Chronic Disease Epidemics Research Articles

International prevalence patterns of low eGFR in adults aged 18-60 without traditional risk factors from population-based cross-sectional studies: a disadvantaged populations eGFR epidemiology (DEGREE) study.

In recent decades there have been reports of epidemics of chronic kidney disease (CKD) killing young men in Central America and South Asia. These cases do not involve the commonly known causes of CKD such as diabetes, so they are known as CKD of unknown cause (CKDu). To understand the size and extent of the problem around the world, we included data from studies that measured kidney function from 43 areas across 14 countries (60 964 people). We calculated the prevalence of poor kidney function in working-age men and women in urban and rural areas, in those without indicators of the commonly known causes of CKD. The most affected groups were rural men in Uddanam, India (14%), and Northwest Nicaragua (14%). Low prevalence (<2%) was seen in included areas outside of Central America and South Asia. These findings are important to direct future research, give clues to the possible causes of CKDu, and as a starting point for global monitoring.

Screening Charity Recipients: Health Philanthropy, Medical Diagnosis, and Kidney Disease Prevention in Sri Lanka

Over the last several decades, epidemics of chronic kidney disease of unknown aetiology (CKDu) have appeared in Mesoamerica, North Africa, and South Asia. Drawing on 14 months of ethnographic fieldwork in a CKDu-affected village in Sri Lanka, I explore how one CKDu ‘hotspot’ came into being following population screening interventions by a community development organisation, a philanthropic foundation, and a university research group. While the production of test results proved vital to the mobilisation of further research and public health resources for the community, this ethnography reveals philanthropy could be seen to have shaped by screening as much as screening was seen to have influenced by philanthropy. The example of medical screening and philanthropic interventions in Ginnoruwa illustrates how bioindicators of failing kidney function became a key metric for demarcating the community into populations of the deserving (or not so deserving) poorly, which in turn helped to create the pattern of disease prevalence and concentration that led to the community being designated a ‘hotspot’. In Ginnoruwa, philanthropy and screening did not operate independently but constituted a novel hybrid, which I refer to as ‘philanthropic science’.

Sugarcane ash and sugarcane ash-derived silica nanoparticles alter cellular metabolism in human proximal tubular kidney cells

Multiple epidemics of chronic kidney disease of an unknown etiology (CKDu) have emerged in agricultural communities around the world. Many factors have been posited as potential contributors, but a primary cause has yet to be identified and the disease is considered likely multifactorial. Sugarcane workers are largely impacted by disease leading to the hypothesis that exposure to sugarcane ash produced during the burning and harvest of sugarcane could contribute to CKDu. Estimated exposure levels of particles under 10 μm (PM10) have been found to be exceptionally high during this process, exceeding 100 μg/m3 during sugarcane cutting and averaging ∼1800 μg/m3 during pre-harvest burns. Sugarcane stalks consist of ∼80% amorphous silica and generate nano-sized silica particles (∼200 nm) following burning. A human proximal convoluted tubule (PCT) cell line was subjected to treatments ranging in concentration from 0.025 μg/mL to 25 μg/mL of sugarcane ash, desilicated sugarcane ash, sugarcane ash-derived silica nanoparticles (SAD SiNPs) or manufactured pristine 200 nm silica nanoparticles. The combination of heat stress and sugarcane ash exposure on PCT cell responses was also assessed. Following 6–48 h of exposure, mitochondrial activity and viability were found to be significantly reduced when exposed to SAD SiNPs at concentrations 2.5 μg/mL or higher. Oxygen consumption rate (OCR) and pH changes suggested significant alteration to cellular metabolism across treatments as early as 6 h following exposure. SAD SiNPs were found to inhibit mitochondrial function, reduce ATP generation, increase reliance on glycolysis, and reduce glycolytic reserve. Metabolomic analysis revealed several cellular energetics pathways (e.g., fatty acid metabolism, glycolysis, and TCA cycle) are significantly altered across ash-based treatments. Heat stress did not influence these responses. Such changes indicate that exposure to sugarcane ash and its derivatives can promote mitochondrial dysfunction and disrupt metabolic activity of human PCT cells.

