Lifestyle Diseases

Number of children, adolescents with obesity increases ten-fold since 1975

Egypt, Kuwait, Qatar and Saudi Arabia among countries showing high increase

Despite the rise in obesity, more children and adolescents remain underweight than obese globally, highlighting the need to improve food security to tackle, at the same time, under-nutrition and excessive weight gain, according to a report in The Lancet.

Worldwide, there has been a more than ten-fold increase in the number of children and adolescents with obesity in the past four decades, increasing from 5 million girls in 1975 to 50 million in 2016, and from 6 million to 74 million boys, according to a new global analysis of trends in child and adolescent obesity in 200 countries, published in The Lancet.

Rates of child and adolescent obesity were highest (above 30%) in some islands in Polynesia, and were around 20% or higher in the USA and some countries in the Middle East and North Africa (e.g. Egypt, Kuwait, Qatar and Saudi Arabia) and the Caribbean (e.g. Bermuda and Puerto Rico). Overall, the global prevalence of child and adolescent obesity increased from 0.7% to 5.6% for girls, and from 0.9% to 7.8% for boys.

Despite the increase in child and adolescent obesity, globally more children remain moderately or severely underweight than obese, with 75 million girls moderately or severely underweight in 2016 and 117 million boys. Almost two thirds of the world’s children and adolescents who are moderately or severely underweight lived in south Asia.

The study, led by Imperial College London (UK) and the World Health Organisation (WHO) and published ahead of World Obesity Day (11 October), brought together data from 2416 studies involving 128.9 million participants worldwide including 31.5 million children and adolescents aged 5-19 years, to estimate trends in body mass index (BMI) in 200 countries

Excessive weight gain in childhood and adolescence is associated with a higher risk and earlier onset of chronic diseases such as type 2 diabetes, worse psychosocial and educational outcomes, and lifelong harms since weight loss is hard to achieve.

Average child and adolescent BMI remains high in many high-income countries in North America and Europe but trends have plateaued in recent years, even while average BMI among adults continues to rise. By contrast, the rise in average BMI has accelerated in many parts of Asia.

In addition to the 124 million children and adolescents classified as obese in 2016, 213 million children and adolescents were in the overweight range.

“Rates of child and adolescent obesity have increased signifi cantly over the past four decades in most countries in the world,” says study author Dr James Bentham, University of Kent, UK. “While average BMI among children and adolescents has recently plateaued in Europe and North America, this is not an excuse for complacency as more than 1 in 5 young people in the USA and 1 in 10 in the UK are obese. Additionally, rates of child and adolescent obesity are accelerating in east, south and southeast Asia, and continue to increase in other low and middle-income regions.”

Unaffordability of healthy food options
Professor Majid Ezzati, study author from Imperial College London, adds: “While there have been some initiatives led by governments, communities or schools to increase awareness about childhood and adolescent obesity, most high-income countries have been reluctant to use taxes and industry regulations to change eating and drinking behaviours to tackle child obesity. Most importantly, very few policies and programmes attempt to make healthy foods such as whole grains and fresh fruits and vegetables affordable to poor families. Unaffordability of healthy food options to the poor can lead to social inequalities in obesity, and limit how much we can reduce its burden.”

The authors also note that policies to prevent child obesity in entire countries and communities need to be matched by improved treatments, such as behavioural therapy to change diet and exercise, screening and management of hypertension and liver problems, and in extreme cases, bariatric surgery.

Leanne Riley, study author from WHO, says: “The trends show that without serious, concerted action to address obesity, from improving diets and providing the means bywhich to increase physical activity, to implementing the health system measures required to address overweight and obesity in young people early on, then the health of millions of people will be needlessly placed in great jeopardy, leading to immense human and economic costs to communities.”

At the other extreme, in 2016 average BMI was lowest for both girls and boys in Ethiopia (16.8 kg/sq m for girls, 15.5 kg/sq m for boys), and was also low in Niger, Senegal, India, Bangladesh, Myanmar, and Cambodia. Underweight among children and adolescents is associated with higher risk of infectious disease, and for girls of childbearing age, is associated with adverse pregnancy outcomes including maternal mortality, delivery complications, preterm birth and slow intrauterine growth. In south Asia, 20.3% of girls and 28.6% of boys were moderately or severely underweight in 2016 (compared to 23.0% and 37.8% in 1975).

