Targeting Modifiable Risk Factors Research Articles

Vascular Risk Factors and Brain Health in Aging: Insights from a Community-Based Cohort Study.

The aging population and high rates of Alzheimer's disease (AD) create significant medical burdens, prompting a need for early prevention. Targeting modifiable risk factors like vascular risk factors (VRFs), closely linked to AD, may provide a promising strategy for intervention. This study investigates how VRFs influence cognitive performance and brain structures in a community-based cohort. In this cross-sectional study, 4,667 participants over 50 years old, drawn from the Beijing Ageing Brain Rejuvenation Initiative project, were meticulously examined. Cognitive function and VRFs (diabetes mellitus, hypertension, hyperlipidemia, obesity, and smoking), were comprehensively assessed through one-to-one interviews. Additionally, a subset of participants (n = 719) underwent MRI, encompassing T1-weighted and diffusion-weighted scans, to elucidate gray matter volume and white matter structural network organization. The findings unveil diabetes as a potent detriment to memory, manifesting in atrophy within the right supramarginal gyrus and diminished nodal efficiency and degree centrality in the right inferior parietal lobe. Hypertension solely impaired memory without significant structural changes. Intriguingly, individuals with comorbid diabetes and hypertension exhibited the most pronounced deficits in both brain structure and cognitive performance. Remarkably, hyperlipidemia emerged as a factor associated with enhanced cognition, and preservation of brain structure. This study illuminates the intricate associations between VRFs and the varied patterns of cognitive and brain structural damage. Notably, the synergistic effect of diabetes and hypertension emerges as particularly deleterious. These findings underscore the imperative to tailor interventions for patients with distinct VRF comorbidities, especially when addressing cognitive decline and structural brain changes.

BRAIN HEALTH TOGETHER: DEVELOPING AND PILOT-TESTING AN ONLINE GROUP PROGRAM TO REDUCE DEMENTIA RISK

Abstract Growing evidence suggests that multi-domain interventions can slow cognitive decline and reduce dementia risk in older adults. However, most programs have been in-person and/or had relatively long intervention periods (1 to 2-years). The primary goal of this study was to develop and pilot-test Brain Health Together, a 12-week, virtual-group program to reduce dementia risk through targeting modifiable risk factors in older adults who report cognitive decline. Initial content was developed with input from an external Science Advisory Board. 7 individuals who had been participating in online group movement classes for the previous 2 years were invited to pilot-test and provide feedback on Brain Health Together content and structure. In addition to the movement classes, the pilot program included weekly 1-hour group brain health education classes and 30-minute individual brain health coaching sessions for 12 weeks. The first 4 education classes included general content. Based on participant feedback, subsequent classes provided in-depth content on a single brain health risk factor each week, including expert videos and facilitated discussion. Before their first coaching session, participants completed a brief survey about their current lifestyle behaviors and medical conditions related to brain health. This was used to generate an individualized brain health report that summarized areas with low, moderate or high opportunity for change. Coaching sessions focused on setting SMART (Specific, Measurable, Achievable, Realistic, Timely) goals to address modifiable risk factors. After 12 weeks, participants reported more exercise, less loneliness, and longer sleep duration. We are currently enrolling for a larger clinical trial.

Modifiable dementia risk factor associations with AT(N) biomarkers: Findings from the European Prevention of Alzheimer’s Dementia study

