UK Recommendations Research Articles

Inadequacy of Protein Intake in Older UK Adults.

The current dietary recommendation for protein intake in the UK is 0.75 g/kg/day, however, this population-wide recommendation does not necessarily reflect altered requirements for older adults to maintain muscle protein synthesis, nor does it encompass the potential impact of intake timing. Optimal muscle protein synthesis in older adults requires both higher intake requirements and a distribution of protein intake above a 25 g threshold, three times across the day. This study aimed to describe the protein intake of older adults in a UK region and compare the results to recommendations. The study re-assessed two existing datasets with rich diet information for older adults in the South Yorkshire area. Data were extracted from food diaries of 256 adults aged between 65 and 89 years old (mean ± SD 72.4 ± 5.3 years). Quantity and timing of intake were coded using Nutritics software and compared to recommendations. The relationship between body mass index (BMI), age, and protein intake was explored. Fewer than 50% of the participants met current UK recommendations (0.75 g/kg/day) and fewer than 15% met the ESPEN 1.2 g/kg/day age-specific recommendation. Only one participant met the 25 g/meal recommendation across three meals. These findings suggest that the older adult population is not achieving recommendations to maintain muscle protein synthesis. Nonetheless it identifies several straightforward opportunities for improvement, notably elevation of morning intake.

Dietary and lifestyle patterns in UK postpartum women

AbstractIntroductionHealthy dietary and physical activity behaviours during and after pregnancy are important for optimal maternal health. Unhealthy lifestyle habits promote excessive weight gain during pregnancy or weight retention in the postpartum period, which increase the risk of obesity. The aim of this study was to explore dietary habits and associated lifestyle patterns and barriers to healthy eating in UK postpartum women.MethodsCross-sectional study of 228 females (56.1% were 25–34 years old) with a mean postpartum period of 5.73 ± 3.31 months. Participants completed an online survey exploring eating habits, weight status, sleep duration, breastfeeding, nutrition knowledge, physical activity, provision of advice and barriers to healthy eating during the postpartum period. A sub-sample of 34 women (50% of the sample were between 35–44 years old) completed an optional online dietary intake assessment using a multiple-pass 24-hour recall.ResultsIn total, 73.7% were not meeting the five a day fruit and vegetable UK recommendations, 40.4% of women were skipping breakfast and 44.7% were skipping lunch every day. Average weight gain from pre-pregnancy to postpartum was 5.56 ± 4.61 kg (range = 0.8 to 25 kg) with only 2.2% of women meeting current UK physical activity guidelines during the postpartum period. Consumption of high calorie snacks and meal skipping were significantly higher during the postpartum period compared to pre-pregnancy (p < 0.01). Women who were breastfeeding had significantly lower body mass index than those who were bottle feeding (p < 0.05). Fatigue, lack of time and feeling stressed had the most impact on women's ability to eat healthily. Barriers to consume a balanced healthy diet were significantly greater for women with low combined household income and those having three or more children (p < 0.05). Poor nutrition knowledge was significantly associated with increased meal skipping (p < 0.05). The sub-sample dietary analysis (N = 34) showed that women were not meeting the UK Dietary Reference Values for energy, fibre, iron, and vitamin D intakes. Those breastfeeding were not meeting requirements for calcium and zinc.DiscussionTo our knowledge, this is the first study to explore dietary habits and lifestyle patterns in UK postpartum women. Health care professionals should support women to adopt lifestyle behaviours following childbirth, with a greater focus on those likely to be experiencing more barriers. Advice given to women during the postpartum period needs to be tailored to potential differences in sociodemographic characteristics, pre-pregnancy health status and baseline nutrition knowledge and target multiple dietary and lifestyle behaviours.

Factors predicting poor glycemic control in the first two years of childhood onset type 1 diabetes in a cohort from East London, UK: Analyses using mixed effects fractional polynomial models.