“There is a continued need for policies that enhance food security in low-income countries and households, especially in south Asia. But, our data also show that the transition from underweight to overweight and obesity can happen quickly in an unhealthy nutritional transition, with an increase in nutrient-poor, energy-dense foods. Our fi ndings highlight the disconnect between the global dialogue on overweight and obesity, which has largely overlooked the remaining under-nutrition burden, and the initiatives and donors focusing on under-nutrition that have paid little attention to the looming burden of overweight and obesity,” Professor Ezzati adds.

Between 1975 and 2016, the prevalence of moderate and severe underweight decreased from 9.2% to 8.4% in 2016 for girls, and from 14.8% to 12.4% for boys, meaning that the rate of increase in the prevalence of obesity in children and adolescents is greater than the rate of decline in under-nutrition. The authors say that if post-2000 trends continue, child and adolescent obesity is expected to surpass moderate and severe underweight by 2022.

While the study used an unprecedented number of data sources from most of the world’s countries, some regions (the Caribbean, Polynesia and Micronesia, central Asia and central Africa) had fewer data sources, meaning that there is more uncertainty in their estimates.

  • doi: 10.1016/S0140-6736(17) 32129-3



World Obesity Federation confirms “obesity is a chronic relapsing disease”


In a statement published recently in the journal Obesity Reviews, the World Obesity Federation confi rms its support for defi ning obesity as a chronic, relapsing disease. The statement was prepared by a scientifi c committee of the Federation which concluded that obesity fits the epidemiological model of a disease process except that the toxic or pathological agent is diet-related rather than a microbe.

The World Obesity Federation is an alliance of over 50 national and regional organisations dedicated to research into obesity, and treatment and prevention of the disease.

The question of whether obesity should be called a ‘disease’ has sparked controversy for most of the last century. In their Obesity Reviews position statement, Dr George Bray, Pennington Biomedical Research Center of Louisiana State University, Baton Rouge, Louisiana, USA, and his colleagues examine how an abundance of food, low physical activity, and several other environmental factors interact with genetic susceptibility. They draw parallels to chronic diseases, noting that the magnitude of obesity and its adverse effects in individuals may relate to the virulence or toxicity of the environment and its interaction with the host.

“Accepting the concept that obesity is a chronic disease process is important for several reasons,” said Dr Bray. “First, it removes the feeling that patients alone are responsible for their excess weight. It also focuses attention on the ways in which this disease process can be tackled. And finally, it shows that if we can successfully treat obesity, many of its associated diseases will be eliminated.”

In an accompanying letter to the editor, the Federation’s policy experts suggest that declaring obesity to be a disease could benefit those people who are suffering with obesity and wish to have access to medical advice and support, “whilst also strengthening the call for dealing with the social determinants, obesogenic environments and systemic causes of individual weight gain”. They note that obesity is a normal response to an obesogenic environment, but is not in itself a biologically normal or healthy condition. They also note that recognizing obesity as a disease may reduce individuals’ internalized stigma, change the public discourse about blame for the condition, and have benefi ts in countries where health service costs are funded from insurance schemes that limit payments for non-disease conditions or risk factors.

  • doi: 10.1111/obr.12551


Statins reduce deaths from heart disease by 28% according to 20-year study

Previous research has shown the benefi t of statins for reducing high cholesterol and coronary heart disease risk amongst different patient populations. However, until now there has been no conclusive evidence from trials for current guidelines on statin usage for people with very high levels of low density lipoprotein (LDL) cholesterol (above 190mg/dL) and no established heart disease.

A recent study published in Circulation focused on men with high levels of ‘bad’ cholesterol and no other risk factors or signs of heart disease.

After studying mortality over a 20-year period, researchers led by Professor Kausik Ray at Imperial in collaboration with the University of Glasgow showed that 40mg daily of pravastatin, a relatively weak type of statin, reduced deaths from heart disease in participants by more than a quarter.

Senior author Professor Ray from Imperial’s School of Public Health said: “For the fi rst time, we show that statins reduce the risk of death in this specifi c group of people who appear largely healthy except for very high LDL levels. This legitimises current guidelines which recommend treating this population with statins.”

In addition, the findings challenge current approaches on treating younger patients with LDL elevations with a ‘watch and wait’ approach. Instead, the authors say even those with slightly elevated cholesterol are at higher long-term risk of heart disease, and that the accumulation of modest LDL reductions over time will translate into large mortality benefi ts.