A chikungunya virus-like particle vaccine induces broadly neutralizing and protective antibodies against alphaviruses in humans.

Chikungunya virus (CHIKV) is a mosquito-transmitted alphavirus that causes epidemics of acute and chronic musculoskeletal disease. Here, we analyzed the human B cell response to a CHIKV-like particle-adjuvanted vaccine (PXVX0317) from samples obtained from a phase 2 clinical trial in humans (NCT03483961). Immunization with PXVX0317 induced high levels of neutralizing antibody in serum against CHIKV and circulating antigen-specific B cells up to 6 months after immunization. Monoclonal antibodies (mAbs) generated from peripheral blood B cells of three PXVX0317-vaccinated individuals on day 57 after immunization potently neutralized CHIKV infection, and a subset of these inhibited multiple related arthritogenic alphaviruses. Epitope mapping and cryo-electron microscopy defined two broadly neutralizing mAbs that uniquely bind to the apex of the B domain of the E2 glycoprotein. These results demonstrate the inhibitory breadth and activity of the human B cell response induced by the PXVX0317 vaccine against CHIKV and potentially other related alphaviruses.

66 Sugarcane Ash and Sugarcane Ash-Derived Silica Nanoparticles Alter Mitochondrial Function and Metabolic Activity in Human Proximal Tubular Kidney Cells

Abstract Multiple epidemics of chronic kidney disease of an unknown etiology (CKDu), primarily in young healthy agricultural workers, have emerged in agricultural communities around the world. We have hypothesized that the harvest and burning of sugarcane leading to inhalation of sugarcane ash may contribute to development of CKDu. Sugarcane stalks consist of ~80% amorphous silica and we have demonstrated that following burning of sugarcane, nano-sized silica particles (~200nm) are generated. To determine what effect such exposures have on kidney cells, a human proximal convoluted tubule (PCT) cell line (HK-2) was subjected to treatments ranging in concentration from 0.025µg/mL to 25µg/mL of sugarcane ash, desilicated sugarcane ash, sugarcane ash-derived silica nanoparticles (SAD SiNPs), or manufactured pristine 200nm silica nanoparticles. Following 6 to 48 hours of exposure, mitochondrial activity and viability were found to be significantly reduced when exposed to SAD particles at concentrations 2.5µg/mL or higher. Oxygen consumption rate (OCR) and pH were investigated with a Seahorse XF Analyzer, revealing significant changes to cellular metabolism across treatments as early as 6 hours following exposure. While most treatments slightly increased respiration, SAD SiNPs were found to inhibit mitochondrial function, reduce ATP generation, increase reliance on glycolysis, and reduce glycolytic reserve. Metabolomic analysis following 24 hours of exposure found several cellular energetics pathways (e.g., fatty acid metabolism, glycolysis, and TCA cycle) significantly altered across ash-based treatments. Such changes indicate that exposure to sugarcane ash and its derivatives can promote mitochondrial dysfunction and disrupt metabolic activity of human PCT cells.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis.

Asthma, rhinitis, and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease," coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitization and multimorbidity, (iii) advances in mHealth for novel phenotype definitions, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches, and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut, and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis." This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis, and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitization patterns (mono- or pauci-sensitization versus polysensitization), (iii) severity of symptoms, and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and autoimmune diseases.

Abundance and absence: Human-microbial co-evolution in the Anthropocene

Human-microbe relations have undergone a profound shift over the past 100 years. The discovery of antibiotics, increasing levels of pollution, and urban and agricultural intensification have led to the proliferation and diversification of novel resistance genes and microorganisms. This abundance has unfolded against a backdrop of microbial absence that is the other side of the antimicrobial coin; reductions in the quantity and diversity of human-microbe interactions are now registering as epidemics of chronic non-communicable diseases in urban populations. Building from this paradoxical situation of ‘abundance’ and ‘absence’, this article reviews the molecular-genetic, macroscale-infrastructural, and community-ecological aspects of microbial evolution at a time when human actions are a critical force in shaping their directions.

