Chagas disease is not associated with diabetes, metabolic syndrome, insulin resistance and beta cell dysfunction at baseline of Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Chagas disease (ChD) affects millions of people worldwide, being endemic in Latin America and emerging in the United States and Europe. Classically described as targeting the heart and gastrointestinal tract, Trypanosoma cruzi parasitism leads to structural and pro-inflammatory changes in the adipose tissue and pancreas. The effects of these changes on insulin resistance (IR), beta cell dysfunction, diabetes mellitus (DM),and metabolic syndrome (MS) are unclear. We aim to evaluate the association of ChD with DM, IR, beta cell dysfunction and MS in the baseline of multi-centric cohort study 'Brazilian Longitudinal Study of Adult Health' (ELSA-Brasil). This cross-sectional analysis included 14,922 (98%) participants of ELSA-Brasil at baseline. To investigate the associations of ChD with DM, IR (assessed by HOMA-IR) and beta cell dysfunction (assessed by HOMA beta), and MS we fitted logistic regression models including socio-demographic and anthropometric variables, health-related conditions and laboratory results. ChD, defined by positive serology, was prevalent in 1.9% (n = 283) of the sample, 17.3% (n = 49) of whom had cardiomyopathy. DM prevalence was 17.25% (n = 2574) and was not different among those with and without ChD (20.5% vs 17.2%; p = 0.28). Fasting and 2 h-blood glucose after a 75 g anhydrous glucose were slightly higher among participants positive for ChD, when compared with those with negative serology (102 mg/dL versus 100 mg/dL, respectively; and 127 mg/dL versus 124 mg/dL, respectively), only in univariate analysis. There was no significant association between these variables and ChD after adjustments. In addition, there was no significant association between DM, IR, beta cell dysfunction or MS and ChD (without and with cardiomyopathy). Our results showed that ChD, regardless of the presence of cardiomyopathy, is not associated with DM, IR, beta cell dysfunction or MS. These findings suggest the parasitism of the adipose tissue and pancreas in Chagas disease do not translate into clinically relevant glucose abnormalities.

Association of metabolic phenotypes, grip strength and diabetes risk: The 15-year follow-up of The North West Adelaide Health Study, Australia.

BACKGROUND: The association of diabetes risk in the long-term, metabolic phenotypes (MP) and muscle strength is unclear. We aimed to investigate the association between strictly defined MP, grip strength (GS) and diabetes. MATERIAL AND METHODS: MP were defined according to BMI and presence of any individual metabolic abnormality for ≥18 years, in participants of the North West Adelaide Health Study (Australia) free of diabetes at baseline. The association of MP and dominant hand GS with incident diabetes over 15-years follow-up and the moderation effect of GS on the association between diabetes and MP were investigated by logistic regression models. RESULTS: Of 3039 participants followed over 13.3 years (SD 2.6), 236 (7.8%) developed diabetes. Compared to the metabolically healthy (MH) normal weight phenotype, the metabolically unhealthy (MU) overweight (OR 6.15, 95%CI 2.43-15.59) and obese (OR 12.32, 95%CI 4.97-30.52) phenotypes were associated with a high risk of diabetes, but not the MU normal weight (OR 1.73, 95%CI 0.57-5.25), MH overweight (OR 1.15, 95%CI 0.31-4.31) or MH obese phenotypes (OR 0.77, 0.07-8.89). GS was inversely associated with diabetes (OR 0.97, 95% CI 0.95-0.99) and attenuated the risk associated with MU overweight (beta = -0.296, p = 0.039) and MU normal weight (beta = -0.773; p for interaction = 0.009). CONCLUSION: Strictly defined MP (rather than based on metabolic syndrome criteria) and GS, a proxy of muscle strength, might be useful for stratifying the risk of diabetes in the long-term. Improving muscle strength might be an important strategy to reduce diabetes risk.

Association between diabetes and cognitive function at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA- Brasil).