Background/ObjectivePoor early glycemic control in childhood onset type 1 diabetes (T1D) is associated with future risk of acute and chronic complications. Our aim was to identify the predictors of higher glycated hemoglobin (HbA1c) within 24 months of T1D diagnosis in children and adolescents.MethodsMixed effects models with fractional polynomials were used to analyze longitudinal data of patients <19 years of age, followed from T1D diagnosis for up to 2 years, at three diabetes clinics in East London, United Kingdom.ResultsA total of 2209 HbA1c observations were available for 356 patients (52.5% female; 64.4% non‐white), followed from within 3 months of diagnosis during years 2005 to 2015, with a mean ± SD of 6.2 ± 2.5 HbA1c observations/participant. The mean age and HbA1c at diagnosis were 8.9 ± 4.3 years and 10.7% ±4.3% (or expressed as mmol/mol HbA1c mean ± SD 92.9 ± 23.10 mmol/mol) respectively.Over the 2 years following T1D diagnosis, HbA1c levels were mostly above the National Institute for Health, Care and Excellence (NICE), UK recommendations of 7.5% (<58 mmol/mol). Significant (P < .05) predictors of poorer glycemic control were: Age at diagnosis (12‐18 years), higher HbA1c at baseline (>9.5%, ie, >80 mmol/mol), clinic site, non‐white ethnicity, and period (pre‐year 2011) of diagnosis. Additionally in univariable analyses, frequency of clinic visits, HbA1c at diagnosis, and type of insulin treatment regimen showed association with poor glycemic control (P < .05).ConclusionsMajor risk factors of poorer glycemic control during 3‐24 months following childhood onset T1D are: diagnosis prior to 2011, higher HbA1c levels at baseline, age at diagnosis, non‐white ethnicity, and clinic site.

Postępowanie okołoporodowe u noworodka matki nosicielki hemofilii

The purpose of this work is to discuss the initial neonatal care for a newborn in whom haemophilia can be suspected before birth. Hemophilia is the most common congenital hemorrhagic diathesis. Some children inherit this disease from their mother, so it is important to determine the genetic status of the mother before giving birth. For this purpose are used the analysis of the family pedigree of the mother's family and prenatal examinations, if the disease occurred in the family. In the case of this disease, it is debatable to use invasive methods of prenatal testing. People with hemophilia in Poland are covered by the National Program for the Treatment of Haemophilia patients and other hemorrhagic blemishes. They receive recombinant blood clotting factors. Thanks to such substitution treatment, the survival and comfort of life of people with haemophilia has significantly improved. Female carriers are more likely to opt for offspring. However, the determining factor for a better prognosis is the detection of the disease in the child as soon as possible. Thanks to this, serious consequences of hemophilia can be avoided. Currently, there are no consistent standards for the care of such a newborn in the Polish maternity and neonatal wards. This work mainly uses UK recommendations.

Vitamin D prescribing in children in UK primary care practices: a population-based cohort study

ObjectiveTo examine temporal changes in the incidence and patterns of vitamin D supplementation prescribing by general practitioners (GPs) between 2008 and 2016.DesignPopulation-based cohort study.SettingUK general practice health records from The...

PDB42 COST-EFFECTIVENESS ANALYSIS FOR HBA1C TEST INTERVALS IN PATIENTS ON TREATMENT FOR STABLE TYPE 2 DIABETES

To determine the optimal HbA1c test interval strategy among type 2 diabetes mellitus (T2DM) patients with stable glycemic control. Markov model was built to study the optimal glycemic monitoring among T2DM patients with stable glycemic control. In the Markov model, different HbA1c test intervals were compared to evaluate costs per quality-adjusted life year (QALY) and the incremental cost-effectiveness ratio (ICER). We compared every 3 months intervals (current Japanese strategy), every six months (US and UK recommendations) and annual monitoring, focusing on HbA1c test characteristics of signal (true change) and noise (error), which were reported in the previous study. All model parameters including screening and treatment costs, complication and mortality rates and utilities were also drawn from published studies. The willingness-to-pay threshold in cost-effectiveness analysis was set to US $50,000/QALY. Based on our analysis, annual interval was most cost-effective to monitor T2DM patients with stable glycemic control. Three months interval was dominated. ICER for annual interval was $463.39/QALY compared to 6 months interval. Once patients achieve stable glycemic control at their HbA1c goal, an informative interval for HbA1c monitoring is once every year. Current guidelines, which suggest testing every six months, may contribute to substantial over-testing.