Comprehensive health assessment of geriatric population: Findings of innovative 60 plus project from a tertiary medical institute in South India

Background: With a rapid increase of more than 7.7% of India’s population being more than 60 years old, India has been designated as “an aging nation”. Advancing through the process of transition in demography, there have been rising epidemics of chronic non-communicable diseases among the elderly in developing countries, especially lifestyle-based, leading to chronic disabilities. Aims and Objectives: (1) To assess the comprehensive health status of elderly individuals recruited under the 60-plus project of a tertiary medical institute in South India. (2) To determine the various sociodemographic factors associated with the morbid conditions of the same population covered under the project. Materials and Methods: The present study was a cross-sectional analytical study that was conducted as part of 60-plus project launched in 2019. The total villages covered were 270 in 7.5 months. Total hospital statistics of geriatric patients: OP = 3902 and IP = 2137 were treated at Trichy SRM Medical College Hospital and Research Centre. Data entry of various variables related to geriatric care was done in an Excel sheet and data analysis was done using SPSS software V 21. Categorical data were depicted in percentages, and Chi-square was used to measure significant differences in categorical variables. Results: The majority of the respondents in this project were aged between the age group of 60–69 years with the mean age of 64.13 ± 8.65 years, of which the mean age among male patients was 66.56 ± 8.76 years and that of female patients was 62.04 + 7.99 years. The most common comorbidity was gonarthrosis (35.7%), followed by essential hypertension (29.5%), cataracts (28.7%), and type 2 diabetes mellitus (25%). The prevalence of most common comorbidities such as gonarthrosis, essential hypertension, cataracts, and type 2 diabetes mellitus proportionally increases in males with increasing age which is statistically significant. Conclusion: The existing program (60-plus project) meets the imperative need to address the needs of the elderly in this part of the country covering all the aspects physical, mental, and social. As a fledgling nation in elderly care, India, with this kind of innovative elderly care projects would constantly evolve to identify and face the various challenges that come up, especially from rural settings, for uplifting the primary care services.

Food as we knew it: Food processing as an evolutionary discourse

BackgroundThe Industrial Revolution presented technological advancements that improved shelflife, palatability, convenience, availability, and safety of foods. These advancements led to reduced micronutrient-related diseases, greater food diversity, and enhanced food security; however, their chronic consumption, starting in the 1960s, has been implicated in epidemics of diet-related chronic diseases. Scope and approachThis commentary implies that diet potentially alters the human genome, evidenced by isolated populations consuming high starch versus low starch over successive generations. The control of fire and subsequent application to cooking illustrate that food processing potentially acts as an evolutionary discourse, and selective pressure favors less tooth dentation. Each is important to establish that the lack of whole food structure, the introduction of xenobiotics, and refined components in ultra-processed foods is an evolutionary discourse. Key findings and conclusionsOver the past 100 years, the displacement of dietary patterns that include meals and dishes prepared from whole or minimally processed foods by those increasingly based on ultra-processed foods and drinks has occurred globally. Such rapid, neoteric changes to food choice/diet had not occurred since the onset of bipedally when Neanderthals ventured from the forest searching for new food sources in response to changing climates. Only time can tell if changes imparted by ultra-processed foods being Western Society's staple represent a significant enough environmental discourse to drive evolutionary adaptations. Epidemiological studies are already pointing to the parallel between the globalization of UPF consumption and the rapid emergence of chronic non-communicable diseases worldwide (244 words).

Noncommunicable diseases and health system responses in Saudi Arabia: focus on policies and strategies. A qualitative study