AbstractBackgroundThere is strong evidence that targeting modifiable risk factors can maintain and improve cognitive function, as well as reducing risk for Alzheimer’s disease (AD) and other forms of dementia. Further, a discrete AT(N) profile exists for hallmark biomarkers: amyloid β (A), p‐tau (T) and neurodegeneration (N), to discriminate between AD and non‐AD pathological changes. Despite evidence of a biologically defined AD continuum and modifiable risk amelioration, there is a paucity of studies investigating modifiable risk factors with respect to AT(N) biomarkers. The aim of this study was to investigate how modifiable risk factors relate to the three hallmark AT(N) biomarkers of AD.MethodParticipants were drawn from the European Prevention of Alzheimer’s Disease (EPAD): a prospective, multicentre, pan‐European cohort study. Eligible participants underwent clinical and neurological assessments, brain magnetic resonance imaging, cerebrospinal fluid (CSF) collection, neuropsychological assessment and completed a variety of demographic, clinical, medical history and lifestyle surveys for 10 binary modifiable risk variables. Data were analysed via the NeuroToolKit Application (NTKApp, BetaVersion, 2022). Generalized additive models with penalized regression splines were used to model the associations between modifiable risk factor adherence and AT(N) biological criterion: A (CSF amyloid‐β 42 [Aβ42 pg/mL]); T (CSF phosphorylated‐tau 181 [p‐tau 181 pg/mL]); N (total hippocampal volume [mm3]).ResultOf the 2737 participants included, 56% were female (n = 1526), 39% had at least one APOE ε4 allele (n = 1598), with an average age of 66.0 years and 14.4 years of education. Adjusting for age, sex and APOE carrier status: age, APOE and traumatic brain injury (TBI) were significantly associated with CSF Aβ42; age, APOE, body mass index (BMI) and exercise were significantly associated with CSF p‐tau181; and age, sex and education were significantly associated with total hippocampal volume.ConclusionModifiable risk factors of less education, less exercise, TBI and higher BMI were all significantly associated with increased AD biomarker burden. Our results support previous studies identifying associations between modifiable risk factors and AD and suggest that early intervention strategies focused on education and lifestyle factors and improvements in prevention and treatment of TBI may modify risk profiles associated with cognitive decline.

The Maintain Your Brain online multidomain intervention for dementia risk reduction: end‐user evaluations of what did and did not work and why

AbstractBackgroundDementia prevalence is increasing, and risk reduction is a priority. Online interventions that are useable and acceptable to people seeking to reduce their dementia risk are needed. We aimed to assess and explore end‐user perceptions of a large‐scale multidomain online intervention targeting modifiable lifestyle risk factors for dementia.MethodMixed methods evaluation involving Maintain Your Brain (MYB) randomised controlled trial participants 55‐77 years of age at baseline who engaged in assessments, brain training, nutrition and physical activity, and mental health modules across three years. Of 5,260 participants invited, 2,386 completed online surveys at trial conclusion of whom 1,589 offered free‐text comments. Of survey respondents, 248 agreed to be contacted for interviews, 70 were invited and 40 were interviewed. Survey respondents rated ease of use and overall experience with MYB, endorsed whether they would recommend MYB, and provided comments. Interview completers further rated satisfaction with support, expressed online or face‐to‐face setting preference, answered open‐ended questions about participation, activities and modules, and provided further comments. Data were summarised using descriptive statistics and explored using multiple qualitative methods.ResultRespondents found computer‐based activities easy to use (92.2%), were satisfied with their overall experience (87.4%) and would recommend MYB (82.7%). Survey free‐text and interview comments addressed topics including computer literacy, health literacy, resource access, motivations, expectations, social relationships, and significant events. Perspectives on activities and information varied. Many enjoyed and/or appreciated the challenge of completing activities and assessments and the potential for health benefits from these activities. Others were disappointed by their own performance in activities and assessments, found testing and reporting repetitious, stressful and/or time‐consuming, and found educational information unhelpful. Many respondents would have preferred to access applications on phones or tablet devices and suggested that interventions should be available across platforms. Respondents wanted researchers to know that flexible and adaptive individually tailored goals and activities and timely feedback are important.ConclusionThe MYB online multidomain dementia risk reduction program was useable and acceptable. Similar programs should be accessible, well‐supported, cross‐IT platforms, and incorporate adaptive, individually tailored activities and feedback that is responsive to the varied and changing needs of older adults.

FC5: The Maintain Your Brain online multidomain intervention for dementia risk reduction: qualitative exploration of lifestyle changes made, continued, or declined, and why

