Measures of Retention in HIV Care: A Study Within a Review

People living with HIV (PLHIV) need lifelong medical care. However, retention in HIV care is not measured uniformly, making it challenging to compare or pool data. The objective of this study within a review (SWAR) is to describe the assortment of definitions used for retention in HIV care in randomized controlled trials (RCTs). We conducted a SWAR, drawing data from an overview of systematic reviews on interventions to improve the HIV care cascade. Ethics review was not required for this analysis of secondary data. We identified RCTs of interventions used to improve retention in care for PLHIV, including all age groups and extracted the definitions used and their characteristics. We identified 50 trials that measured retention published between 2007 and 2021 and provided 59 definitions for retention in care. The definitions consisted of nine different characteristics with follow-up time (n = 47), and clinical visits (n = 36) most used. The definitions of retention in HIV care are highly heterogeneous. In this study, we present the pros and cons of characteristics used to measure retention in HIV care.

Body mass index trajectories and their predictors in undergraduate students from Canada: Results from the GENEiUS study

Objective: To explore the patterns and predictors of body mass index (BMI) change among undergraduate students from Ontario (Canada). Participants: 68 undergraduate students were followed longitudinally for 3 years with anthropometric data collected bi-annually. Methods: BMI measurements were plotted to generate individual BMI trajectory curves, which were categorized, based on the observed trajectory pattern. Within and between group comparisons of BMI were conducted via nonparametric paired tests. The association of baseline BMI, sex, and ethnicity with BMI trajectory type was assessed using multinomial logistic regression. Results: Four BMI trajectory types were observed: "stable weight" (n = 15, 22.1%), "weight gain" (n = 30, 44.1%), "weight loss" (n = 12, 17.6%), and "weight cycling" (n = 11, 16.2%) trajectories. Higher baseline BMI was significantly associated with the "weight gain," "weight loss," and the "weight cycling" trajectories as compared to the "stable weight" trajectory type. Conclusions: Our findings demonstrate an association between high baseline BMI and "nonstable" subsequent BMI change patterns among Canadian students.

Causal language use in systematic reviews of observational studies is often inconsistent with intent: A systematic survey

OBJECTIVE

We systematically evaluated causal language use in systematic reviews of observational studies and explored the relation between language use and the intent of the investigation.

STUDY DESIGN AND SETTING

We searched Embase, Medline, and Epistemonikos. We randomly selected 199 reviews published in 2019, stratified in a 1:1 ratio by use and non-use of the GRADE approach to rating quality of evidence.

RESULTS

Of 199 reviews of observational studies 56.8% had causal intent. Reviews with causal intent were more likely to investigate therapeutic clinical intervention (33.6% vs 12.8%). While 78.8% of those with causal intent used causal language in one or more sections of the title, abstract, or main text, only 4.4% consistently used causal language throughout the manuscript, and 21.2% did not use causal language at all. Of reviews without causal intent, 51.2% used causal language somewhere in the manuscript.

CONCLUSION

Systematic reviews of observational studies sometimes do and sometimes do not have causal intent. Both those are inconsistent in causal language use and often use language inconsistent with the intent. Journal policies would better serve clarity of thinking and appropriateness of inferences by demanding authors clearly specify their intent and consistently use language consistent with that intent.

Assessments of risk of bias in systematic reviews of observational nutritional epidemiologic studies are often not appropriate or comprehensive: a methodological study

BACKGROUND

An essential component of systematic reviews is the assessment of risk of bias. To date, there has been no investigation of how reviews of non-randomised studies of nutritional exposures (called 'nutritional epidemiologic studies') assess risk of bias.

OBJECTIVE

To describe methods for the assessment of risk of bias in reviews of nutritional epidemiologic studies.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews (Jan 2018-Aug 2019) and sampled 150 systematic reviews of nutritional epidemiologic studies.

RESULTS

Most reviews (n=131/150; 87.3%) attempted to assess risk of bias. Commonly used tools neglected to address all important sources of bias, such as selective reporting (n=25/28; 89.3%), and frequently included constructs unrelated to risk of bias, such as reporting (n=14/28; 50.0%). Most reviews (n=66/101; 65.3%) did not incorporate risk of bias in the synthesis. While more than half of reviews considered biases due to confounding and misclassification of the exposure in their interpretation of findings, other biases, such as selective reporting, were rarely considered (n=1/150; 0.7%).

CONCLUSION

Reviews of nutritional epidemiologic studies have important limitations in their assessment of risk of bias.