Professor Ray added: “Our fi ndings provide the fi rst trial-based evidence to support the guidelines for treating patients with LDL above 190mg/dL and no signs of heart disease. They also suggest that we should consider prescribing statins more readily for those with elevated cholesterol levels above 155 mg/dl and who also appear otherwise healthy.”

The West of Scotland Coronary Prevention Study
The paper is published in the journal Circulation. It follows a fi ve-year 1995 study in which researchers observed the long-term effects of statins on patients involved in the West of Scotland Coronary Prevention Study (WOSCOPS) trial. The researchers took into account the original fi ve-year study and followed the patients for a further 15 years.

The WOSCOPS study provided the fi rst conclusive evidence that treating high LDL in men with pravastatin for fi ve years signifi cantly reduces the risk of heart attack or death from heart disease compared with placebo. Statins were subsequently established as the standard treatment for primary prevention in people with elevated cholesterol levels.

Now, researchers have completed analyses of the 15-year follow up of 5,529 men, including 2,560 with LDL cholesterol above 190 mg/dL of the original 6,595, chosen because they had no evidence of heart disease at the beginning of the present study.

Participants were aged 45-64 years. During the fi ve-year initial trial they were given pravastatin or placebo. Once the trial ended the participants returned to their primary care physicians, and an additional 15-year period of follow-up ensued.

The 5,529 men were split into two groups: those with ‘elevated’ LDL (between 155 and 190mg/dL) and those with ‘very high’ LDL (above 190mg/dL). The standard ‘ideal’ level of LDL for high risk patients is below 100mg/dL, but this varies depending on individual risk factors.

The researchers found that giving pravastatin to men with ‘very high’ LDL reduced 20-year mortality rates by 18%. Statins also reduced the overall risk of death by coronary heart disease by 28%, and reduced the risk of death by other cardiovascular disease by 25% among those with very high LDL cholesterol.

The 15-year follow up also meant the researchers could compare patients’ original predicted risk of heart disease with actual observed risk. According to the risk equations for cardiovascular disease, 67% of patients included in the WOSCOPS trial with LDL above 190mg/dL would have less than a 7.5% risk of heart disease by year ten, and thus would not have been treated with statins based on that risk.

However, the present study shows that in fact, this group actually had a 7.5% risk by year fi ve, meaning their 10-year risk was 15%. Following statin therapy, this group’s 10-year risk was reduced compared with those that were given placebo during the trial.

Standing by statins
The authors say the findings provide the fi rst direct randomised trial evidence to confirm that current guidelines should stand as they are for those with very high LDL, and those with LDL levels above the 190mg/dL threshold should be considered for statin therapy without risk assessment, as the LDL elevation provides enough risk on its own.

Professor Ray said: “This is the strongest evidence yet that statins reduce the risk of heart disease and death in men with high LDL. Our study lends support to LDL’s status as a major driver of heart disease risk, and suggests that even modest LDL reductions might offer signifi cant mortality benefi ts in the long-term. The analysis fi rmly establishes that controlling LDL over time translates to fewer deaths in this population.”

  • doi: 10.1161/ CIRCULATIONAHA.117.027966

Misdiagnosis of diabetes type renders treatment inefficient

  • By Dr Sara Suliman
    Consultant Endocrinologist and Diabetologist at Imperial College London
    Diabetes Centre (ICLDC)

Diabetes mellitus is one of the major healthcare challenges in the UAE with close to one in five adults currently affected. It places a substantial burden on society not only due to the material costs of treatment of diabetes and its associated complications (most notably cardiovascular disease), but also due to reduced productivity, chronic disability and premature mortality. Other intangible costs include: reduced quality of life, pain and suffering of people living with diabetes, as well as the physical, psychological and material strains on family and friends of affected individuals e.g. the parents of a child with diabetes.

Precision medicine (or personalised medicine) is an emerging approach to disease diagnosis, treatment and prevention that considers variations in genes (genomics), proteins (proteomics), metabolites (metabolomics), environment, lifestyle and other factors (e.g. gut micro-biome). This approach helps to properly classify diseases such as diabetes offering individualised treatment and moving away from the ‘one size fi ts all’ model. Diabetes is a prime example of a condition where many patients and their physicians are aware of two sub-types (type-1 or type-2), whereas in practice there are in excess of 15 subtypes of diabetes each of which has a different aetiology and as such could and should be treated differently.