Objective:Explore end-user evaluations and feedback focused on lifestyle change in a large-scale multidomain online intervention targeting modifiable risk factors for dementia.Methods:Online survey and semi-structured interviews at conclusion of the Maintain Your Brain (MYB) randomized controlled trial. Participants were 55-77 years of age at baseline, and had engaged in assessments, brain training, nutrition and physical activity, and mental health modules over three years. Of 5,260 participants invited, 2,386 completed online surveys and 1,589 of these respondents provided free text comments. Nearly 250 survey respondents agreed to be contacted for additional interviews; 70 of these were invited, 40 interviewed. Survey respondents and interview completers endorsed whether they had made lifestyle changes because of MYB participation and whether they would continue healthy lifestyle changes going forward. Interview participants endorsed whether they thought similar programs can be useful in delaying or preventing dementia, whether their views regarding this type of program had changed over time, answered open-ended follow-up questions and provided additional feedback. Data were summarized using descriptive statistics and explored using multiple qualitative methods.Results:Of survey respondents, 90.5% endorsed intention to continue a healthier lifestyle; 63.2% endorsed that lifestyle changes had occurred. Interview participants thought similar programs could be useful in delaying or preventing dementia, but some were unsure. Trial participation had not changed many individuals’ views about online lifestyle programs. Survey free-text and interview comments indicated diversity in pre-intervention knowledge, lifestyle and health-related behavior. Many respondents reported improved knowledge and awareness, some detailed relevant and continued lifestyle change. Those who were already well informed and/or leading healthy lifestyles explained that trial participation had confirmed their existing practices. Trial characteristics, personal characteristics, social relationships and significant events impacted whether respondents had made and/or continued changes. More flexible, adaptive individually tailored goals and timely feedback were requested to better support change.Conclusion:Surveyed participants who engaged in the 3-year MYB online multidomain dementia risk reduction program reported lifestyle changes and intention to continue having a healthier lifestyle. Older adults in this study suggested that similar online programs need to provide flexible, individualized guidance and feedback to support lifestyle change.

Contribution of life course cardiovascular risk factors to racial disparities in dementia incidence

BackgroundRacial disparities in dementia outcomes persist in the United States. Targeting modifiable risk factors, including cardiovascular risk factors (CVRFs), is a conceivable way to reduce health disparities. Life course CVRFs are often higher in non-White adults and are associated with risk of dementia, but it is unknown whether they contribute to racial disparities in dementia and cognition.MethodsUsing a pooled cohort of 4,159 White and 939 Black participants aged 65–95 years, we conducted a mediation analysis to estimate the proportional effect of race on dementia that is explained by four CVRFs imputed over the life course (20–49, 50–69, and 70–89 years of age): body mass index, fasting glucose, systolic blood pressure, and low-density lipoprotein cholesterol.ResultsCompared to White participants, Black participants had greater risk of dementia (adjusted OR = 1.37; 95% CI: 1.17–1.60). BMI and fasting glucose over the life course were significant mediators of the effect of race on dementia risk, mediating 39.1% (95% CI: 10.5–67.8%) and 8.2% (95% CI: 0.1–16.2%) of the effect, adjusted for sex and age. All four CVRFs together were also significant mediators of the effect of race on scores on global cognition and processing speed, accounting for approximately 11% of the effect.ConclusionsWe found that CVRFs across the life course partially explain disparities in dementia risk and cognition in late-life. Improved prevention and treatment of CVRFs across the life course may be important to reduce health disparities for dementia.

Association of Dementia Risk With Focal Epilepsy and Modifiable Cardiovascular Risk Factors

Epilepsy has been associated with cognitive impairment and potentially dementia in older individuals. However, the extent to which epilepsy may increase dementia risk, how this compares with other neurological conditions, and how modifiable cardiovascular risk factors may affect this risk remain unclear. To compare the differential risks of subsequent dementia for focal epilepsy compared with stroke and migraine as well as healthy controls, stratified by cardiovascular risk. This cross-sectional study is based on data from the UK Biobank, a population-based cohort of more than 500 000 participants aged 38 to 72 years who underwent physiological measurements and cognitive testing and provided biological samples at 1 of 22 centers across the United Kingdom. Participants were eligible for this study if they were without dementia at baseline and had clinical data pertaining to a history of focal epilepsy, stroke, or migraine. The baseline assessment was performed from 2006 to 2010, and participants were followed up until 2021. Mutually exclusive groups of participants with epilepsy, stroke, and migraine at baseline assessment and controls (who had none of these conditions). Individuals were divided into low, moderate, or high cardiovascular risk groups based on factors that included waist to hip ratio, history of hypertension, hypercholesterolemia, diabetes, and smoking pack-years. Incident all-cause dementia; measures of executive function; and brain total hippocampal, gray matter, and white matter hyperintensity volumes. Of 495 149 participants (225 481 [45.5%] men; mean [SD] age, 57.5 [8.1] years), 3864 had a diagnosis of focal epilepsy only, 6397 had a history of stroke only, and 14 518 had migraine only. Executive function was comparable between participants with epilepsy and stroke and worse than the control and migraine group. Focal epilepsy was associated with a higher risk of developing dementia (hazard ratio [HR], 4.02; 95% CI, 3.45 to 4.68; P < .001), compared with stroke (HR, 2.56; 95% CI, 2.28 to 2.87; P < .001), or migraine (HR, 1.02; 95% CI, 0.85 to 1.21; P = .94). Participants with focal epilepsy and high cardiovascular risk were more than 13 times more likely to develop dementia (HR, 13.66; 95% CI, 10.61 to 17.60; P < .001) compared with controls with low cardiovascular risk. The imaging subsample included 42 353 participants. Focal epilepsy was associated with lower hippocampal volume (mean difference, -0.17; 95% CI, -0.02 to -0.32; t = -2.18; P = .03) and lower total gray matter volume (mean difference, -0.33; 95% CI, -0.18 to -0.48; t = -4.29; P < .001) compared with controls. There was no significant difference in white matter hyperintensity volume (mean difference, 0.10; 95% CI, -0.07 to 0.26; t = 1.14; P = .26). In this study, focal epilepsy was associated with a significant risk of developing dementia, to a greater extent than stroke, which was magnified substantially in individuals with high cardiovascular risk. Further findings suggest that targeting modifiable cardiovascular risk factors may be an effective intervention to reduce dementia risk in individuals with epilepsy.