BackgroundNoncommunicable diseases (NCDs) are responsible for an increasing disease and economic burden in Saudi Arabia, particularly those due to chronic diseases such as diabetes and cardiovascular disease. Efforts are being made to improve chronic disease control through greater prevention and disease management. This research examines the scope, comprehensiveness and perceived effectiveness of Saudi Arabia’s national policies and strategies to prevent and control NCDs and their risk factors.MethodsSemi-structured interviews were conducted with 25 managers of the Ministry of Health in Saudi Arabia. The interviewees were public health leaders, national programme directors and programme implementation staff. The interviews were transcribed and coded into key themes.ResultsInterviewee responses indicated a belief that Ministry of Health programmes for the prevention and control of NCDs have achieved initial success, but have not yet been adequately evaluated. Interviewees reported faster development and implementation of policies for tobacco, sugar-sweetened drinks and obesity than for physical activity. Major challenges identified included inefficient programme management and low community awareness. There was a reported need for greater emphasis on health promotion and improving the effectiveness of existing multisectoral coordination.ConclusionEffective national NCD policies and strategies have a critical role to play in the control of chronic disease epidemics. In Saudi Arabia, opportunities exist to improve the policy and strategies in response to NCDs by establishing a comprehensive surveillance system and linking epidemiological surveillance with health programme evaluation, as well as using a multisectoral and integrated approach. For better management and control of NCDs, a cohesive multisectoral collaboration with a comprehensive surveillance programme and adequate evaluation is urgently needed.

The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases.

Sugar-sweetened beverages (SSBs) are a major source of added sugars in the diet. A robust body of evidence has linked habitual intake of SSBs with weight gain and a higher risk (compared with infrequent SSB consumption) of type 2 diabetes mellitus, cardiovascular diseases and some cancers, which makes these beverages a clear target for policy and regulatory actions. This Review provides an update on the evidence linking SSBs to obesity, cardiometabolic outcomes and related cancers, as well as methods to grade the strength of nutritional research. We discuss potential biological mechanisms by which constituent sugars can contribute to these outcomes. We also consider global trends in intake, alternative beverages (including artificially-sweetened beverages) and policy strategies targeting SSBs that have been implemented in different settings. Strong evidence from cohort studies on clinical outcomes and clinical trials assessing cardiometabolic risk factors supports an aetiological role of SSBs in relation to weight gain and cardiometabolic diseases. Many populations show high levels of SSB consumption and in low-income and middle-income countries, increased consumption patterns are associated with urbanization and economic growth. As such, more intensified policy efforts are needed to reduce intake of SSBs and the global burden of obesity and chronic diseases.

Plant-predominant eating patterns – how effective are they for treating obesity and related cardiometabolic health outcomes? – a systematic review

The obesity epidemic is a main driver of the chronic disease epidemic; however, present treatment approaches have suboptimal efficacy. To assess the efficacy of plant-predominant (vegan, vegetarian, plant-based whole foods [PBWFs]) diets in treating obesity and its main cardiometabolic sequelae: hyperlipidemia (HLD); indices of insulin resistance, glycemic control, and diabetes mellitus type 2 (DM2); and cardiovascular disease (CVD), including hypertension (HTN). A systematic search of multiple databases was conducted for articles published between November 2019 and February 2020; databases searched included: PubMed, Medline (Ovid), Cochrane, CENTRAL, and CINAHL. All interventional trials (randomized controlled trials [RCTs] and trials of non-randomized experimental design) that met the inclusion criteria (English language, duration of at least 4 weeks, primary end point congruent with above objectives, no major flaws in research design that would prevent interpretation) were included in the review. A total of 3135 articles were scanned and 84 were selected. The articles were collated and summarized in 2 evidence tables. Risk of bias for RCTs was assessed using the Cochrane Risk-of-Bias tool 2 as a guide. For non-randomized trials, higher risk of bias was assumed, and the JBI Critical Appraisal tool was used as a guide to determine inclusion. Plant-based diets, in general, demonstrated improved weight control and cardiometabolic outcomes related to lipids, cardiovascular end points, blood pressure, insulin sensitivity, A1C, and fasting glucose, and a lower risk of diabetes compared with usual diets and in some cases standard health-oriented diets such as the American Heart Association (AHA), American Diabetic Association (ADA), and Mediterranean diets. Preliminary studies suggest plant-predominant diets practiced as part of healthy lifestyle interventions may stabilize or even reverse DM 2 and CVD. The acceptability and sustainability of plant-predominant diets where measured were generally similar to other health-oriented diets. Plant-predominant diets can play a major role in reversing the obesity and chronic disease epidemics. In the setting of sustained lifestyle intervention programs, they may arrest or even reverse DM2 and CVD. Further higher-level RCTs are needed to confirm and expand on these findings.