The majority (95-98%) of those living with diabetes worldwide have either type-1 or type-2 diabetes. However, in an estimated 2-5% of diabetic patients (i.e. approximately 20,000 – 50,000 individuals in the UAE), a genetic abnormality (often due to a single gene defect) causes abnormalities in insulin secretion or action that can lead to diabetes. This condition is called monogenic diabetes and is diagnosed based on certain criteria, and more specifi cally, genetic testing. Importantly, many of these conditions are familial affecting 50% of an affected individuals off-spring.

The benefits of genetic testing in diabetes management
Individuals with monogenic diabetes are often misdiagnosed with either type 1 or 2 diabetes, and as such often treated inappropriately. Genetic testing can have immense benefi ts in diabetes management, as the correct diagnosis allows some patients to transfer from insulin injections to oral medication with marked improvements in glycaemic control and, in turn, quality of life. It may also identify families with diabetes and high cardiovascular risk e.g. familial partial lipodystrophy who require vigilance in investigation and early management, whereas on the other end of the spectrum diabetic families with glucokinase mutations have a very low risk of diabetes-related complications similar to non-diabetic populations.

Monogenic diabetes remains largely under- diagnosed and under-researched. With strong indications pointing to previously undiscovered mutations, perhaps specifi c to the UAE and the wider Middle East, in some patients.

Imperial College London Diabetes Centre (ICLDC) opened the fi rst dedicated genetics of diabetes and endocrine disorders clinic in the GCC region in March 2016. Currently serving 165 individuals with diverse types of monogenic diabetes and genetic endocrine disorders, the facility sees on average three to four new cases every week. This offers a personalised service focusing on accurate diagnosis using genetic testing, and tailors investigations and treatment accordingly. In 2016, six patients could come off insulin after their diabetes was diagnosed as monogenic and not type 1 as originally believed.

The prevalence of monogenic diabetes in the UAE is currently unknown. ICLDC’s Genetics Clinic is setting the benchmark for monogenic diabetes clinical care and research in the region with its ground-breaking work. The team is expanding to include a genetic counsellor and dedicated diabetes genetics nurses to enable the facility to treat more people, identify affected family members as well as raise awareness of monogenic diabetes and its risks among the community. Data collected at the clinic will provide an ideal base for establishing a national and regional registry of monogenic diabetes that is set to become an invaluable resource for research of the condition and the most effective treatments locally and regionally.


Use of new swallowable gastric balloon results in substantial weight loss

The Elipse Ballon

Research presented at this year’s European Congress on Obesity (ECO) in Porto, Portugal (17-20 May) shows that a swallowable gastric balloon – that can be inserted without endoscopy or anaesthesia – is a safe and effective way to induce substantial weight loss.

The study is by Dr Roberta Ienca, Sapienza University of Rome, Italy, and colleagues.

Intragastric balloons (IGBs) have been used as weight loss devices for decades. Their mechanism of action is likely multifactorial, but they appear to make it easier to adhere to a low-calorie diet by inducing feelings of satiety. However, all IGBs have historically required endoscopy and sedation resulting in a low adoption rate and high cost.

In this new study, the authors evaluated the efficacy and safety of a new swallowable IGB (Elipse™ Balloon, Allurion Technologies, MA, USA), not needing endoscopy or anaesthesia, optimised to reduce risk and discomfort, in combination with a very low-calorie ketogenic diet (low calorie and low carbohydrate) (VLCKD) in the final month of therapy. The researchers did a prospective, nonrandomised study in 50 obese individuals (BMI 30-45 kg/m2) who had failed to lose weight by diet alone and who had refused other IGB treatment, because of the need of an endoscopy and/or anesthesia, and had been offered the Elipse Balloon.

The balloon was swallowed under fluoroscopy and then filled with 550mL of liquid. The balloon remains in the stomach for 16 weeks after which it spontaneously opens, empties, and is excreted. Follow-up was performed every 2 weeks. In the last 4 weeks of treatment, a ketogenic diet (~700 kcal/day) was introduced to enhance weight loss and maximise the results to increase patient satisfaction. Once the balloon was excreted, patients were transitioned to a Mediterranean diet for weight maintenance.

A total of 42 patients (29 men and 13 women) patients were enrolled. Eight of the original 50 patients were contraindicated for balloon implantation for various reasons.

Mean age was 46 years, mean initial weight was 110 kg, and mean initial BMI was 39 kg/m2. After 16 weeks, the mean weight loss was 15.2 kg, mean % excess weight loss was 31%, and mean BMI reduction was 4.9 kg/m2. At 4, 8 and 12 weeks a mean weight loss of 5.4 kg, 8.9 kg and 11.5 kg was observed, respectively. In the VLCKD period (the final four weeks), a mean weight loss of 3.7 kg, was observed, similar to that seen between weeks 4 and 8.