Reducing incidence of postoperative acute kidney injury in trauma and orthopaedics patients: a quality improvement project

BackgroundAcute kidney injury (AKI) is a common postoperative complication which increases morbidity and mortality. This quality improvement project aimed to implement measures targeting known risk factors to decrease the incidence...

Prevalence of the metabolic syndrome and associated factors among inpatients with severe mental illness in Botswana: a cross-sectional study

IntroductionThe metabolic syndrome, a cluster of inter-related risk factors for cardiovascular diseases is highly prevalent among individuals with obesity and sedentary lifestyle. Chronic psychiatric disorders such as severe mental illness are associated with increased risk for cardiovascular diseases. We aimed to assess the prevalence and correlates of metabolic syndrome among inpatients with severe mental illness in a resource limited setting with high HIV prevalence.MethodsThis was a cross-sectional study among adult inpatients at a referral psychiatric hospital in Botswana. We used convenience sampling to enrol participants available at the time of the study. The National Cholesterol Education Program Adult Treatment Panel-III (NCEP-ATP III) criteria was used to define the metabolic syndrome. Data were analysed using descriptive statistics as well as multiple logistic regression modelling.ResultsA total of 137 participants were enrolled. Of these, 119 (87%) had complete data for the main analysis. The overall prevalence of metabolic syndrome was 22.6% (95% CI 15.9, 30.6) and did not differ significantly by gender or HIV status. Age was significantly associated with the risk of having the metabolic syndrome while gender, body mass index, HIV status, and days of moderate physical activity were not.ConclusionThere was a moderately high prevalence of metabolic syndrome. Thus, the management of individuals with severe mental illness in resource limited settings should include assessment of cardiovascular risk and target modifiable risk factors in this population. Consideration for the patient’s age should be made when rationalizing the limited resources available for assessing metabolic syndrome among patients with severe mental illness.

Genetic evidence that the causal association of educational attainment with reduced risk of Alzheimer’s disease is driven by intelligence

AbstractBackgroundAlzheimer’s disease (AD) is predicted to affect 132 million people by 2050. Targeting modifiable lifestyle risk factors that are associated with an increased risk of AD could prevent a large proportion of dementia cases, allowing people to reach the end of their life dementia free. However, evidence obtained from observational studies does not take into account how risk factors are correlated with one another, and whether they causally contribute to increased AD risk. In this study, we determine whether the relationship between twelve previously speculated AD risk factors and AD susceptibility is consistent with causality using large‐scale genetic data (table 1).MethodWe conduct multivariable Mendelian Randomization (MR) analyses to identify causal risk factors of AD while controlling for genetic pleiotropy, using genetic instruments from the most well powered GWAS studies currently available. We also use GWAS‐by‐subtraction implemented with genomic structural equation modelling (genomic SEM) to understand the cognitive and non‐cognitive components of the causal association of EA on AD risk.ResultWe identified significant positive correlations between AD and physical activity and loneliness, and significant negative correlations with educational attainment (EA), intelligence and household income. Using GWAS‐by‐subtraction to partition EA into cognitive (intelligence) and noncognitive genetic factors, we showed a significant genetic correlation between AD and the cognitive factor, but not the noncognitive factor (figure 1).Univariable MR found EA, intelligence, household income and the cognitive factor to all be causally protective against AD. Multivariable MR analysis showed that higher intelligence lowers AD risk, independent of EA and household income. There was no evidence that EA lowers AD risk, independent of intelligence. In addition the cognitive (intelligence) component of EA decreased AD risk with no significant influence of the noncognitive factor (table 2).ConclusionFrom the risk factors tested only the cognitive component of EA (i.e., intelligence) is an independent causal risk factor for AD. To reduce incidence of AD this cognitive aspect of EA would need to be modified. It is questionable whether substantial modification of intelligence is achievable through simple interventions such as improving access to extended education.

