Incorporating selected non-communicable diseases into facility-based surveillance systems from a resource-limited setting in Africa.

BACKGROUND: As Mozambique faces a double burden of diseases, with a rise of Non Communicable Diseases (NCD) superimposed to uncontrolled communicable diseases (CD), routine disease surveillance system does not include NCD. The objectives of our study were to i) upgrade of the current surveillance system by adapting the data collection tools to NCD; ii) describe the occurrence and profile of selected NCD using these data collection tools. METHODS: Workshops were implemented in a first referral urban hospital of Mozambique to train clinical staff, administrative workers and nurses on NCD surveillance, as well as select conditions to be prioritized. Based on the WHO Global Action Plan and Brazaville Declaration for NCD prevention and control, we selected arterial hypertension, diabetes, stroke, chronic respiratory diseases, mental illness and cancers. Data collection tools used for CD were changed to include age, gender, outcome and visit type. Between February/2014 and January/2015 we collected data at an urban hospital in Mozambique's capital. RESULTS: Over 12 months 92,018 new patients were assisted in this hospital. Data was missing or diagnosis was unreadable in 2637 (2.9%) thus only 89,381 were used for analysis; of these 6423 (median age 27 years; 58.4% female) had at least one selected NCD as their primary diagnosis: arterial hypertension (2397;37.31%), mental illness (1497;23.30%), asthma (1495;23.28%), diabetes (628;9.78%), stroke (299;4.66%), chronic obstructive pulmonary disease 61 (0.95%) and cancers 46 (0.72%). Emergency transfers were needed for 76 patients (1.2%), mainly due to hypertensive emergencies (31; 40.8%) and stroke (18;23.7%). Twenty-four patients died at entry points (0.3%); 10 of them had hypertensive emergencies. CONCLUSION: Changes in existing surveillance tools for communicable diseases provided important data on the burden and outcomes of the selected NCD helping to identify priority areas for training and health care improvement. This information can be used to design the local NCD clinics and to strengthen the health information system in resource-limited settings in a progressive and sustainable way.

Community Gardens as Environmental Health Interventions: Benefits Versus Potential Risks.

PURPOSE OF REVIEW: The purpose of this paper was to summarize current findings on community gardens relevant to three specific areas of interest as follows: (1) health benefits, (2) garden interventions in developing versus developed countries, and (3) the concerns and risks of community gardening. RECENT FINDINGS: Community gardens are a reemerging phenomenon in many low- and high-income urban neighborhoods to address the common risk factors of modern lifestyle. Community gardens are not limited to developed countries. They also exist in developing low-income countries but usually serve a different purpose of food security. Despite their benefits, community gardens can become a source of environmental toxicants from the soil of mostly empty lands that might have been contaminated by toxicants in the past. Therefore, caution should be taken about gardening practices and the types of foods to be grown on such soil if there was evidence of contamination. We present community gardens as additional solutions to the epidemic of chronic diseases in low-income urban communities and how it can have a positive physical, mental and social impact among participants. On balance, the benefits of engaging in community gardens are likely to outweigh the potential risk that can be remedied. Quantitative population studies are needed to provide evidence of the benefits and health impacts versus potential harms from community gardens.

The relationships among physical activity, sedentary behaviour, obesity and quitting behaviours within a cohort of smokers in California.

BACKGROUND: Smoking, insufficient physical activity (PA), sedentary behaviour (SB) and obesity are leading risk factors for morbidity and premature mortality. Few studies examining the relationship between these behavioural risk factors and quitting behaviours among cohorts of smokers have been published. PURPOSE: The goals of this study are to examine the cross-sectional relationships among behavioural health risk factors (insufficient PA, SB and obesity) and past year quitting behaviours within a sample of smokers. METHODS: The California Smokers Cohort, conducted from 2011 through 2013, is a population-based survey of adult smokers in California. Using follow-up data (n = 1050), participants' self-reported health behaviours and past year quitting behaviours were examined in univariate analyses and multivariate logistic regression analyses controlling for demographic covariates. RESULTS: In univariate analyses examining health behaviours among smokers, all three health behaviours examined (PA, SB and obesity) were related, and significantly more obese smokers with high PA and low SB reported a ≥20% smoking rate reduction than smokers with other combinations of health behaviours (48.8%, Chi-squared = 4.765, P = 0.045). In multivariate models adjusted for sociodemographic characteristics, obese smokers (odds ratio [OR] = 1.450, 95% confidence interval [CI]: 1.088-1.932, P = 0.011) and smokers with higher levels of PA (OR = 1.448, 95% CI: 1.111-1.887, P = 0.006) were more likely to report a past year ≥24-hour quit attempt regardless of SB, and obese smokers (OR = 1.760, 95% CI: 1.095-2.828, P = 0.019) were more likely to report being quit for ≥30 days regardless of PA and SB. CONCLUSIONS: Overall, the results demonstrated that more physically active and obese smokers were more likely to report positive strides towards quitting. These findings support the potential positive effect of addressing multiple health behaviours along with smoking.

