and evidence-based treatments, current management strategies for diabetes-associated retinopathy and cardiovascular disease are largely based on real-time and face-to-face approaches. There are limited data re telehealth facilitation in type 2 diabetes management. Therefore, we aim to investigate efficacy of telehealth facilitation of diabetes and cardiovascular disease care in high-risk vulnerable Aboriginal and Torres Strait Islanders in remote/very remote Australia.

Methods

Using a pre-post intervention design, 600 Indigenous Australians with type 2 diabetes will be recruited from three primary-care health-services in the Northern Territory. Diabetes status will be based on clinical records. There will be four technological interventions: 1. Baseline retinal imaging [as a real-time patient education/engagement tool and telehealth screening strategy]. 2. A lifestyle survey tool administered at ≈ 6-months. 3. At ≈ 6— and 18-months, an electronic cardiovascular disease and diabetes decision-support tool based on current guidelines in the Standard Treatment Manual of the Central Australian Rural Practitioner’s Association to generate clinical recommendations. 4. Mobile tablet technology developed to enhance participant engagement in self-management. Data will include: Pre-intervention clinical and encounter-history data, baseline retinopathy status, decision-support and survey data/opportunistic mobile tablet encounter data. The primary outcome is increased participant adherence to clinical appointments, a marker of engagement and self-management. A cost-benefit analysis will be performed.

Discussion

Remoteness is a major barrier to provision and uptake of best-practice chronic disease management. Telehealth, beyond videoconferencing of consultations, could facilitate evidence-based management of diabetes and cardiovascular disease in Indigenous Australians and serve as a model for other conditions.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404 was retrospectively registered on 22/03/2016

Prevalence and risk factors for diabetic retinopathy in a hospital-based population of Australian children and adolescents with type 1 diabetes

BACKGROUND

The aim of this study was to investigate the prevalence of, and traditional and emerging risk factors associated with, retinopathy in a hospital-based population of Australian children and adolescents with type 1 diabetes.

METHODS

This was a cross-sectional study of 483 children and adolescents with type 1 diabetes. Medical files were audited to collect all relevant clinical data. Diabetic retinopathy was assessed from colour retinal images by an ophthalmologist.

RESULTS

Diabetic retinopathy was observed in 11 (2.3%) participants. Logistic regression revealed that the principal components analysis derived risk profile of: higher serum creatinine, older age, higher systolic blood pressures, higher body mass index, abnormal estimated glomerular filtration rate (eGFR) (<59 mL/min), lower high density lipoproteins (HDL) cholesterol, higher serum sodium, longer duration of diabetes and narrower retinal arteriolar calibre was associated with diabetic retinopathy (ExpB=2.60, 95% CI 1.36/4.96, p=0.004).

CONCLUSIONS

These results support the concept that the pathogenesis of diabetic retinopathy is likely due to the combined influence of various risk factors, many already identified.

Dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes

PURPOSE

To examine the association between dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes.

METHODS

A hospital-based cross-sectional study of 83 children and adolescents with type 1 diabetes was conducted over an 8-month period. Dietary patterns were extracted using principal components analysis from completed food frequency questionnaires. Retinal vascular calibre was measured by a trained grader using a standardized protocol and later summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) using a semi-automated computer program.

RESULTS

Three major dietary patterns were identified as follows: (1) processed foods, (2) plant-based foods and (3) vegetable/fish avoidance pattern. The processed pattern had high component loadings for processed meats and high fat takeaway foods. The plant-based pattern had high component loadings for a number of fruits including, but not limited to, pineapple, grapes oranges and mangos as well as a smaller number of vegetables, including beans and leeks. The vegetable and fish avoidance pattern had high inverse component loadings for canned and fresh fish as well as a number of vegetables including, but not limited to, pumpkin, green beans, broccoli, sweet potato and cabbage. Adjusted regression analysis revealed the 'vegetable/fish avoidance' dietary pattern was associated with a wider CRVE (ExpB = 3.67, 95% CI = 0.11/7.24, p = 0.039). After multivariable adjustments, a vascular risk profile that included: older age, higher BMI, higher systolic blood pressure, greater gestational age, longer screen viewing time, lower maternal education level, lower physical activity levels and lower high-density lipoproteins concentrations were more likely to display narrower CRAE (ExpB = -2.43, 95% CI = -4.92/0.06, p = 0.041).