Nutrient Composition of Popularly Consumed African and Caribbean Foods in The UK.

(1) Background: Traditional foods are important in the diets of Black Africans and Caribbeans and, more widely, influence UK food culture. However, little is known about the nutritional status of these ethnic groups and the nutrient composition of their traditional foods. The aim was to identify and analyse African and Caribbean dishes, snacks and beverages popularly consumed in the UK for energy, macronutrients and micronutrients. (2) Methods: Various approaches including focus group discussions and 24-h dietary recalls were used to identify traditional dishes, snacks, and beverages. Defined criteria were used to prioritise and prepare 33 composite samples for nutrient analysis in a UK accredited laboratory. Quality assurance procedures and data verification were undertaken to ensure inclusion in the UK nutrient database. (3) Results: Energy content ranged from 60 kcal in Malta drink to 619 kcal in the shito sauce. Sucrose levels did not exceed the UK recommendation for adults and children. Most of the dishes contained negligible levels of trans fatty acid. The most abundant minerals were Na, K, Ca, Cu, Mn and Se whereas Mg, P, Fe and Zn were present in small amounts. (4) Conclusion: There was wide variation in the energy, macro- and micronutrients composition of the foods analysed.

Geographic variation in the use of lymphadenectomy and external-beam radiotherapy for endometrial cancer: a cross-sectional analysis of population-based data.

To quantify geographic variation in the use of lymphadenectomy and/or external-beam radiotherapy (EBRT) for endometrial cancer in England. Cross-sectional analysis of population-based data. English cancer registry data, linked to chemotherapy, radiotherapy and hospital episodes statistics data. Twenty-two thousand four hundred and eighty-three women with endometrial cancer presenting without clinical or radiological evidence of distant metastatic spread, diagnosed in England from 2013 to 2016. Proportions of patients receiving lymphadenectomy and/or EBRT were compared across 19 Cancer Alliances, to identify variations in clinical practice. Two separate logistic regression models assessed the impact on variation of adjustment for tumour and patient characteristics. Receipt of lymphadenectomy, receipt of EBRT. There was substantial variation by Cancer Alliance in the adjusted proportion of women with endometrial cancer receiving lymphadenectomy (range 5% [95% CI 4-6%] to 48% [95% CI 45-52%]) and EBRT (range 10% [95% CI 7-12%] to 31% [95% CI 28-33%]), after adjusting for variation in pathological grade, age, comorbidities, deprivation, ethnic group and (EBRT only) FIGO stage. Different approaches to clinical practice were identified; (i) one Cancer Alliance had significantly higher than average lymphadenectomy and significantly lower than average EBRT use, (ii) three had high use of both lymphadenectomy and EBRT, (iii) one had low lymphadenectomy use and high EBRT use, and (iv) three had low use of both lymphadenectomy and EBRT. Lymphadenectomy is probably used to triage for EBRT when lymphadenectomy use is high and EBRT use is low. This is probably a result of variation in local endometrial cancer management guidelines, suggesting that UK recommendations should be clarified. There is geographic variation in England in the use of lymphadenectomy and radiotherapy to treat endometrial cancer.

Second-line Glucose-Lowering Therapy in Type 2 Diabetes Mellitus.