Characteristics and quality of systematic reviews and meta-analyses of observational nutritional epidemiology: a cross-sectional study

BACKGROUND

Dietary recommendations and policies should be guided by rigorous systematic reviews. Reviews that are of poor methodological quality may be ineffective or misleading. Most of the evidence in nutrition comes from nonrandomized studies of nutritional exposures (usually referred to as nutritional epidemiology studies), but to date methodological evaluations of the quality of systematic reviews of such studies have been sparse and inconsistent.

OBJECTIVES

We aimed to investigate the quality of recently published systematic reviews and meta-analyses of nutritional epidemiology studies and to propose guidance addressing major limitations.

METHODS

We searched MEDLINE (January 2018-August 2019), EMBASE (January 2018-August 2019), and the Cochrane Database of Systematic Reviews (January 2018-February 2019) for systematic reviews of nutritional epidemiology studies. We included a random sample of 150 reviews.

RESULTS

Most reviews were published by authors from Asia (n = 49; 32.7%) or Europe (n = 43; 28.7%) and investigated foods or beverages (n = 60; 40.0%) and cancer morbidity and mortality (n = 54; 36%). Reviews often had important limitations: less than one-quarter (n = 30; 20.0%) reported preregistration of a protocol and almost one-third (n = 42; 28.0%) did not report a replicable search strategy. Suboptimal practices and errors in the synthesis of results were common: one-quarter of meta-analyses (n = 30; 26.1%) selected the meta-analytic model based on statistical indicators of heterogeneity and almost half of meta-analyses (n = 50; 43.5%) did not consider dose-response associations even when it was appropriate to do so. Only 16 (10.7%) reviews used an established system to evaluate the certainty of evidence.

CONCLUSIONS

Systematic reviews of nutritional epidemiology studies often have serious limitations. Authors can improve future reviews by involving statisticians, methodologists, and researchers with substantive knowledge in the specific area of nutrition being studied and using a rigorous and transparent system to evaluate the certainty of evidence.

Effect of sex/gender on obesity traits in Canadian first year university students: The GENEiUS study

BACKGROUND

While weight gain during first year of university has been well documented in North America, literature on sex-specific effects is scarce and inconsistent. The objective of this investigation was to explore sex-specific changes in obesity traits during first year of university at McMaster University (Ontario, Canada).

METHODS

245 first-year students (80.4% females) were followed longitudinally with data collected early in the academic year and towards the end of the year. Obesity parameters including weight, waist and hip circumferences, BMI, and waist to hip ratio were investigated. The Mann-Whitney U test and the Wilcoxon signed-rank test were used for pairwise comparison of traits in the absence of adjustments. Additionally, the repeated-measures ANOVA test was used with covariate adjustments to investigate the interaction between sex and time.

RESULTS

Overall sample trends indicated a significant increase in mean weight by 1.55 kg (95% CI: 1.24-1.86) over the school year (p<0.001). This was accompanied by significant gains in BMI, and waist and hip circumferences (p<0.001) in the overall sample. At baseline, males presented with higher body weight, BMI, waist and hip circumferences, and WHR, as compared to their females counterparts (p<0.01). Additionally, sex-stratified analysis indicated significant gains in weight, BMI, and waist and hip circumferences in both males and females (p<0.01). However, a comparison of the magnitude of change over time between the two sex groups revealed no significant difference for any of the investigated traits (p>0.05).

CONCLUSION

While our study confirms significant weight gain in both male and female first year university students in Ontario, Canada, it does not show sex specific differences within this context. Our investigation highlights the importance of accounting for sex and gender in health research and supports the need of further studies in this area.

The effect of race/ethnicity on obesity traits in first year university students from Canada: The GENEiUS study

Background

Little is known about the impact of race/ethnicity on weight change at university. The objective of this study is to determine if ethnicity has an impact on obesity traits in a multiethnic cohort of first-year students at McMaster University in Ontario, Canada.

Methods

183 first year students from the three most represented ethnic groups (South Asian, East Asian, and white-Caucasian) in our study sample were followed longitudinally with data collected early in the academic year and towards the end of the year. Obesity parameters including body weight, body mass index (BMI), waist and hip circumference, and waist hip ratio (WHR) were analyzed. The Wilcoxon signed-rank test was used for pairwise comparison of traits from the beginning to the end of the year in the absence of adjustments. Linear regression was used with covariate adjustments to investigate the effect of ethnicity on obesity traits.