CONCLUSIONS

This study provides the first evidence for a diet-calibre relationship in children and adolescents with type 1 diabetes. This outcome has potential public health implications, as promotion of healthy eating patterns in children and adolescents might attenuate changes in microvasculature that have been related to an increased risk of microvascular disease, such as retinopathy, in adulthood. Additional studies are warranted to explore and validate this novel finding.

Physical Activity, Sedentary Behaviors, and Retinal Vascular Caliber in Children and Adolescents With Type 1 Diabetes

PURPOSE

The aim of this study was to investigate associations of physical activity and sedentary behaviors with retinal vascular caliber in children and adolescents with type 1 diabetes.

DESIGN

This was a hospital-based cross-sectional study.

METHODS

A study of 122 children and adolescents with type 1 diabetes was conducted over an 8-month period. Self-reported physical activity time and time spent watching TV or playing computer or video games were obtained using interviewer-administered questionnaires. Retinal vascular caliber was measured by a trained grader using a standardized protocol and later summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) using a semiautomated computer program.

RESULTS

After adjusting for confounders (age, sex, ethnicity, body mass index, systolic blood pressure, HbA1c, maternal smoking status, age at which cow's milk was introduced, and CRVE/CRAE, respectively), narrower CRAE was independently related to more time spent playing computer/video games [ExpB = -3.85; 95% confidence interval (CI), -6.41 to -1.29; P = 0.004], whereas wider CRVE was independently related to lower physical activity level (ExpB = -1.08; 95% CI, -2.01 to -0.15; P = 0.03) and more time spent playing computer/video games (ExpB = 4.72; 95% CI, 0.52-8.92; P = 0.02). Television viewing time was not associated with retinal vascular caliber after adjustment.

CONCLUSIONS

The results of this study suggest that physical activity and sedentary behaviors in the form of "screen viewing time" are associated with retinal vessel caliber early in life. These results suggest that retinal vascular caliber may provide prognostic information beyond current traditional cardiovascular risk factors. Future longitudinal and interventional studies are warranted to evaluate the relevance of these observations.

Diabetes, Diabetic Retinopathy, and Retinal Vascular Alterations: A Systematic Review

The aim of this review is to summarize the available findings from previous research that has focused on retinal vascular caliber characteristics in diabetes and diabetic retinopathy and identify any gaps that exist in the current literature. A systematic Medline, EMBASE, and PubMed search of relevant articles was conducted with coverage up to the 30th of September, 2012. The search was not restricted by language but was limited to studies conducted in humans. The majority of articles conducted on children and adolescents with type 1 diabetes have reported that arterioles with larger caliber were present in the early stages of diabetic retinopathy (n = 5). Only a few studies conducted on older individuals with type 1 diabetes (n = 2) suggest that smaller retinal arteriolar caliber is associated with increased severity of diabetic retinopathy. Much stronger trends have been identified between venular caliber and older individuals with diabetes, with the vast majority of studies reporting that retinal venular dilation represents a later sign of severe diabetic retinopathy (n = 6), with only 1 study highlighting associations with incident diabetes (n = 1). Significant developments have occurred to better understand the relationship between retinal vascular caliber and the onset and progression of diabetes and diabetic retinopathy. Recent evidence suggests that retinal arteriolar dilation may be a possible risk factor in the early development diabetic retinopathy and retinal venules are dilated in persons with severe diabetic retinopathy. Despite this, the clinical significance of these findings requires further evaluation.

A preference based measure of complementary feeding quality: application to the Avon longitudinal study of parents and children

This paper presents the development of the Complementary Feeding Utility Index (CFUI), a composite index aimed to measure adherence to infant feeding guidelines. Through an axiomatic characterization this paper shows the advantages in using the CFUI are the following: it avoids the use of arbitrary cut-offs, and by converting observed diet preferences into utilities, summing the score is meaningful. In addition, as the CFUI is designed to be scored continuously, it allows the transition from intake of beneficial foods (in low quantities) and intake of detrimental foods (in high quantities) to be more subtle. The paper first describes the rationale being the development of the CFUI and then elaborates on the methodology used to develop the CFUI, including the process of selecting the components. The methodology is applied to data collected from the Avon Longitudinal Study of Parents and Children to show the advantages of the CFUI over traditional diet index approaches. Unlike traditional approaches, the distribution of the CFUI does not peak towards mean value but distributes evenly towards the tails of the distribution.