There is consensus that metformin should be the first-line pharmacological therapy for type 2 diabetes. Although new evidence on effective treatments for type 2 diabetes is rapidly evolving, there is uncertainty regarding the optimal choice of second-line therapy. Our aim was to review the current major guidelines for second-line therapy in type 2 diabetes, along with findings from the recent cardiovascular outcome trials, focusing on two particularly promising classes of glucose-lowering drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP1 RAs). In the recent randomized controlled trials, two SGLT2 inhibitors (i.e., empagliflozin and canagliflozin) and two GLP1 RAs (i.e., liraglutide and albiglutide) reduced cardiovascular events in patients with type 2 diabetes, of whom most had established atherosclerotic cardiovascular disease. Some clinical guidelines have changed their recommendations for second-line therapy based on these findings. The first choice for a second-line therapy by the new American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines is SGLT2 inhibitors or GLP1 RAs for patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. For patients without these conditions, the ADA/EASD lists five options of noninsulin second-line therapy without a suggested hierarchy of use. On the other hand, the 2019 consensus statement from the American Association of Clinical Endocrinologists/American College of Endocrinology lists nine hierarchical options, with GLP1 RAs as the first recommended therapy, followed by SGLT2 inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors, and sulfonylurea as the last option. The American College of Physicians recommends four oral treatment options, which do not include GLP1 RAs. The International Diabetes Federation recommends sulfonylureas, DPP4 inhibitors, or SGLT2 inhibitors as preferred second-line drugs with GLP1 RAs as an alternative in obese patients. The World Health Organization strongly recommends sulfonylureas in low-resource settings. The National Institute for Health and Care Excellence in the UK recommends DPP4 inhibitors, thiazolidinediones, or sulfonylureas, with use of SGLT2 inhibitors only under special circumstances. Clinical guidelines for the choice of second-line therapy in type 2 diabetes are inconsistent. A comprehensive assessment of the risks and benefits of second-line therapy is needed to address knowledge gaps that underlie core clinical practice.

Priorities for research in multiple conditions in later life (multi-morbidity): findings from a James Lind Alliance Priority Setting Partnership.

multiple conditions in later life (multi-morbidity) is a major challenge for health and care systems worldwide, is of particular relevance for older people, but has not (until recently) received high priority as a topic for research. We have identified the top 10 research priorities from the perspective of older people, their carers, and health and social care professionals using the methods of a James Lind Alliance Priority Setting Partnership. in total, 354 participants (162 older people and carers, 192 health professionals) completed a survey and 15 older people and carers were interviewed to produce 96 'unanswered questions'. These were further refined by survey and interviews to a shortlist of 21 topics, and a mix of people aged 80+ living with three or more conditions, carers and health and social care providers to prioritised the top 10. the key priorities were about the prevention of social isolation, the promotion of independence and physical and emotional well-being. In addition to these broad topics, the process also identified detailed priorities including the role of exercise therapy, the importance of falls (particularly fear of falling), the recognition and management of frailty and Comprehensive Geriatric Assessment. these topics provide a unique perspective on research priorities on multiple conditions in later life and complement existing UK and International recommendations about the optimisation of health and social care systems to deliver essential holistic models of care and the prevention and treatment of multiple co-existing conditions.

Whooping cough and travel: advising patients on guidelines

With the recent re-emergence of whooping cough, practice nurses may encounter travellers seeking advice on this vaccine more frequently. Mary Gawthrop provides a brief update on UK vaccination provisions and Public Health England recommendations The re-emergence of whooping cough (also known as pertussis) worldwide may be a concern for travellers, particularly those visiting newborn babies in countries reporting an increase in cases. Newborns can become significantly unwell if they catch pertussis, therefore it is recommended that infants are vaccinated against the infection as a routine childhood vaccination. In particular, children aged under 6 months old have a higher risk of severe complications: they may experience breathing difficulties and can even stop breathing for short periods. The following article provides a brief update that summarises routine UK vaccine provisions and recommendations for adults and children over 10 years old requesting information about the pertussis vaccine prior to international travel.

Are chest compressions learned in two minutes by untrained bystanders a suitable alternative to fatigued trained cardiopulmonary resuscitation providers?

Background: Fatigue is a detrimental factor in the quality of chest compressions (CC). The Resuscitation Council UK (2015) recommends frequent changes between two or more trained cardiopulmonary resuscitation providers (TCPR) to avoid fatigue, but no mention is made of what to do if there is only one TCPR and an untrained bystander (UCPR). To address these situations, in this study we explored if CC delivered UCPR could be a suitable alternative to fatigued CPR trained providers in an out of hospital cardiac arrest, when learned by observation and a talk through during a period of two minutes.

Factors influencing application of behavioural science evidence by public health decision-makers and practitioners, and implications for practice.