Results

A significant increase in weight by 1.49 kg (95%CI: 1.13–1.85) was observed over the academic year in the overall analyzed sample. This was accompanied by significant gains in BMI, waist and hip circumferences, and WHR. Ethnicity stratified analysis indicated significant increase in all investigated obesity traits in East Asians and all traits, but WHR, in South Asians. White-Caucasians only displayed significant increases in weight and BMI. Body weight and hip circumference were significantly lower in East Asians compared to white-Caucasians at baseline. However, East Asians displayed a significantly larger increase in mean BMI and weight compared to white-Caucasians after first-year. South Asians displayed larger waist circumference at baseline compared to East Asians and larger WHR compared to white-Caucasians.

Conclusion

Our findings demonstrate that ethnicity has an impact on obesity traits in first-year university students. Universities should take ethnicity into account while implementing effective obesity prevention programs to promote healthy and active lifestyles for students.

Identifying factors associated with obesity traits in undergraduate students: a scoping review

OBJECTIVES

This scoping review identifies factors associated with obesity traits including body mass index, weight, and body fat percentage in undergraduate students.

METHODS

We searched CINAHL, EMBASE, MEDLINE, and PsycINFO for original studies of undergraduate students where an obesity trait was associated with a risk factor.

RESULTS

Two-hundred sixty-eight articles were included comprising of 251 studies: 186 cross-sectional, 50 cohort, 11 interventional, and 4 qualitative. We extracted data on risk/protective factors, obesity traits, and the direction of effect between them. We identified a variety of factors including age, sex, ethnicity, socioeconomic status, religion, diet, eating habits, physical activity, sedentary activity, sleep, stress, university campus life, alcohol use, smoking, psychiatric disorders, body image, eating attitude, eating regulation, personality, sociocultural influences, and genetics. The majority of associations were cross-sectional. For longitudinal findings, usually only one study investigated each trait.

CONCLUSIONS

This review identifies a need for higher quality evidence to support results from cross-sectional studies and replication of findings of longitudinal studies. This review identifies gaps in the literature, generates hypotheses, guides researchers to plan future studies, and helps decision-makers design obesity-prevention programs in universities.

Pangenotypic direct acting antivirals for the treatment of chronic hepatitis C virus infection: A systematic literature review and meta-analysis

BACKGROUND

Recent approval and adoption of pangenotypic direct acting antivirals (DAAs) necessitated a revision of the 2015 World Health Organization guidelines for the management of persons with hepatitis C virus (HCV) infection.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and relevant conference proceedings to identify randomized and non-randomized trials, as well as prospective observational studies of DAAs. The proportions of persons with events were pooled for sustained virological response at 12 weeks post-treatment (SVR12), discontinuations due to adverse events (DAEs), serious adverse events (SAEs), and all-cause mortality. Analyses were stratified by HCV genotype and antiviral treatment experience, with subgroup analyses based on presence of cirrhosis and HIV-HCV coinfection.

FINDINGS

The evidence base consisted of 238 publications describing 142 studies. In the overall analysis, which included all persons irrespective of treatment experience or comorbidities, the pooled proportion achieving SVR12 exceeded 0.94 for all pangenotypic regimens across genotypes 1, 2, and 4. Some heterogeneity may have led to lower SVR rates in persons with genotype 3 infection. High SVR12 (>0.90) was observed in persons with genotype 1 infection with cirrhosis, though evidence varied and was limited for genotypes 2-4. Evidence was sparse for persons with HIV-HCV coinfection. All regimens were associated with small proportions of persons with DAEs, SAEs, or all-cause mortality.

INTERPRETATION

Based on this and other supporting evidence, the WHO issued updated guidelines with a conditional recommendation, based on moderate quality evidence, for the use of pangenotypic DAA regimens for persons with chronic HCV infection aged 18 years and older (July 2018).

FUNDING

This study was funded by the World Health Organization.

Methods for the Selection of Covariates in Nutritional Epidemiology Studies: A Meta-Epidemiological Review

BACKGROUND

Observational studies provide important information about the effects of exposures that cannot be easily studied in clinical trials, such as nutritional exposures, but are subject to confounding. Investigators adjust for confounders by entering them as covariates in analytic models.

OBJECTIVE

The aim of this study was to evaluate the reporting and credibility of methods for selection of covariates in nutritional epidemiology studies.

METHODS

We sampled 150 nutritional epidemiology studies published in 2007/2008 and 2017/2018 from the top 5 high-impact nutrition and medical journals and extracted information on methods for selection of covariates.