Diabetes has been associated with cognitive changes and an increased risk of vascular dementia and Alzheimer's disease, but it is unclear whether there are associations between diabetes and early alterations in cognitive performance. The present study consisted of a cross-section analysis of 14,444 participants aged 35-74 years and from a developing country at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil); these participants were recruited between 2008 and 2010. We investigated whether there was an association between diabetes and early changes in the cognitive performance of this Brazilian population. To assess cognitive domains, we used the word-list learning, word-list delayed recall and word recognition tests along. Phonemic verbal fluency tests included semantic phonemic test (animals) and a phonemic test (words beginning with the letter F). Executive functions associated with attention, concentration and psychomotor speed were evaluated using the Trail Making Test B. The exposure variable in the study was defined as diabetes. Multiple linear regression was used to estimate the association between diabetes and cognitive performance. The results were adjusted for age, sex, education, hypertension, coronary disease, depression, physical activity, smoking, alcohol consumption, and the cholesterol/HDL-C ratio. We found a significant association between diabetes and decreased memory, language and executive function (attention, concentration and psychomotor speed) performance in this population from a country with a distinct epidemiological profile, even after adjusting for the main intervening variables.

Accuracy of Self-Reported Weight Collected Through a Web-Based Platform in a Weight Loss Trial: Validation Study of the POEmaS Clinical Trial.

Self-reported anthropometric data in web-based weight loss interventions may be inaccurate. We studied the agreement between online self-reported and measured weight in the course of the POEmaS randomized controlled trial. Measured weight was not different from reported one (-0.4 kg; 95%CI -0.93 to 0.12). 95.6% of the cases were within the limits of agreement (Bland-Altman method). Self-reported weight collected online was accurate, which suggests that interventions and outcomes assessment can rely on these data.

Exploring the User Engagement Scale Short Form as a Determinant of Adherence in Digital Health Interventions.

Adherence determines the impact of digital health interventions. Standard tools provide a measure for user experience and predict adherence. We evaluated the User Engagement Scale Short Form (UES-SF) during the POEmaS project, a randomized clinical trial of an online weight loss platform. We received answers from 178 participants (13.7% of the cohort) and correlated the UES-SF scores with the number of sessions attended. Our findings suggest the UES-SF is an accurate evaluation of user experience, but only one domain (reward) was associated with long-term use.

The Care Informatics and Technologies Project - Enhancing Capability, Motivation and Opportunities in Digital Health Among Health Professionals and Students.

A change in the behaviour of the current and future workforce in regards to how they approach the needs and challenges in the healthcare sector is necessary to transit from the current curative paradigm in health to a new one focused on prevention and rational use of resources. Digital health is instrumental in the adoption of this new paradigm as most e-health applications focus on a preventive and personalized approach, on lifestyle changes (e.g. fitness and nutrition), health literacy and self-tracking allowing consumers to manage their own heath. The Capability-Opportunity-Motivation Behaviour (COM-B) model and the Behaviour Change Wheel framework (BCW) have been applied to characterise interventions for behaviour change in health professionals. They provide a systematic way of characterising interventions and enable their outcomes to be linked to mechanisms of action. Acknowledging the potential of informatics and technologies in current and emerging health issues and the importance of focusing on care needs rather than on the development of technologies per se to achieve meaningful clinical outcomes, the College of Nursing and Health Sciences (CNHS) in Flinders University is undertaking the Care Informatics and Technologies project. This priority project aims to build capacity in digital health within the College's students and staff, so that informatics, digitisation and technologies become part of clinical learning, research and ongoing clinical practice. We aim to report the protocol of this project and discuss it in the context of the expected change in behaviour of health professionals that is deemed necessary to address the Australian digital health agenda.

Web-Based Digital Health Interventions for Weight Loss and Lifestyle Habit Changes in Overweight and Obese Adults: Systematic Review and Meta-Analysis.