Diet spanning infancy and toddlerhood is associated with child blood pressure at age 7.5 y

BACKGROUND

Diet in the first 2 y of life may be a pivotal period regarding effects on future blood pressure (BP). However, data on early-life diet and BP in childhood are sparse.

OBJECTIVE

We prospectively assessed associations between types of diet spanning infancy and toddlerhood (ie, transition diets across the complementary feeding period) and BP at age 7.5 y.

DESIGN

In a birth cohort study (Avon Longitudinal Study of Parents and Children; United Kingdom), a total of 1229 children had complete dietary intake data at 6, 15, and 24 mo; BP data at 7.5 y of age; and all 18 covariables.

RESULTS

Of the 2 transition diets that were extracted by using principal components analysis, the less-healthy diet was associated with an increase in systolic BP of 0.62 mm Hg (95% CI: 0.00, 1.24 mm Hg) and an increase in diastolic BP of 0.55 mm Hg (95% CI: 0.10, 1.00 mm Hg) for every one-unit (SD) increase in the less-healthy-diet score after adjustment for 15 potential confounders, including maternal characteristics and sociodemographic factors, birth variables, and breastfeeding duration. In contrast with systolic BP, the positive association between the less-healthy transition-diet score and diastolic BP persisted after additional adjustment for child body-size factors [height, body mass index (BMI), and waist circumference] at 7.5 y.

CONCLUSIONS

A less-healthy transition diet by age 2 y was associated with higher BP at 7.5 y. The BMI-related reduction in effect size reinforces the importance of BMI on the diet-BP relation.

A randomised, controlled trial of a dietary intervention for adults with major depression (the "SMILES" trial): study protocol

BACKGROUND

Despite increased investment in its recognition and treatment, depression remains a substantial health and economic burden worldwide. Current treatment strategies generally focus on biological and psychological pathways, largely neglecting the role of lifestyle. There is emerging evidence to suggest that diet and nutrition play an important role in the risk, and the genesis, of depression. However, there are limited data regarding the therapeutic impact of dietary changes on existing mental illness. Using a randomised controlled trial design, we aim to investigate the efficacy and cost-efficacy of a dietary program for the treatment of Major Depressive Episodes (MDE).

METHODS/DESIGN

One hundred and seventy six eligible participants suffering from current MDE are being randomised into a dietary intervention group or a social support group. Depression status is assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (Non Patient Edition) (SCID-I/NP). The intervention consists of 7 individual nutrition consulting sessions (of approximately 60 minutes), delivered by an Accredited Practising Dietitian (APD). Sessions commence within one week of baseline assessment. The intervention focuses on advocating a healthy diet based on the Australian Dietary Guidelines and the Dietary Guidelines for Adults in Greece. The control condition comprises a befriending protocol using the same visit schedule and length as the diet intervention. The study is being conducted at two locations in Victoria, Australia (a metropolitan and regional centre). Data collection occurs at baseline (pre-intervention), 3-months (post-intervention) and 6- months. The primary endpoint is MADRS scores at 3 months. A cost consequences analysis will determine the economic value of the intervention.

DISCUSSION

If efficacious, this program could provide an alternative or adjunct treatment strategy for the management of this highly prevalent mental disorder; the benefits of which could extend to the management of common co-morbidities including cardiovascular disease (CVD), obesity, and type 2 diabetes.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820.

Do dietary trajectories between infancy and toddlerhood influence IQ in childhood and adolescence? Results from a prospective birth cohort study

OBJECTIVE

We examined whether trajectories of dietary patterns from 6 to 24 months of age are associated with intelligence quotient (IQ) in childhood and adolescence.

METHODS

Participants were children enrolled in a prospective UK birth cohort (n = 7,652) who had IQ measured at age 8 and/or 15 years. Dietary patterns were previously extracted from questionnaires when children were aged 6, 15 and 24 months using principal component analysis. Dietary trajectories were generated by combining scores on similar dietary patterns across each age, using multilevel mixed models. Associations between dietary trajectories and IQ were examined in generalized linear models with adjustment for potential confounders.