Behaviours and attitudes related to smoking among a Bedouin population in rural Jordan.

ABSTRACT There is limited research about tobacco-related behaviours and attitudes among rural populations in the Eastern Mediterranean Region. The aim of this study was to determine smoking behaviours and attitudes among the nomadic Bedouin in rural southern Jordan. Patients visiting a village clinic over 2 months of 2009 were invited by the attending physician to participate in the survey, which was adapted from the California Tobacco Survey. The smoking prevalence among the 92 participants was 46.7%. Most smokers were men who smoked heavily (> 1 pack/day) (90.7%). There was general low self-efficacy to quit among smokers, yet 81.4% acknowledged that smoking was harming their health. Although 79.1% of smokers and 89.1% of non-smokers believed second-hand smoke was harmful to non-smokers, most of them had no restrictions on smoking for residents and guests (66.3%) and most had children at home (73.9%). These data demonstrate contradictions between attitudes and behaviours about smoking of this rural population.

Reliability of biomarkers of iron status, blood lipids, oxidative stress, vitamin D, C-reactive protein and fructosamine in two Dutch cohorts.

Biomarkers are widely used in epidemiology, yet there are few reliability studies to assess the appropriateness of using these biomarkers for the assessment of exposure-disease relationships. The aim of the study was to assess the reliability of 20 biomarkers in serum collected from two Dutch centres (Utrecht and Bilthoven) participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) at two points several years apart. Blood samples were collected from 30 men from Bilthoven and 35 women from Utrecht. Ferritin, total iron, total iron-binding capacity, transferrin saturation, transferrin, C-reactive protein, bilirubin, cholesterol, triglycerides, apo lipoprotein-A, apo lipoprotein-B, high-density lipoproteins, low-density lipoproteins, uric acid, creatinine, reactive oxygen metabolites, the ferric-reducing ability of plasma, protein thiol oxidation, fructosamine, and vitamin D biomarkers in serum were analysed from the blood samples at the two points of time. For all biomarkers, except C-reactive protein, there were no substantial changes in the mean levels over time. Uric acid, ferritin, creatinine, HDL, and apo lipoprotein-B levels consistently showed the highest reliability for men and women (intra-class correlation = 0.69-0.86). Among women, the ferric-reducing ability of plasma, and protein thiol oxidation had poor reliability; and among men iron-related biomarkers (except serum ferritin) had poor reliability. With the exception of a few gender-specific differences, most of the 20 biomarkers performed well and can be considered to have sufficient reliability to be used in future cohort studies.

Plasma carotenoids as biomarkers of intake of fruits and vegetables: ecological-level correlations in the European Prospective Investigation into Cancer and Nutrition (EPIC).

OBJECTIVE: The aim of this study was to assess the ability of a single 24-h dietary recall (24HDR) and food questionnaires (FQ) to predict plasma carotenoid levels at the ecological level by assessing the relationship between mean plasma carotenoid levels and mean intake of fruit and vegetables measured by 24HDR and FQ across 16 European regions. DESIGN: A random subsample of 3089 subjects was included, stratified by age and gender. They provided blood samples and dietary information between 1992 and 2000 as part of the European Prospective Investigation into Cancer and Nutrition. RESULTS: Using Spearman's correlation coefficients, the correlations between mean regional 24HDR fruit and vegetable variables and corresponding mean plasma carotenoid levels were generally higher than the correlations using FQ means. The highest correlation was between the 24HDR citrus fruit variable and beta-cryptoxanthin (r = 0.90). For 24HDR, total fruits and vegetables were highly correlated with lutein, zeaxanthin, and beta-cryptoxanthin (r = 0.83-0.87), while vegetables were more closely related with lutein (r = 0.69) and zeaxanthin (r = 0.68), and fruits correlated with zeaxanthin (r = 0.87) and beta-cryptoxanthin (r = 0.84). Root vegetables (r = 0.81) and total carrots (r = 0.71) were well correlated with alpha-carotene. In the multivariate models adjusting for age, body mass index, and season, and using observations of means stratified by sex and region, the association was generally higher for 24HDR compared to FQ. CONCLUSION: Mean regional intakes of fruits and vegetables in several European countries were closely correlated with corresponding mean plasma levels of individual carotenoids. Fruits and vegetables measured by 24HDR were generally better able to predict plasma carotenoids at the ecological level.