RESULTS

Most studies did not report selecting covariates a priori (94.0%) or criteria for selection of covariates (63.3%). There was general inconsistency in choice of covariates, even among studies investigating similar questions. One-third of studies did not acknowledge potential for residual confounding in their discussion.

CONCLUSION

Studies often do not report methods for selection of covariates, follow available guidance for selection of covariates, nor discuss potential for residual confounding.

Structured diet and exercise guidance in pregnancy to improve health in women and their offspring: study protocol for the Be Healthy in Pregnancy (BHIP) randomized controlled trial

BACKGROUND

Evidence from epidemiological and animal studies support the concept of programming fetal, neonatal, and adult health in response to in utero exposures such as maternal obesity and lifestyle variables. Excess gestational weight gain (GWG), maternal physical activity, and sub-optimal and excess nutrition during pregnancy may program the offspring's risk of obesity. Maternal intake of dairy foods rich in high-quality proteins, calcium, and vitamin D may influence later bone health status. Current clinical practice guidelines for managing GWG are not founded on randomized trials and lack specific "active intervention ingredients." The Be Healthy in Pregnancy (BHIP) study is a randomized controlled trial (RCT) designed to test the effectiveness of a novel structured and monitored Nutrition + Exercise intervention in pregnant women of all pre-pregnancy weight categories (except extreme obesity), delivered through prenatal care in community settings (rather than in hospital settings), on the likelihood of women achieving recommended GWG and a benefit to bone status of offspring and mother at birth and six months postpartum.

METHODS

The BHIP study is a two-site RCT that will recruit up to 242 participants aged > 18 years at 12-17 weeks of gestation. After baseline measures, participants are randomized to either a structured and monitored Nutrition + Exercise (intervention) or usual care (control) program for the duration of their pregnancy. The primary outcome of the study is the percent of women who achieve GWG within the Institute of Medicine (IOM) guidelines. The secondary outcomes include: (1) maternal bone status via blood bone biomarkers during pregnancy; (2) infant bone status in cord blood; (3) mother and infant bone status measured by dual-energy absorptiometry scanning (DXA scan) at six months postpartum; (4) other measures including maternal blood pressure, blood glucose and lipid profiles, % body fat, and postpartum weight retention; and (5) infant weight z-scores and fat mass at six months of age.

DISCUSSION

If effective, this RCT will generate high-quality evidence to refine the nutrition guidelines during pregnancy to improve the likelihood of women achieving recommended GWG. It will also demonstrate the importance of early nutrition on bone health in the offspring.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01689961 Registered on 21 September 2012.

Rationale and design of GENEiUS: a prospective observational study on the genetic and environmental determinants of body mass index evolution in Canadian undergraduate students

INTRODUCTION

Obesity is a global epidemic and is a risk factor for developing other comorbidities. Young adulthood is a critical period for body weight change and establishing healthy lifestyle behaviours. The 'Freshman 15' suggests that undergraduate students gain 15 lbs (6.8 kg) during their first year of university, although evidence estimates a more modest weight gain of approximately 3-5 lbs (1.4-2.3 kg). Previous studies have only investigated weight change in the first year and do not study potential risk factors. Genetic and EnviroNmental Effects on weight in University Students (GENEiUS) is a prospective observational study which will investigate the environmental and biological determinants of weight change in undergraduate students over 4 years.

METHODS AND ANALYSIS

The GENEiUS study will recruit 2500 multiethnic undergraduates aged 17-25 years at McMaster University at the start of their first year and will follow them every 6 months for 4 years. Primary outcomes are obesity traits: body mass index, waist circumference, waist-to-hip ratio, body fat mass and body fat percentage. The contribution of well-established and novel genetic variants for obesity traits and heritability values will be derived from whole-genome single-nucleotide polymorphism genotyping arrays. Civil status, age, sex, ethnicity, length of residence in Canada, religiosity, energy intake, physical activity, exercise motivation, electronic screen time, sleep patterns, history of assault, smoking status, alcohol consumption, medication and drug use, stress, impulsivity, body image perception, self-esteem, anxiety, eating disorders and depression will be investigated for their effect on obesity traits. The findings of the GENEiUS study will be used to help design obesity prevention programme in North American universities with multiethnic populations.

ETHICS AND DISSEMINATION

Ethical approval of the study protocol has been obtained from the Hamilton Integrated Research Ethics Board. Study results will be disseminated through scientific publications, scholarly meetings, and collaborative meetings with university administration and student groups.