RESULTS

Four dietary pattern trajectories were constructed from 6 to 24 months of age and were named according to foods that made the strongest contribution to trajectory scores; Healthy (characterised by breastfeeding at 6 months, raw fruit and vegetables, cheese and herbs at 15 and 24 months); Discretionary (biscuits, chocolate, crisps at all ages), Traditional (meat, cooked vegetables and puddings at all ages) and, Ready-to-eat (use of ready-prepared baby foods at 6 and 15 months, biscuits, bread and breakfast cereals at 24 months). In fully-adjusted models, a 1 SD change in the Healthy trajectory was weakly associated with higher IQ at age 8 (1.07 (95%CI 0.17, 1.97)) but not 15 years (0.49 (-0.28, 1.26)). Associations between the Discretionary and Traditional trajectories with IQ at 8 and 15 years were as follows; Discretionary; 8 years -0.35(-1.03, 0.33), 15 years -0.73(-1.33, -0.14) Traditional; 8 years -0.19(-0.71, 0.33)15 years -0.41(-0.77, -0.04)). The Ready-to-eat trajectory had no association with IQ at either age (8 years 0.32(-4.31, 4.95), 15 years 1.11(-3.10, 5.33).

CONCLUSIONS

The Discretionary and Traditional dietary pattern trajectories from 6 to 24 months of age, over the period when food patterns begin to emerge, are weakly associated with IQ in adolescence.

Plasma retinol: a novel marker for cardiovascular disease mortality in Australian adults

BACKGROUND AND AIMS

Vitamin A affects inflammation and immune function and is thus a factor of interest in relation to cardiovascular disease (CVD). As vitamin A circulates in the plasma in the form of retinol, this study aims to describe the relationship between plasma retinol and the 5-year incidence of CVD mortality.

METHODS AND RESULTS

Community-dwelling adults (n = 441, 45% with type 2 diabetes) were recruited in Melbourne, assessed at baseline and followed for 5 years. At baseline, CVD risk factors were assessed by clinical evaluation, by personal lifestyle questionnaire and from biochemistry (plasma fasting glucose, lipids, total homocysteine, C-reactive protein, retinol and carotenoids plus the urinary albumin excretion rate over 24 h.). Dietary intake was assessed by a validated food frequency questionnaire. CVD mortality over 5-years was determined by consulting state or national registries. The majority of participants had adequate plasma retinol concentrations (≥30 μg/dL). The final Cox regression model indicated that those in the highest tertile of plasma retinol (mean ± SD) 76 ± 14 μg/dL) had a significantly lower risk of 5-year CVD mortality (hazard ratio 0.27 [95% confidence interval 0.11, 0.68], P = 0.005), an effect that was not readily explained in terms of traditional CVD risk factors or dietary intake.

CONCLUSION

In well-nourished older Australian adults, plasma retinol was inversely associated with CVD mortality via mechanisms apparently unrelated to established CVD risk factors and dietary intake.

Telemedicine and ocular health in diabetes mellitus

Teleretinal/teleophthalmological programs that use existing health information technology infrastructure solutions for people with diabetes increase access to and adherence to appropriate eye care. Teleophthalmological studies indicate that the single act of patients viewing their own retinal images improves self-management behaviour and clinical outcomes. In some settings this can be done at lower cost and with improved visual outcomes compared with standard eye care. Cost-effective and sustainable teleretinal surveillance for detection of diabetic retinopathy requires a combination of an inexpensive portable device for taking low light-level retinal images without the use of pharmacological dilation of the pupil and a computer-assisted methodology for rapidly detecting and diagnosing diabetic retinopathy. A more holistic telehealth-care paradigm augmented with the use of health information technology, medical devices, mobile phone and mobile health applications and software applications to improve health-care co-ordination, self-care management and education can significantly impact a broad range of health outcomes, including prevention of diabetes-associated visual loss. This approach will require a collaborative, transformational, patient-centred health-care program that integrates data from medical record systems with remote monitoring of data and a longitudinal health record. This includes data associated with social media applications and personal mobile health technology and should support continuous interactions between the patient, health-care team and the patient's social environment. Taken together, this system will deliver contextually and temporally relevant decision support to patients to facilitate their well-being and to reduce the risk of diabetic complications.