Plasma carotenoids as biomarkers of intake of fruits and vegetables: individual-level correlations in the European Prospective Investigation into Cancer and Nutrition (EPIC).

OBJECTIVE: The aim in this study was to assess the association between individual plasma carotenoid levels (alpha-carotene, beta-carotene, lycopene, beta-cryptoxanthin, lutein, zeaxanthin) and fruit and vegetable intakes recorded by a calibrated food questionnaire (FQ) and 24-h dietary recall records (24HDR) in nine different European countries with diverse populations and widely varying intakes of plant foods. DESIGN: A stratified random subsample of 3089 men and women from nine countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC), who had provided blood samples and dietary and other lifestyle information between 1992 and 2000, were included. RESULTS: beta-Cryptoxanthin was most strongly correlated with total fruits (FQ r = 0.52, 24HDR r = 0.39), lycopene with tomato and tomato products (FQ r = 0.38, 24HDR r = 0.25), and alpha-carotene with intake of root vegetables (r = 0.39) and of total carrots (r = 0.38) for FQ only. Based on diet measured by FQ and adjusting for possible confounding by body mass index (BMI), age, gender, smoking status, alcohol intake, and energy intake, the strongest predictors of individual plasma carotenoid levels were fruits (R(partial)(2) = 17.2%) for beta-cryptoxanthin, total carrots ((partial)(2) = 13.4%) and root vegetables (R(partial)(2) = 13.3%) for alpha-carotene, and tomato products (R(partial)(2) = 13.8%) for lycopene. For 24HDR, the highest R(partial)(2) was for fruits in relation to beta-cryptoxanthin (7.9%). CONCLUSIONS: Intakes of specific fruits and vegetables as measured by food questionnaires are good predictors of certain individual plasma carotenoid levels in our multicentre European study. At individual subject levels, FQ measurements of fruits, root vegetables and carrots, and tomato products are, respectively, good predictors of beta-cryptoxanthin, alpha-carotene, and lycopene in plasma.

Hair as a biomarker for exposure to tobacco smoke.

This article provides an overview of the hair nicotine biomarker for assessment of exposure to tobacco smoke, with emphasis on environmental tobacco smoke (ETS). Measurement of nicotine in hair can be an informative tool for research looking at ETS and related illnesses. There are still unresolved issues in relation to this biomarker such as influence of hair treatment, hair colour, and growth rate on nicotine levels in hair, which need to be addressed in order to further refine this biomarker for exposure assessment. Nevertheless, hair nicotine promises to be a valid and reliable measure of longer term exposure that can be readily applied in epidemiological studies of exposure to tobacco smoke, and more specifically ETS, and its risk to health.

Is the hair nicotine level a more accurate biomarker of environmental tobacco smoke exposure than urine cotinine?

STUDY OBJECTIVE: The aim of this study was to compare the two biomarkers of exposure to environmental tobacco smoke (ETS); urine cotinine and hair nicotine, using questionnaires as the standard. DESIGN: A cross sectional study of children consecutively admitted to hospital for lower respiratory illnesses during the period of the study. SETTINGS: Three regional hospitals in the larger Wellington area, New Zealand. PARTICIPANTS: Children aged 3-27 months and admitted to the above hospitals during August 1997 to October 1998. A total of 322 children provided 297 hair samples and 158 urine samples. MAIN RESULTS: Hair nicotine levels were better able to discriminate the groups of children according to their household's smoking habits at home (no smokers, smoke only outside the home, smoke inside the house) than urine cotinine (Kruskall-Wallis; chi(2)=142.14, and chi(2)=49.5, respectively (p<0.0001)). Furthermore, hair nicotine levels were more strongly correlated with number of smokers in the house, and the number of cigarettes smoked by parents and other members of the child's households. Hair nicotine was better related to the questionnaire variables of smoking in a multivariate regression model (r(2)=0.55) than urine cotinine (r(2)=0.31). CONCLUSIONS: In this group of young children, hair nicotine was a more precise biomarker of exposure to ETS than urine cotinine levels, using questionnaire reports as the reference. Both biomarkers indicate that smoking outside the house limits ETS exposure of children but does not eliminate it.

Smoking and mortality among women with type 2 diabetes: The Nurses' Health Study cohort.