Lifestyle interventions for preventing and ameliorating CKD in primary and secondary care.

Despite the growth in chronic kidney disease (CKD) epidemics, evidence-based lifestyle recommendations for primary prevention of CKD are limited by reliance on observational studies and predominantly pilot clinical trials. Emerging data have shown lifestyle modification strategies for primary CKD prevention with the most evidence favoring a healthy dietary pattern (rich in fruit, vegetables, potassium and have a higher plant-based to animal protein ratio), and diet low in sodium, being physically active, avoiding tobacco smoking, moderating alcohol consumption and maintaining a healthy body weight. The way these behavioral interventions can be implemented in practice should consider their synergistic benefit as well as mechanisms to facilitate long-term behavior change. Sustaining long-term behavior change remains a challenge in practice, particularly due to a lack of healthcare resources and behavior relapse. Some suggestions to mitigate this include ensuring adequate time is spent in intervention codesign and planning, utilizing adaptive trial/intervention designs with regular intervention tailoring for intervention dose, intensity, duration, and modality. A number of modifiable lifestyle behaviors consistently associate with developing CKD in the community. The current evidence base, despite its inherent limitations, may inform both public health recommendations and clinical practice.

Physical Activity and Public Health: Four Decades of Progress

Over the past 40 years, physical activity (PA) and public health has been established as a field of study. A robust evidence base has emerged demonstrating that participation in recommended amounts of PA results in a wide array of physical and mental health benefits. This led to the establishment of federal and global PA guidelines and surveillance programs. Strong evidence supports the efficacy of individual-level (e.g., goal setting) and environmental (e.g., policies) interventions to promote PA. There has also been progress in establishing a skilled and diverse workforce to execute the work of PA and public health. Looking forward, major challenges include stemming the obesity and chronic disease epidemics, addressing health inequities, and diversifying the workforce. Given the known benefits of PA and the availability of evidence-based interventions, efforts now must focus on implementing this knowledge to improve population health and reduce inequities through PA.

Developing a Flexible National Wastewater Surveillance System for COVID-19 and Beyond.

Background:Wastewater testing offers a cost-effective strategy for measuring population disease prevalence and health behaviors. For COVID-19, wastewater surveillance addresses testing gaps and provides an early warning for outbreaks. As U.S. federal agencies build a National Wastewater Surveillance System around the pandemic, thinking through ways to develop flexible frameworks for wastewater sampling, testing, and reporting can avoid unnecessary system overhauls for future infectious disease, chronic disease, and drug epidemics.Objectives:We discuss ways to transform a historically academic exercise into a tool for epidemic response. We generalize lessons learned by a global network of wastewater researchers around validation and implementation for COVID-19 and opioids while also drawing on our experience with wastewater-based epidemiology in the United States.Discussion:Sustainable wastewater surveillance requires coordination between health and safety officials, utilities, labs, and researchers. Adapting sampling frequency, type, and location to threat level, community vulnerability, biomarker properties, and decisions that wastewater data will inform can increase the practical value of the data. Marketplace instabilities, coupled with a fragmented testing landscape due to specialization, may require officials to engage multiple labs to test for known and unknown threats. Government funding can stabilize the market, balancing commercial pressures with public good, and incentivize data sharing. When reporting results, standardizing metrics and contextualizing wastewater data with health resource data can provide insights into a community’s vulnerability and identify strategies to prevent health care systems from being overwhelmed. If wastewater data will inform policy decisions for an entire community, comparing characteristics of the wastewater treatment plant’s service population to those of the larger community can help determine whether the wastewater data are generalizable. Ethical protocols may be needed to protect privacy and avoid stigmatization. With data-driven approaches to sample collection, analysis, and interpretation, officials can use wastewater surveillance for adaptive resource allocation, pandemic management, and program evaluation. https://doi.org/10.1289/EHP8572