BACKGROUND: Obesity is a highly prevalent condition with important health implications. Face-to-face interventions to treat obesity demand a large number of human resources and time, generating a great burden to individuals and health system. In this context, the internet is an attractive tool for delivering weight loss programs due to anonymity, 24-hour-accessibility, scalability, and reachability associated with Web-based programs. OBJECTIVE: We aimed to investigate the effectiveness of Web-based digital health interventions, excluding hybrid interventions and non-Web-based technologies such as text messaging, short message service, in comparison to nontechnology active or inactive (wait list) interventions on weight loss and lifestyle habit changes in individuals with overweight and obesity. METHODS: We searched PubMed or Medline, SciELO, Lilacs, PsychNet, and Web of Science up to July 2018, as well as references of previous reviews for randomized trials that compared Web-based digital health interventions to offline interventions. Anthropometric changes such as weight, body mass index (BMI), waist, and body fat and lifestyle habit changes in adults with overweight and obesity were the outcomes of interest. Random effects meta-analysis and meta-regression were performed for mean differences (MDs) in weight. We rated the risk of bias for each study and the quality of evidence across studies using the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS: Among the 4071 articles retrieved, 11 were included. Weight (MD -0.77 kg, 95% CI -2.16 to 0.62; 1497 participants; moderate certainty evidence) and BMI (MD -0.12 kg/m2; 95% CI -0.64 to 0.41; 1244 participants; moderate certainty evidence) changes were not different between Web-based and offline interventions. Compared to offline interventions, digital interventions led to a greater short-term (<6 months follow-up) weight loss (MD -2.13 kg, 95% CI -2.71 to -1.55; 393 participants; high certainty evidence), but not in the long-term (MD -0.17 kg, 95% CI -2.10 to 1.76; 1104 participants; moderate certainty evidence). Meta-analysis was not possible for lifestyle habit changes. High risk of attrition bias was identified in 5 studies. For weight and BMI outcomes, the certainty of evidence was moderate mainly due to high heterogeneity, which was mainly attributable to control group differences across studies (R2=79%). CONCLUSIONS: Web-based digital interventions led to greater short-term but not long-term weight loss than offline interventions in overweight and obese adults. Heterogeneity was high across studies, and high attrition rates suggested that engagement is a major issue in Web-based interventions.

Implementation of a text message intervention to promote behavioural change and weight loss among overweight and obese Brazilian primary care patients.

INTRODUCTION: Mobile-technology-based interventions are promising strategies for promoting behavioural change in obese patients. The aims of this study were to evaluate the feasibility of implementing a text message intervention, and to assess the effects of the intervention on body mass index (BMI) and self-reported behavioural change. METHODS: TELEFIT was a three-phase feasibility study comprising the following stages: (a) the development of text messages; (b) testing; and (c) a quasi-experimental pilot study in which patients who were engaged in obesity/overweight educational groups in public primary care centres in Belo Horizonte, Brazil, were recruited. A bank of text messages was drafted and reviewed by an expert panel, text message delivery software was developed and tested, and a pilot study assessed patients before and after receiving the intervention using validated questionnaires and body measures. The data were analysed using the Wilcoxon test. RESULTS: A total of 46 patients completed the follow-up; 93.5% were women and the median age was 42 years (interquartile range (IQR) 34-52 years). At four months, participants had a significant reduction in BMI (median 31.3 (IQR 28.2-34.6) vs. 29.9 (IQR 27.2-34.6) kg/m2, p < 0.001), systolic (median 125 (IQR 120-132) vs. 120 (IQR 110-130) mmHg, p = 0.013) and diastolic blood pressure (median 80 (IQR 70-100) vs. 80 (IQR 70-80) mmHg, p = 0.006), when compared to baseline. All patients reported to be satisfied and willing to continue receiving the intervention, and 93.3% felt that the intervention helped them change their behaviours. DISCUSSION: This study has shown that a text message intervention to promote behavioural change and weight loss was feasible and effective in a short-term period. Participants were satisfied and willing to continue receiving the SMS messages.

Using the Behaviour Change Wheel for Designing an Online Platform for Healthy Weight Loss - "POEmaS".