OBJECTIVE: To assess the relationship between cigarette smoking and mortality among women with type 2 diabetes in the Nurses' Health Study cohort. RESEARCH DESIGN AND METHODS: The Nurses' Health Study, a prospective cohort of U.S. female registered nurses, included 7,401 women with type 2 diabetes diagnosed at baseline or during follow-up from 1976 to 1996. Total and cause-specific mortality of these diabetic women were the outcomes of interest. RESULTS: We documented 724 deaths during 20 years of follow-up (67,420 person-years) among women with type 2 diabetes. In multivariate analyses, adjusting for age, history of high blood pressure and high cholesterol, and other cardiovascular risk factors, compared with never smokers, the RRs of mortality were 1.31 (95% CI 1.11-1.55) for past smokers, 1.43 (0.96-2.14) for current smokers of 1-14 cigarettes/day, 1.64 (1.24-2.17) for current smokers of 15-34 cigarettes/day, and 2.19 (1.32-3.65) for current smokers of > or =35 cigarettes/day (P for trend = 0.0002). Women with type 2 diabetes who had stopped smoking for > or =10 years had a mortality RR of 1.11 (0.92-1.35) compared with diabetic women who were never smokers. CONCLUSIONS: Cigarette smoking is associated in a dose-response manner with an increased mortality among women with type 2 diabetes. Furthermore, quitting smoking appears to decrease this excess risk substantially. Diabetes patients should be strongly advised against smoking.

Passive smoking in children: effect of avoidance strategies, at home as measured by hair nicotine levels.

Hair nicotine levels were studied among children, relative to their caregivers' reported exposure to environmental tobacco smoke. A total of 117 children, aged 3 months to 10 years, were recruited consecutively from hospital inpatients, and their respective parents or caregivers were interviewed. Degree of exposure to environmental tobacco smoke was assessed via questionnaire. Scalp hair samples were collected from children and were assayed for nicotine. Levels of nicotine in hair among children reportedly exposed to smokers were higher than levels among unexposed children (chi2 = 26.46, p < .0001). In addition, hair nicotine levels were higher among children with mothers who smoked, compared with those whose mothers did not smoke. Whether household members smoked outside or inside the house had no significant effect on hair nicotine levels of children. Hair nicotine levels differed between children who were reportedly unexposed to environmental tobacco smoke at home and those who were exposed. Smoking outside the home, as reported by parents, did not cause a reduction in nicotine levels in the hair of children.

Measurement of nicotine in hair by reversed-phase high-performance liquid chromatography with electrochemical detection.

We have developed an assay for nicotine in hair based on reversed-phase HPLC with electrochemical detection. The method uses a low-metal, high-purity silica reversed-phase column. We have investigated the washing, digestion and extraction procedures and discuss the important points in the HPLC method development. The assay is presented as an application in a population of exposed and non-exposed children. Analytical parameters are satisfactory with linearity, recoveries, limit of quantitation and precision all suitable for epidemiological studies involving environmental tobacco smoke exposure assessment.

Nicotine in hair of bar and restaurant workers.

AIM: To measure the relation between workplace smoking policies and exposures to Environmental Tobacco Smoke (ETS) of workers in bars and restaurants. METHODS: 114 workers in Wellington and Auckland were questioned about sources of exposure to ETS and smoking habits, and details of the smoke-free policy in their work place were recorded. A hair sample was collected from each participant and tested for nicotine. RESULTS: Among non-smoking workers, hair nicotine levels varied strongly according to the smoke free policy at their place of work (Kruskall-Wallis, chi2 = 26.38, p < 0.0001). Those working in 100% smoke free restaurants had much lower levels than staff working in bars with no restrictions on smoking, and levels were intermediate for staff working in places with a partial smoking ban. These findings were not changed when adjustments were made for other sources of ETS exposure. Hair nicotine levels among nonsmokers working in places with no restriction on smoking were similar to hair nicotine levels of active smokers. CONCLUSION: The present New Zealand Smoke Free Environment Act does not protect workers in the hospitality industry from exposure to ETS. The findings from this study highlight the substantial levels of exposure of bar and restaurant staff from patrons' smoking.

The effects of carbon dioxide on exercise-induced asthma: an unlikely explanation for the effects of Buteyko breathing training.