Depression, anxiety, and psychological distress among caregivers of young children in rural Lesotho: Associations with food insecurity, household death and parenting stress

Good mental health is a critical resource for mothers and caregivers of young children, given the central role of mental health in enabling responsive caregiving. However, fulfilling caregiving responsibilities under challenging circumstances such as extreme poverty, food insecurity, and gender inequality intensifies vulnerability to poor mental health. Previous research focuses on mental health of mothers, while in many LMICs children are cared for by other caregivers, such as grandparents. We examined the prevalence of mental health problems among primary caregivers of young children in rural Lesotho, and investigated factors associated with these mental health problems.We analysed baseline data from a cluster randomised controlled trial, where all caregivers with children between 1 and 5 years old across 34 villages were invited to participate. The analysis included mental health data from 781 caregivers of 998 children. We assessed caregiver mental health using three self-report screening instruments. Univariate and multivariate regression modelling tested associations between caregiver, child and household variables and (1) depression symptoms (PHQ-9), (2) anxiety symptoms (GAD-7), (3) psychological distress (SRQ-20), (4) suicidal ideation and (5) help-seeking for mental health.This study reported a high prevalence of symptoms of psychological distress (46.2%), depression (25.7%), anxiety (17.1%) and suicidal ideation (27.5%) among caregivers. Greater prevalence was associated with food insecurity, parenting stress or recent death in the family/household. Older caregivers reported higher rates of psychological distress and depression, while younger caregivers reported higher rates of anxiety. Suicidal ideation was associated with greater food insecurity and parenting stress, and lower caregiver education.Our findings support the need to address intersecting public health issues to improve conditions for caregivers in these settings. Targeting modifiable risk factors such as food insecurity among individuals within a society who carry disproportionate burdens of caregiving should be prioritised, especially in contexts of scarcity, where mental health is not prioritised.

September 2022 Stroke Highlights

September 2022 <i>Stroke</i> Highlights

Genetic evidence that the causal association of educational attainment with reduced risk of Alzheimer's disease is driven by intelligence

Alzheimer's disease (AD) is predicted to affect 132 million people by 2050. Targeting modifiable lifestyle risk factors that are associated with an increased risk of AD could prevent a large proportion of dementia cases, allowing people to reach the end of their life dementia free. However, evidence obtained from the observational studies does not take into account how risk factors are correlated with one another, and whether they causally contribute to increased AD risk. In this study, we determine whether the relationship between previously speculated AD risk factors and AD susceptibility is consistent with causality using large-scale genetic data. We focus on educational attainment (EA), intelligence and household income which have been previously shown to be causally associated with AD. Using GWAS-by-subtraction and Multivariable Mendelian Randomization we show that of these, only the cognitive component of EA (intelligence) is independently causally associated with AD. This work has ramifications for the modifiability of lifestyle risk factors for AD.

Transdiagnostic model of psychological factors and sex differences in depression in a large sample of Ecuador

Background/ObjectiveDepression represents a leading cause of disability and a major contributor to the overall global burden of disease with women systematically reporting a higher prevalence than men. This study aimed to examine the predictive value and relation of three transdiagnostic psychological factors (perceived stress, psychological inflexibility and loneliness) on depression and its sex differences for the general population in a large sample of Ecuador. MethodA non-probabilistic and non-clinical sample of 16.074 people from across Ecuador were online surveyed using a cross-sectional design. The structural equation model was based on scores from standardized questionnaires as measures of depression, psychological perceived stress, psychological inflexibility, and loneliness. ResultsWomen reported significantly higher levels of depression, mediated by differences in perceived stress, psychological inflexibility and loneliness. Perceived stress was the most important predictor of depression and mediated the effect of loneliness on depression. Complementarily, psychological inflexibility partially mediated the effect of perceived stress and loneliness on depression. The overall model accounted for the 78% of the total variance in depression. ConclusionsResults of this study provide a novel and robust transdiagnostic model of sex differences on depression and insights on how to design effective programs for preventing depression targeting modifiable transdiagnostic risk factors.