INTRODUCTION: Behaviour change is a key point in weight management. Digital health interventions are attractive tools to deliver behaviour interventions for weight loss, due to the potential to reach a large number of people. We aimed to report how the Behaviour Change Wheel (BCW) was used to develop and implement a web platform to promote weight loss in Brazilian adults with overweight and obesity. Moreover, we aimed to describe the first 12 weeks of usage of the platform in a randomized controlled trial. METHODS: The BCW framework was used to define intake of fruit/vegetables, ultra-processed products and sweetened beverages, leisure physical activity and sitting time as target behaviours. The BCW components of behaviour-capability, opportunity and motivation were used to make a behaviour diagnosis of the population and BCW second layer oriented the selection of information, goal setting, self-monitoring, feedback, social support and incentives as behaviour techniques. Using these behaviour techniques, a 24-week behaviour intervention delivered by seven different platform functionalities was developed. The platform was tested in a three-arm parallel (basic platform versus enhanced platform versus minimal intervention control group) randomized controlled trial from September 2017 to April 2018. In the present analysis, we classified the platform functionalities according to the BCW behaviour component (capability, opportunity and behaviour) and used descriptive statistics and Spearman correlations to report functionalities usage according to the BCW behaviour component over the first 12 weeks of the trial. The study was approved by the Ethics Committee of the Federal University of Minas Gerais, Brazil and was registered under NCT 03435445. RESULTS: Over the first 12 weeks of the RCT, the 809 participants (619, 76.5% women; mean age 33.7 years, SD 10.3; mean BMI 29.9 kg/m2, SD 4.3) were enrolled for use of the basic and enhance versions of the platform. Capability-driven functionalities were accessed by 455 (56.2%) users with median access of 1 (IQR 1-6) times, whereas opportunity-driven platform functionalities were accessed by 592 participants with 8 (IQR 1-27) median access times and motivation-driven functionalities were accessed by 560 (69.2%) participants with 13 (IQR 1-30) median times of access. Spearman correlations between the use of capability and opportunity functionalities, capability and motivation functionalities and opportunity and motivation functionalities were 0.74 (95% CI 0.70-0.77), 0.74 (95% CI 0.70-0.78), 0.89 (95% CI 0.87-0.91), respectively. DISCUSSION: BCW provided a systematic approach to planning, designing and implementing a complex weight loss intervention based on behaviour change. Moreover, it promoted a clear understanding of the relation between platform functionalities and behaviour determinants. The low use of the capability-driven functionalities might have been related to lack of accuracy in the behaviour diagnosis, as well as to implementation issues. The high correlation between the functionalities use suggests that the BCW approach did not determine the platform usage profile. CONCLUSION: The BCW provided a framework for an evidence-based intervention on weight loss delivered by a web platform. Using the framework led to a clear understanding of the behaviour determinants and their relation to the platform features.

C-reactive protein and B-type natriuretic peptide yield either a non-significant or a modest incremental value to traditional risk factors in predicting long-term overall mortality in older adults.

BACKGROUND: New biomarkers may aid in preventive and end-of-life decisions in older adults if they enhance the prognostic ability of traditional risk factors. We investigated whether C-reactive protein (CRP) and/or B-type natriuretic peptide (BNP) improve the ability to predict overall mortality among the elderly of the Bambuí, Brazil Study of Aging when added to traditional risk factors. METHODS: From 1997 to 2007, 1,470 community-dwelling individuals (≥60 years) were followed-up. Death was ascertained by continuous verification of death certificates. We calculated hazard ratios per 1 standard deviation change (HR) of death for traditional risk factors only (old model), and traditional risk factors plus CRP and/or BNP (new models) and assessed calibration of the models. Subsequently, we compared c-statistic of each of the new models to the old one, and calculated integrated discriminative improvement (IDI) and net reclassification improvement (NRI). RESULTS: 544 (37.0%) participants died in a mean follow-up time of 9.0 years. CRP (HR 1.28, 95% CI 1.17-1.40), BNP (HR 1.31 95% CI 1.19-1.45), and CRP plus BNP (HR 1.26, 95% CI 1.15-1.38, and HR 1.29, 95% CI 1.16-1.42, respectively) were independent determinants of mortality. All models were well-calibrated. Discrimination was similar among the old (c-statistic 0.78 [0.78-0.81]) and new models (p=0.43 for CRP; p=0.57 for BNP; and p=0.31 for CRP plus BNP). Compared to the old model, CRP, BNP, and CRP plus BNP models led to an IDI of 0.009 (p<0.001), -0.005 (p<0.001) and -0.003 (p=0.84), and a NRI of 0.04 (p=0.24), 0.07 (p=0.08) and 0.06 (p=0.10), respectively. CONCLUSIONS: Despite being independent predictors of long-term risk of death, compared to traditional risk factors CRP and/or BNP led to either a modest or non-significant improvement in the ability of predicting all-cause mortality in older adults.