The National Institute of Health and Care Excellence (NICE) in the UK recommends behavioural science evidence underpins public health improvement services. In practice, level of implementation varies. This study is the first to explore factors affecting use of behaviour-specific evidence by public health decision-makers and practitioners for design and delivery of health improvement services. Twenty semi-structured interviews were conducted, along with a review of the commissioning cycle with public health decision-makers and practitioners across a range of health improvement fields (e.g. weight management). Interviews were informed and analysed using the Theoretical Domains Framework (TDF). Limited comprehension of behaviour change, challenges identifying specific behaviour change strategies and translating research into practice were prevalent. Local authority processes encouraged uptake of evidence to justify solutions as opposed to evidence-driven decision-making. Some decision-makers perceived research evidence may stifle innovation and overwhelm practitioners. Potential facilitators of research use included: ensuring uptake and implementation of evidence is compulsory within commissioning and its potential to show value for money. A strong belief in local evidence and achieving outcomes were identified as barriers to research evidence uptake. Social and environmental challenges included cultural, political, and workload pressures and journal article accessibility. Embedding behavioural science systematically into public health practice requires changes throughout the public health system; from priorities set by national public health leaders to the way in which relevant evidence is disseminated. Framing factors affecting use of behavioural science evidence using the TDF is helpful for identifying the range of interventions and support needed to affect change.

Improving patient care and outcomes: Standardisation of resuscitation training and equipment provision for health care providers

Background: The Resuscitation Council UK recommends standardisation of equipment used for CPR, throughout an entire organisation. It is recognised that NHS collaboration with the private health care sector occurs more frequently in the UK in this current health care environment. This audit aimed to assess the provision of current resuscitation equipment of privately owned static and mobile medical imaging MRI, PET and CT facilities provided by Alliance healthcare to NHS patients.

Impact of issuing longer- versus shorter-duration prescriptions: a systematic review

Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown. To examine the impact of longer-duration (2-4 months) versus shorter-duration (28-day) prescriptions. Systematic review of primary care studies. Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2-4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists' time and/or costs, patient experience, and patient out-of-pocket costs. From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events. There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.

Early initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study protocol for a randomised controlled trial and economic evaluation

IntroductionCurrent guidelines recommend abstinence from supervised cardiac rehabilitation (CR) exercise training for 6 weeks post-sternotomy. This practice is not based on empirical evidence, thus imposing potentially unnecessary activity restrictions. Delayed...

Economic evaluation of type 2 diabetes prevention programmes: Markov model of low- and high-intensity lifestyle programmes and metformin in participants with different categories of intermediate hyperglycaemia

BackgroundNational guidance on preventing type 2 diabetes mellitus (T2DM) in the UK recommends low-intensity lifestyle interventions for individuals with intermediate categories of hyperglycaemia defined in terms of impaired fasting glucose (IFG) or ‘at-risk’ levels of HbA1c. In a recent systematic review of economic evaluations of such interventions, most studies had evaluated intensive trial-based lifestyle programmes in participants with impaired glucose tolerance (IGT). This study examines the costs and effects of different intensity lifestyle programmes and metformin in participants with different categories of intermediate hyperglycaemia.MethodsWe developed a decision tree and Markov model (50-year horizon) to compare four approaches, namely (1) a low-intensity lifestyle programme based on current NICE guidance, (2) a high-intensity lifestyle programme based on the US Diabetes Prevention Program, (3) metformin, and (4) no intervention, modelled for three different types of intermediate hyperglycaemia (IFG, IGT and HbA1c). A health system perspective was adopted and incremental analysis undertaken at an individual and population-wide level, taking England as a case study.ResultsLow-intensity lifestyle programmes were the most cost-effective (£44/QALY, £195/QALY and £186/QALY compared to no intervention in IGT, IFG and HbA1c, respectively). Intensive lifestyle interventions were also cost-effective compared to no intervention (£2775/QALY, £6820/QALY and £7376/QALY, respectively, in IGT, IFG and HbA1c). Metformin was cost-effective relative to no intervention (£5224/QALY, £6842/QALY and £372/QALY in IGT, IFG and HbA1c, respectively), but was only cost-effective relative to other treatments in participants identified with HbA1c. At a willingness-to-pay threshold of £20,000/QALY, low- and high-intensity lifestyle programmes were cost-effective 98%, 99% and 98% and 81%, 81% and 71% of the time in IGT, IFG and HbA1c, respectively. An England-wide programme for 50–59 year olds could reduce T2DM incidence by < 3.5% over 50 years and would cost 0.2–5.2% of the current diabetes budget for 2–9 years.DiscussionThis analysis suggests that current English national policy of low-intensity lifestyle programmes in participants with IFG or HbA1c will be cost-effective and have the most favourable budget impact, but will prevent only a fraction of cases of T2DM. Additional approaches to prevention need to be investigated urgently.