Prevalence and Risk Factors for Postoperative Complications Following Open A1 Pulley Release for a Trigger Finger or Thumb

Although A1 pulley release is an effective treatment to reduce pain and improve hand function, complications may occur. More insight into risk factors for complications is essential to improve patient counseling and potentially target modifiable risk factors. This study aimed to identify factors associated with complications following A1 pulley release. Patients completed baseline questionnaires, including patient characteristics, clinical characteristics, and the Michigan Hand outcomes Questionnaire. We retrospectively reviewed medical records to identify complications classified using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions tool. Grade 1 complications comprise treatment with additional hand therapy, splinting, or analgesics, grade 2 treatment with antibiotics or steroid injections, grade 3A minor surgical treatment, grade 3B major surgical treatment, and grade 3C complex regional pain syndrome. Logistic regression analyses were performed to examine the contribution of patient characteristics, clinical characteristics, and patient-reported outcome measurement scores to complications. Of the included 3,428 patients, 16% incurred a complication. The majority comprised milder grades 1 (6%) and 2 (7%) complications, followed by more severe grades 3B (2%), 3C (0.1%), and 3A (0.1%) complications. A longer symptom duration (standardized odds ratio [SOR], 1.09), ≥3 preoperative steroid injections (SOR, 3.22), a steroid injection within 3 months before surgery (SOR, 2.02), and treatment of the dominant hand (SOR, 1.34), index finger (SOR, 1.65), and middle finger (SOR, 2.01) were associated with a higher complication rate. This study demonstrates that ≥3 preoperative steroid injections and a steroid injection within 3 months before surgery were the most influential factors contributing to complications. These findings can assist clinicians during patient counseling and may guide preoperative treatment. We recommend that clinicians should consider avoiding steroid injections within 3 months before surgery and to be reluctant to perform >2 steroid injections. Prognostic II.

The shared genetic architecture of modifiable risk for Alzheimer's disease: a genomic structural equation modelling study

Targeting modifiable risk factors may help to prevent Alzheimer's disease (AD), but the pathways by which these risk factors influence AD risk remain incompletely understood. We identified genome-wide association studies for AD and its major modifiable risk factors. We calculated the genetic correlation among these traits and modelled this using genomic structural equation modelling. We identified complex networks of genetic overlap among AD risk factors, but AD itself was largely genetically distinct. The data were best explained by a bi-factor model, incorporating a Common Factor for AD risk, and 3 orthogonal sub-clusters of risk factors. Taken together, our findings suggest that there is extensive shared genetic architecture between AD modifiable risk factors, but this is largely independent of AD genetic pathways. Extensive genetic pleiotropy between risk factors may influence AD indirectly by decreasing cognitive reserve or increasing risk of multimorbidity, leading to poorer brain health. Further work to understand the biology reflected by this communality may provide novel mechanistic insights that could help to prioritise targets for dementia prevention.

Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes.

To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019. We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography. Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76). One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.