OBJECTIVES: To examine the effect of breathing 3% CO2 on exercise-induced asthma (EIA), as a raised airway CO2 level is suggested to mediate the effects of Buteyko breathing training (BBT). DESIGN: Double-blind crossover study, using a standard laboratory-based exercise challenge, with EIA defined as a fall of 15% or greater in the forced expiratory volume in one second (FEV1) within 30 minutes of completing a standard exercise protocol. SUBJECTS: 10 adults with confirmed EIA. INTERVENTION: Air enriched with 3% CO2 during and for 10 minutes after exercise. OUTCOME MEASURES: Maximum percentage fall in FEV1 after exercise. Area under curve (AUC) of the decrease in FEV1 with time. RESULTS: Mean maximum fall in FEV1 was similar: 19.9% with air, and 26.9% with 3% CO2 (P = 0.12). The mean AUC for the total 30-minute post-exercise period was 355 for air and 520 for 3% CO2 (P = 0.07). After discontinuing the 3% CO2 at 10 minutes after exercise, there was a further and sustained fall in FEV1. Mean AUC for the period 10-30 minutes post-exercise was significantly greater for CO2 than air (275 and 137, respectively [P = 0.02]). Mean minute ventilation was increased when subjects exercised breathing 3% CO2: 77.5 L/min for 3% CO2, compared with 68.7 L/min for air (P = 0.02). CONCLUSION: Breathing 3% CO2 during exercise does not prevent EIA. The shape of the FEV1 response curve after 3% CO2 suggests that a greater degree of EIA (because of increased minute ventilation during exercise) was opposed by a direct relaxant effect of CO2 on the airway. Increased airway CO2 alone is an unlikely mechanism for the reported benefits of BBT; nevertheless, further study of the effects of voluntary hypoventilation in asthma is warranted.

Questionnaire and hair measurement of exposure to tobacco smoke.

To assess the relation between nicotine and cotinine levels in hair and reported exposure to environmental tobacco smoke (ETS), hair samples from 112 children (aged 3 months to 10 years) and 76 of their mothers were analyzed and information on the smoking habits of household adults in the preceding 6 months recorded. It was found that the levels of nicotine in children's hair were related to the number of smokers in the house, and increased with the total number of cigarettes smoked by all household adults (P<0.0001). In a multiple regression analysis, mother's smoking was much more a contributor to children's nicotine levels than smoking by the father or other household adults. Cotinine levels were less strongly associated with reported ETS exposure than nicotine. There was a strong correlation between nicotine hair levels in children and mothers (r(s)=0.7, P<0.0001). However, nicotine levels in the hair of active smokers were not correlated with the reported number of cigarettes they smoked per day. In this population, there was a consistent relation between exposure to ETS (assessed by questionnaire) and dose (as measured by nicotine in hair). We conclude that hair nicotine levels rather than hair cotinine levels provide an informative and objective measure of ETS exposure. The number of cigarettes smoked by active smokers may not be an accurate measure of the total nicotine levels in their bodies.

Smoking hygiene: a study of attitudes to passive smoking.

AIM: To study the attitudes and knowledge of adults in the Wellington area about the effects of passive smoking and measures to reduce exposure to smoke. METHODS: A sample of 200 people, randomly selected in the Wellington area, answered a telephone survey on passive smoking. RESULTS: Of the 200 respondents, 160 (80%) were males, 40 (20%) were females and approximately one-third (30%) were smokers. Most people (85.5%) thought public and private areas should be smoke-free when there were children around, but only half (53.5%) thought that smoking should be banned in cars when there are passengers. Most people (92.5%) correctly defined passive smoking. Half were aware that passive smoking negatively contributed to all the following diseases (asthma, cancer, heart disease, respiratory problems) and cot death but a higher percentage identified cancer (75.5%) and cot deaths (68.5%) specifically. Most smokers reported that they smoke at home or in their cars rather than in public places. Half the smokers (50.9%) did not smoke in front of children; a further 17.3% reported that they smoked less. CONCLUSIONS: In this sample there was a relatively low level of awareness of the effects of passive smoking on health and a high prevalence of smoking in the presence of children. Smokers and non-smokers were almost equally divided on whether there should be a law restricting smoking in private cars, although the majority agreed that cars carrying children should be smoke-free. Public health efforts to reduce the harm from passive smoking should be focused on discouraging smoking, in settings in which children are exposed, including private cars when children are passengers.

Measures of exposure to environmental tobacco smoke. Validity, precision, and relevance.

It is often not clear what the best measures of exposure are for a risk assessment, or even how one should answer this question. Environmental tobacco smoke (ETS) provides a good example for an exploration of uncertainty. There are a variety of methods for estimating exposure and each has short-comings. In this paper we summarize the physical characteristics of ETS and the principal methods for assessing exposure. We review the accuracy and applicability of these methods, and explore major sources of uncertainty in the assessment of ETS.