An adaptive behavioral immune system: a model of population health behavior

The understanding that immunity could be strengthened in the general population (e.g., through vaccine interventions) supported global advances upon acute infectious disease epidemics in the eighteenth, nineteenth, and twentieth centuries. However, in the twenty-first century, global populations face chronic disease epidemics. Research demonstrates that diseases largely emerge from health risk behavior. The understanding of how health behavior, like the biological immune system, can be strengthened in the general population, could support advances in the twenty-first century. To consider how health behavior can be strengthened in the general population, the authors present a theoretical model of population health behavior. The model operationalizes health behavior as a system of functions that, like the biological immune system, exists in each member of the population. Constructs are presented that operationalize the specific decisions and habits that drive health behavior and behavior change in the general population. The constructs allow the authors to present parallels (1) among existing behavior change theories and (2) between the proposed system and the biological immune system. Through these parallels, the authors introduce a model and a logic of population-level health behavior change. The Adaptive Behavioral Immune System is an integrative model of population health behavior.

Regional variations in medical trainee diet and nutrition counseling competencies: Machine learning-augmented propensity score analysis of a prospective multi-site cohort study.

Medical professionals and students are inadequately trained to respond to rising global obesity and nutrition-related chronic disease epidemics, primarily focusing on cardiovascular disease. Yet, there are no multi-site studies testing evidence-based nutrition education for medical students in preventive cardiology, let alone establishing student dietary and competency patterns. Cooking for Health Optimization with Patients (CHOP; NIH NCT03443635) was the first multi-national cohort study using hands-on cooking and nutrition education as preventive cardiology, monitoring and improving student diets and competencies in patient nutrition education. Propensity-score adjusted multivariable regression was augmented by 43 supervised machine learning algorithms to assess students outcomes from UT Health versus the remaining study sites. 3,248 medical trainees from 20 medical centers and colleges met study criteria from 1 August 2012 to 31 December 2017 with 60 (1.49%) being from UTHealth. Compared to the other study sites, trainees from UTHealth were more likely to consume vegetables daily (OR 1.82, 95%CI 1.04-3.17, p=0.035), strongly agree that nutrition assessment should be routine clinical practice (OR 2.43, 95%CI 1.45-4.05, p=0.001), and that providers can improve patients' health with nutrition education (OR 1.73, 95%CI 1.03-2.91, p=0.038). UTHealth trainees were more likely to have mastered 12 of the 25 competency topics, with the top three being moderate alcohol intake (OR 1.74, 95%CI 0.97-3.11, p=0.062), dietary fats (OR 1.26, 95%CI 0.57-2.80, p=0.568), and calories (OR 1.26, 95%CI 0.70-2.28, p=0.446). This machine learning-augmented causal inference analysis provides the first results that compare medical students nationally in their diets and competencies in nutrition education, highlighting the results from UTHealth. Additional studies are required to determine which factors in the hands-on cooking and nutrition curriculum for UTHealth and other sites produce optimal student - and, eventually, preventive cardiology - outcomes when they educate patients in those classes.

Status of evidence-based chronic diseases prevention implementation in Shanghai, China: A qualitative study.

Given the rapid increase in chronic disease epidemics in developing countries and the lagging research and practice in evidence-based chronic diseases prevention (EBCDP), we evaluated the status of public health practitioners' implementation of EBCDP and its impeding factors in China, as well as made a comparison between China and the developed countries to encourage better utilisation of this new field of science in China. We interviewed health practitioners and patients from various health institutions in China and conducted a literature review to assess the current status of EBCDP practice in developed countries and identify the contextual driving factors. China is in its initial stage of EBCDP practice, as it lacks evidence-based interventions. Moreover, health practitioners' awareness of EBCDP is inadequate. The lack of policy support, especially funding, has restricted the efficiency and quality of EBCDP in terms of its adoption, implementation, and maintenance. Currently, EBCDP practice is limited to the practitioners' spontaneous behaviours. The literature review showed that developed countries practising EBCDP did well in evidence development and awareness; however, much has yet to be explored regarding practitioners' adoption and implementation and the maintenance of evidence-based practice. The impeding factors in developed countries were related to individual (patients and physicians) and organisational factors (such as resources, leaders, and climate). To promote EBCDP practice in China, more evidence for effective chronic disease prevention programmes is needed, and multiple and flexible measures should be implemented for a successful transition to evidence-based practice.