Association of the Mediterranean diet with cognition in a Western population

AbstractBackgroundThe Mediterranean‐style diet (MD) is promoted as one of the healthiest dietary patterns and has been shown to reduce cognitive decline in some randomised controlled trials (RCTs). This pattern is plant‐based with a focus on vegetables, legumes, fish, and olive oil, with low intake of red meats and foods high in sugar and saturated fats. The Maintain Your Brain (MYB) study is an online multi‐domain RCT targeting modifiable risk factors for dementia, including diet. This study investigated cross‐sectional associations between adherence to a MD pattern and cognition.MethodsParticipants enrolled in MYB were recruited from the Sax Institute’s larger 45 and Up Study, and included those with all baseline MYB assessments (n=6236). Diet was assessed using the validated Mediterranean Diet and Culinary Index tool. This 50‐item tool assesses intake of nine desirable and four undesirable features of the MD diet and allows derivation of the Mediterranean Diet Adherence Screener (MEDAS). Computerised cognitive tests, administered through the MYB digital platform, were used to assess domains of executive function, complex attention, learning and memory and global cognition.ResultsParticipants were 46% male, with mean (SD) age 65.0 (5.8) years, BMI 26.6 (4.9) kg/m2 and well educated (46% with tertiary education). Higher MEDAS scores were associated with being female, younger, better educated and having a lower BMI (all p&lt;0.001). Overall participant adherence to a MD pattern was low; MEDAS score 6.1 (2.1)/14. After covariate adjustment and correction for multiple analyses in hierarchical linear regression models, better MEDAS scores were significantly associated with worse (lower) z‐scores for executive function (β ‐0.018, p=0.003). For every 1‐point higher MEDAS score, executive function z‐scores were 0.018 lower. This unexpected negative association was clinically very small. There were no significant associations with other cognitive domains.ConclusionAdherence to a MD was sub‐optimal in this well‐educated Australian sample. The one unexpected finding is likely not clinically meaningful given its size. Additionally, as this was a cross‐sectional study, reverse causality cannot be ruled out. Results from the main MYB RCT will provide data on MD acceptance and impact in a Western dietary environment.

Chronic hypertension, perinatal mortality and the impact of preterm delivery: a population-based study.

To estimate the association between chronic hypertension and perinatal mortality and to evaluate the extent to which risks are impacted by preterm delivery. Cross-sectional analysis. United States, 2015-18. Singleton births (20-44 weeks of gestation). Chronic hypertension, defined as elevated blood pressure diagnosed before pregnancy or recognised before 20 weeks of gestation. We derived the risk of perinatal mortality in relation to chronic hypertension from Poisson models, adjusted for confounders. The impacts of misclassification and unmeasured confounding were assessed. Causal mediation analysis was performed to quantify the impact of preterm delivery on the association. Of the 15 090 678 singleton births, perinatal mortality rates were 22.5 and 8.2 per 1000 births in chronic hypertensive and normotensive pregnancies, respectively (adjusted risk ratio 2.05, 95% CI 2.00-2.10). Corrections for exposure misclassification and unmeasured confounding biases substantially increased the risk estimate. Although causal mediation analysis revealed that most of the association of chronic hypertension on perinatal mortality was mediated through preterm delivery, the perinatal mortality rates were highest at early term, term and late term gestations, suggesting that a planned early term delivery at 37-386/7 weeks may optimally balance risk in these pregnancies. Additionally, 87% (95% CI 84-90%) of perinatal deaths could be eliminated if preterm deliveries, as a result of chronic hypertension, were preventable. Chronic hypertension is associated with increased risk for perinatal mortality. Planned early term delivery and targeting modifiable risk factors for chronic hypertension may reduce perinatal mortality rates. Maternal chronic hypertension is associated with increased risk for perinatal mortality, largely driven by preterm birth.

Facilitators and barriers to implementing lifestyle intervention programme to prevent cognitive decline.

BackgroundThe Finnish Intervention Study to Prevent Cognitive Impairment and Disability is a randomized controlled trial that has tested the efficacy of a multidomain intervention targeting modifiable risk factors to prevent cognitive impairment/dementia. A combination of healthy diet, physical, social and cognitive activity, and management of cardiovascular risks was shown to be an effective model to promote brain health among older people. The aim of this qualitative study was to explore healthcare professionals’ perceptions of facilitators and barriers to implementing this lifestyle programme into health care.MethodsFour semi-structured focus group interviews were conducted among healthcare professionals working in primary care and in non-governmental organizations (N=27). Participants were asked to discuss their perceptions of facilitators and barriers for implementing the multidomain intervention into clinical practice. Interviews were analyzed using content analysis.ResultsBarriers and facilitators described by the healthcare professionals were related to infrastructure and resources, client’s personal characteristics and the lifestyle intervention itself. These main categories included several sub-categories related to knowledge, motivation, resources, individualization and collaboration. The interviewees pointed out that more education on dementia prevention is needed, the work should be coordinated efficiently, resources to provide preventive health care should be adequate and multiprofessional collaboration is needed.ConclusionsTransferring a lifestyle intervention from a trial-setting to real life requires knowledge about the factors that influence effective implementation. Identifying drivers and constraints of successful implementation helps to design and tailor future prevention programmes, increases motivation and adherence and supports system change.