Complementary and Alternative Medicine Use and Initiatives in Europe

Complementary and Alternative Medicine Use and Initiatives in Europe

Detection And Management Of Diabetes In England: Results From The Health Survey For England

As part of a control strategy current guidance in the UK recommends more intense surveillance of HbA1C levels among those of South-east Asian or Chinese ethnicity above specified BMI thresholds. The objective of this study was to determine whether disparities in the identification and control of diabetes in England persisted despite these guidelines and assess current strategies in light of these findings. Data were extracted from the 2013 Health Survey for England that included ethnicity, BMI status and HbA1C levels. Descriptive statistics and logistic regression analyses were used to examine relationships among undetected diabetes, poorly controlled diabetes and a range of covariates including ethnicity and BMI. Concentration indices were used to examine the socio-economic gradient in disease detection and control among and between ethnic groups. In regression models that controlled for a range of covariates Asians were found to have a 5% point higher risk of undetected diabetes than Whites. With respect to disease management, Bangladeshis and Pakistanis were found to be at a 28% point and 21% point higher risk of poor disease control respectively than Whites. Concentration indices revealed better disease control among more affluent Whites than poor Whites, no significant pattern between income and disease management was found among Pakistanis and poorer disease control was more evident among more affluent than poorer Bangladeshis. In the UK current guidance recommends practitioners consider testing for diabetes among South-east Asians and Chinese where BMI exceeds 23. Our findings suggest that the risk experienced by Asians in disease detection is independent of BMI and may warrant a more active screening policy than currently recommended. With respect to disease management, our findings suggest that Indians and Pakistanis experience particularly high levels of poor disease control that may also be usefully reflected in guidance.

Detection and Management of Diabetes in England: Results from the Health Survey for England.

IntroductionAs part of a control strategy current guidance in the UK recommends more intense surveillance of HbA1C levels among those of South-east Asian or Chinese ethnicity above specified BMI thresholds. The objective of this study was to determine whether disparities in the identification and control of diabetes in England persisted despite these guidelines and assess current strategies in light of these findings.MethodsData were extracted from the 2013 Health Survey for England that included ethnicity, BMI status and HbA1C levels. Descriptive statistics and logistic regression analyses were used to examine relationships among undetected diabetes, poorly controlled diabetes and a range of covariates including ethnicity and BMI. Concentration indices were used to examine the socio-economic gradient in disease detection and control among and between ethnic groups.ResultsIn regression models that controlled for a range of covariates Asians were found to have a 5% point higher risk of undetected diabetes than Whites. With respect to disease management, Bangladeshis and Pakistanis were found to be at a 28% point and 21% point higher risk of poor disease control respectively than Whites. Concentration indices revealed better disease control among more affluent Whites than poor Whites, no significant pattern between income and disease management was found among Pakistanis and poorer disease control was more evident among more affluent than poorer Bangladeshis.ConclusionIn the UK current guidance recommends practitioners consider testing for diabetes among South-east Asians and Chinese where BMI exceeds 23. Our findings suggest that the risk experienced by Asians in disease detection is independent of BMI and may warrant a more active screening policy than currently recommended. With respect to disease management, our findings suggest that Indians and Pakistanis experience particularly high levels of poor disease control that may also be usefully reflected in guidance.