Overweight and class I obesity are associated with lower 10-year risk of mortality in Brazilian older adults: the Bambuí Cohort Study of Ageing.

BACKGROUND: Prospective studies mostly with European and North-American populations have shown inconsistent results regarding the association of overweight/obesity and mortality in older adults. Our aim was to investigate the relationship between overweight/ obesity and mortality in an elderly Brazilian population. METHODS AND FINDINGS: Participants were 1,450 (90.2% from total) individuals aged 60 years and over from the community-based Bambuí (Brazil) Cohort Study of Ageing. From 1997 to 2007, 521 participants died and 89 were lost, leading to 12,905 person-years of observation. Body mass index (BMI) and waist circumference (WC) were assessed at baseline and at the 3rd and 5th years of follow-up. Multiple imputation was performed to deal with missing values. Hazard ratios (HR) of mortality for BMI or WC alone (continuous and categorical), and BMI and WC together (continuous) were estimated by extended Cox regression models, which were fitted for clinical, socioeconomic and behavioral confounders. Adjusted absolute rates of death at 10-year follow-up were estimated for the participants with complete data at baseline. Continuous BMI (HR 0.85; 95% CI 0.80-0.90) was inversely related to mortality, even after exclusion of smokers (HR 0.85; 0.80-0.90), and participants who had weight variation and died within the first 5 years of follow-up (HR 0.83; CI 95% 0.73-0.94). Overweight (BMI 25-30 kg/m(2)) was inversely (HR 0.76; 95%CI 0.61-0.93) and obesity (BMI ≥ 30 kg/m(2); HR 0.85; 95% CI 0.64-1.14) not significantly associated with mortality. Subjects with BMI between 25-35 kg/m(2) (23.8-25.9%) had the lowest absolute rates of death at 10-years follow-up. The association between WC and death was not significant, except after adjusting WC for BMI levels, when the relationship turned into marginally positive (HR 1.01; CI 95% 1.00-1.02). CONCLUSIONS: The usual BMI and WC cut-off points should not be used to guide public health and clinical weight control interventions in elderly in Brazil.

Strain imaging in morbid obesity: insights into subclinical ventricular dysfunction.

BACKGROUND: Obesity has become an important health problem throughout the world. Early detection of cardiovascular abnormalities may be useful in the future for patient management. This study aimed to identify subclinical ventricular dysfunction in obese patients. HYPOTHESIS: Morbid obesity is associated with ventricular dysfunction. METHODS: Doppler echocardiogram was performed in 92 morbidly obese and in 31 healthy controls. Conventional echocardiography and tissue Doppler-based strain imaging were used to analyze ventricular function. Intra- and interobserver strain imaging variabilities were tested on 15 randomly selected cases. RESULTS: Left ventricular (LV) global strain (22.5% ± 3.5 vs 24.4% ± 2.5, P<0.005) and right ventricular (RV) strain (25.8% ± 5.2 vs 28.2% ± 5.2, P<0.029) were lower in obese patients when compared with healthy controls. Echocardiographic parameters of diastolic function were also different from controls. LV strain correlated with LV mass, E/e' ratio, left atrial volume, and RV strain. At multivariate analysis, morbid obesity remained a significant determinant of global LV strain, independently of associated comorbidities. CONCLUSIONS: These findings suggest that incipient biventricular dysfunction is present in morbidly obese patients when new echocardiographic indices are used to investigate ventricular function. In addition, strain imaging may provide a more accurate assessment of the ventricular function in obese patients.