Disseminating and implementing a lifestyle-based healthy weight program for mothers in a national organization: a study protocol for a cluster randomized trial

BackgroundExcessive weight gain among young adult women age 18–45 years is an alarming and overlooked trend that must be addressed to reverse the epidemics of obesity and chronic disease. During this vulnerable period, women tend to gain disproportionally large amounts of weight compared to men and to other life periods. Healthy Eating and Active Living Taught at Home (HEALTH) is a lifestyle modification intervention developed in partnership with Parents as Teachers (PAT), a national home visiting, community-based organization with significant reach in this population. HEALTH prevented weight gain, promoted sustained weight loss, and reduced waist circumference. PAT provides parent–child education and services free of charge to nearly 170,000 families through up to 25 free home visits per year until the child enters kindergarten.MethodsThis study extends effectiveness findings with a pragmatic cluster randomized controlled trial to evaluate dissemination and implementation (D&I) of HEALTH across three levels (mother, parent educator, PAT site). The trial will evaluate the effect of HEALTH and the HEALTH training curriculum (implementation strategy) on weight among mothers with overweight and obesity across the USA (N = 252 HEALTH; N = 252 usual care). Parent educators from 28 existing PAT sites (14 HEALTH, 14 usual care) will receive the HEALTH training curriculum through PAT National Center, using PAT’s existing training infrastructure, as a continuing education opportunity. An extensive evaluation, guided by RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), will determine implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, and adaptation) at the parent educator level. The Conceptual Framework for Implementation Research will characterize determinants that influence HEALTH D&I at three levels: mother, parent educator, and PAT site to enhance external validity (reach and maintenance).DiscussionEmbedding intervention content within existing delivery channels can help expand the reach of evidence-based interventions. Interventions, which have been adapted, can still be effective even if the effect is reduced and can still achieve population impact by reaching a broader set of the population. The current study will build on this to test not only the effectiveness of HEALTH in real-world PAT implementation nationwide, but also elements critical to D&I, implementation outcomes, and the context for implementation.Trial registrationhttps://ClinicalTrials.gov, NCT03758638. Registered 29 November 2018

Dietary Influence on Body Fluid Acid-Base and Volume Balance: The Deleterious "Norm" Furthers and Cloaks Subclinical Pathophysiology.

The popular modern diet, characterized by an excess of animal protein and salt but insufficient in fruits, vegetables and water, is a poor fit for human physiological and homeostatic regulatory systems. Sustained net acid and sodium retention, coupled with an insufficient intake of cardiovascular protective potassium-rich foods and hydration in the modern diet can give rise to debilitating chronic organ dysfunction and ultimately, mortality. This holds true, especially in our aging population who are already facing inevitable decline in organ functional reserve. Importantly, in most cases, despite the mismatch and adverse effects to multiple organ systems, plasma electrolyte and acid-base parameters can, on the surface, be maintained within a “normal” reference range, primarily by activating (often maximally activating) compensatory homeostatic mechanisms. These diet-induced effects can thus be clinically silent for decades. Embodied in the chronic corrective homeostatic processes, however, are real risks for multiorgan damage. According to the Dietary Guideline Advisory Committee (DGAC), half of American adults have one or more chronic diseases that are preventable with dietary modification. Here, homeostasis of body fluid acid-base, sodium, potassium and water is examined. Our current dietary habits and their required regulatory adaptation, maladaptation and relevant physiology and pathophysiology are discussed. A framework of dietary modifications to avoid a propensity for maladaptation and thus lowers the risks of common modern diseases (primary prevention) and minimizes the risk of chronic and age-related disease progression (secondary prevention) is emphasized. Although there are other variables at play, a key to restoring the all-important dietary potassium to sodium ratio is greater consumption of vegetables/fruits and adopting salt temperance. Dietary and nutritional optimization is an under-emphasized area of health care that has an enormous potential to temper the epidemics of prevalent chronic diseases in modern society and improve population health.