An index measuring adherence to complementary feeding guidelines has convergent validity as a measure of infant diet quality

The complementary feeding period is an important stage of child development. The study aim was to develop an index reflecting the degree of adherence to complementary feeding guidelines, evaluate its convergent validity, and explore associations with socio-demographic factors and dietary pattern scores in childhood. Data were analyzed from the Avon Longitudinal Study of Parents and Children (n = 6065) using parent-completed dietary questionnaires at 6 mo of age, socio-demographic information, and dietary patterns derived by principal component analysis at age 3 y. The Complementary Feeding Utility Index (CFUI) consists of 14 components: breastfeeding duration, feeding to appetite, timing of introduction to solids, exposure to iron-rich cereals, fruit and vegetable intake, exposure to high-fat/-salt/-sugar foods including sugary drinks, food texture, and meal/snack frequency. Regression analyses were undertaken to investigate associations between index scores, socio-demographic factors, food and nutrient intakes, and dietary pattern scores at age 3 y. Milk and food intake at 6 mo and nutrient intake at 8 mo of age varied across quintiles of index score in largely the expected directions. Associations were found among index score, maternal age, education, social class, maternal smoking history, and prepregnancy BMI. After adjustment for socio-demographic factors, the index score was associated with "processed" [β = -0.234 (95% CI = -0.260, -0.209)] and "healthy" [β = 0.185 (95% CI = 0.155, 0.215)] dietary pattern scores at age 3 y. The CFUI is able to discriminate across food intake, nutrient intake, and socio-demographic factors and is associated with later dietary patterns.

Characterization of transition diets spanning infancy and toddlerhood: a novel, multiple-time-point application of principal components analysis

BACKGROUND

The portrayal of diet over time is a natural progression from the characterization of diet at single time points. The transition dietary period, a dynamic period of rapid dietary change spanning infancy and toddlerhood when children shift from a milk-based to a food-based diet, has not been characterized.

OBJECTIVE

The objective was to summarize variation in dietary intakes spanning infancy and toddlerhood.

DESIGN

A prospective principal components analysis was applied to dietary intakes from 3 successive follow-ups of children enrolled in the ALSPAC (Avon Longitudinal Study of Parents and Children). The frequency of food and beverage consumption was assessed via questionnaire at ages 6, 15, and 24 mo (n = 2169).

RESULTS

Two types of transition diet were identified. The first transition diet was characterized by the consumption of home-prepared and raw foods ("healthy") at all time points and the second by ready-prepared and discretionary foods ("less healthy") consistently over time. Higher educational level and maternal age were associated with higher scores on the "healthy" diet, whereas younger maternal age and a lower educational level were associated with higher scores on the "less healthy" diet. Maternal BMI, number of older siblings, and lower social class were associated with the less-healthy transition diet but not with the healthy transition diet.

CONCLUSIONS

Unique transition diets, including a less-healthy type, emerge by age 2 y. These diets are consistent with childhood and adult dietary patterns reported at single time points and show convergent validity both with known maternal sociodemographic predictors of childhood diet and with intake gradients across diet scores.

Characterizing whole diets of young children from developed countries and the association between diet and health: a systematic review

Early childhood is an important nutritional period that involves the transition from a milk-based diet to ordinary foods. A systematic review was conducted of studies that applied whole-of-diet analysis of children aged 1-5 years to examine associations between diet and nutrition, health, and development. Literature searches identified 40 articles using dietary indices, principal component analysis, or cluster analysis. Reports that applied indices (n = 23, 18 indices) were cross-sectional, and most measured diet quality or variety. Articles reporting principal component or cluster analyses (n =17) described between two and six dietary patterns, and most identified healthy, unhealthy, and traditional patterns. In cross-sectional analyses, mixed associations were found between index or pattern scores and nutrient intake (n = 10), nutritional biomarkers (n = 1), and anthropometry (n = 10). Five reports from two birth cohorts showed healthier dietary patterns were associated with better lean mass, cognition, and behavior, but not with bone mass or body mass index at later ages. Few studies have characterized the diets of children under 5 years of age and linked diet with health. Given the limited evidence, research establishing the predictive validity of whole-of-diet methods in childhood is needed.

Can the Mediterranean diet lower HbA1c in type 2 diabetes? Results from a randomized cross-over study

BACKGROUND AND AIMS

To investigate the impact of a diet modeled on the traditional Cretan Mediterranean diet on metabolic control and vascular risk in type 2 diabetes.

METHODS AND RESULTS

Twenty-seven subjects (47-77 yrs) with type 2 diabetes were randomly assigned to consume either the intervention diet ad libitum or their usual diet for 12 weeks and then cross over to the alternate diet. Most of the meals and staple foods for the intervention diet were provided. Lipids, glycemic variables, blood pressure, homocysteine, C-reactive protein, plasma carotenoids and body composition (anthropometry and dual energy X-ray absorptiometry) were assessed at baseline, and at the end of both diet periods. Dietary adherence was monitored using plasma carotenoid and fatty acid (FA) analysis, complemented by diet diaries. Compared with usual diet, on the ad libitum Mediterranean intervention diet glycosylated haemoglobin fell from 7.1% (95% CI: 6.5-7.7) to 6.8% (95% CI: 6.3-7.3) (p=0.012) and diet quality improved significantly [plant:animal (g/day) food ratio increased from 1.3 (95% CI: 1.1-1.5) to 5.4 (95% CI: 4.3-6.6) (p<0.001)], plasma lycopene and lutein/zeaxanthin increased (36% and 25%, respectively), plasma saturated and trans FAs decreased, and monounsaturated FAs increased.

CONCLUSION

A traditional moderate-fat Mediterranean diet improves glycemic control and diet quality in men and women with well-controlled type 2 diabetes, without adverse effects on weight.

Is risk of diabetic retinopathy lower in Australia's Greek-born migrants?

AIM

The standardized cardiovascular disease death rate for the Greek population in Crete has increased since the 1960s, unlike the all-cause and cardiovascular disease death rate for Australia's Greek migrant population, which has remained paradoxically low. A small window of opportunity remains in which the vascular profile of this interesting atypical migrant population can be characterized. This study assessed whether ethnicity modulates the risk of diabetic retinopathy in Greek-born migrants to Australia.

METHODS

The study design was a community-based cross-sectional study of diabetic retinopathy in 107 Greek-born and Australian-born men with Type 2 diabetes, aged 44-83 years. Diabetic retinopathy was assessed by mydriatic three-field retinal photography.

RESULTS

Prevalence of diabetic retinopathy was lower in Greek-born than in Australian-born participants (22 and 37%, respectively). Despite having a higher mean systolic blood pressure level (148 vs. 137 mmHg), Greek-born men had a significantly lower risk of diabetic retinopathy than Australian-born men, after adjusting for age, duration of diabetes, glycated haemoglobin, systolic blood pressure, diastolic blood pressure, albumin to creatinine ratio, and total cholesterol and triglyceride levels [odds ratio 0.32 (0.10-0.99); r(2) = 0.41, P = 0.047].

CONCLUSION

Greek ethnicity may confer some protection against diabetic retinopathy to Australia's Greek-born migrants, an effect not explained by established risk factors for diabetic retinopathy. A small window of opportunity remains in which to elucidate the ethnicity-related exposures that modulate vascular risk in this older migrant population.

Plasminogen activator inhibitor-1 (PAI-1) activity and retinal vascular calibre in type 2 diabetes

OBJECTIVE

To describe relationships of retinal vascular calibre with plasminogen activator inhibitor-1 (PAI-1) and other cardiovascular risk factors in people with type 2 diabetes.

METHODS

We recruited 112 community-based persons aged 44-83years with type 2 diabetes, photo-documented retinal status using a digital fundus camera, and measured traditional and novel vascular risk factors. Retinal arteriolar and venular calibre and the arterio-venous ratio (AVR) were determined from fundus photographs using a validated computer-assisted method.

RESULTS

In adjusted linear regression models, PAI-1 activity was strongly associated with all measures of retinal vascular calibre: positively with arterioles (p=0.005) and AVR (p=0.001), and inversely with venules (p=0.001). In addition, wider arterioles were independently associated with waist-hip ratio (p<0.0001), HDL-C (p=0.015), and lower systolic blood pressure (p=0.042), whereas narrower venules were associated with older age and a higher albumin excretion rate. Neither arteriolar nor venular calibre was associated with plasma total homocysteine or C-reactive protein concentration.

CONCLUSION

Retinal vascular calibre is independently associated with PAI-1 activity in type 2 diabetes. This finding supports a role for PAI-1 activity in the microvasculature of persons with type 2 diabetes and may explain the link between retinal vascular calibre and cardiovascular disease.