There were no serious adverse events recorded. All other adverse events including nausea, vomiting, and abdominal pain were either self-limiting or resolved with medication. Significant reductions were alsoobserved in comorbidities such as diabetes, high blood pressure, high cholesterol, and metabolic syndrome.

Dr Ienca concludes: “The Elipse Balloon appears to be a safe and effective weight loss method. Furthermore, the introduction of a VLCKD improves weight loss. Because the Elipse Balloon does not require endoscopy, surgery or anaesthesia, this may make it suitable for a larger population of obese patients not responding to diet/lifestyle treatment; and also for use by a variety of clinicians – nutritionists, dietitians, and internists – who currently do not have access to or are qualified to fit endoscopic or surgical weight loss devices. Furthermore, the absence of endoscopy and anaesthesia for placement and removal can lead to significant cost savings.”

The Elipse Balloon is approved for commercial use in Europe and parts of the Middle East. There are some conditions that would make a person unsuitable for treatment with this IGB. These include those with dysphagia (difficulty swallowing) or other swallowing disorders may be unsuitable for a swallowable balloon. In addition, individuals with a history of bowel obstruction or other disorders of the gastrointestinal tract may also be unsuitable for a balloon that passes and is excreted.


Metabolically healthy obese individuals remain at risk of coronary heart disease


New research presented at this year’s European Congress on Obesity (ECO) in Porto, Portugal earlier this year shows that so called ‘metabolically healthy’ obese people are still at higher risk of cardiovascular disease events such as heart failure or stroke than normal weight people.

The study is by Dr Rishi Caleyachetty and colleagues at The Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK.

People with metabolically healthy obesity (MHO) are clinically obese in terms of their body mass index (BMI) (more than 30 kg/m2), but do not have metabolic complications that usually come with obesity, such as abnormal blood fats, poor blood sugar control or diabetes, and high blood pressure. Whether MHO is associated with excess risk of cardiovascular disease (CVD) events is a subject of debate. Important limitations in the evidence to date include inconsistent definitions of metabolic health, inconsistent control for other factors (confounders), and small sample sizes. In this new study, the authors address these limitations in a large contemporary cohort, based on linked primary care electronic health records.

The researchers used linked electronic health records from 1995 to 2015 in The Health ImprovementNetwork (THIN) — a large UK database of general practice records — to assemble a cohort of 3.5 million individuals aged 18 years or older and initially free from CVD. To determine metabolic health, they divided the population into groups according to BMI and the presence or absence of 3 metabolic abnormalities (diabetes, hypertension, and hyperlipidemia) which were added together to create a metabolic abnormalities score (0, 1, 2 and 3). To be classified as MHO, individuals had to have none of these metabolic abnormalities.

The study examined whether the risk of developing four cardiovascular conditions [coronary heart disease (CHD), cerebrovascular disease (transient ischaemic attack or stroke), heart failure, and peripheral vascular disease (PVD)] was different for normal weight people with no metabolic conditions or people with MHO.

The authors found that, compared to normal weight individuals with no metabolic abnormalities, individuals with MHO had a 50% increased risk of CHD; a 7% increased risk of cerebrovascular disease and a doubled risk of heart failure, (all statistically significant), after taking into account demographics and smoking behaviour. Against these trends, MHO individuals had a 9% lower risk of PVD. However, in further analyses that excluded cigarette smokers, individuals with MHO had a significantly (11%) increased risk of developing PVD compared with those with normal weight and zero metabolic abnormalities.

The analysis also showed that the risk of CVD events in obese individuals increased with increased number of metabolic abnormalities present. For example, compared to a normal weight person with zero metabolic abnormalities, an obese person with 3 metabolic abnormalities had a 2.6 times increased risk of CHD; a 58% increased risk cerebrovascular disease including stroke; a 3.8 times increased risk of heart failure, and a 2.2 times increased risk of PVD.

Dr Caleyachetty says: “This is the largest prospective study of the association between metabolically health obesity and cardiovascular disease events. Metabolically healthy obese individuals are at higher risk of coronary heart disease, cerebrovascular disease and heart failure than normal weight metabolically healthy individuals. The priority of health professionals should be to promote and facilitate weight loss among obese persons, regardless of the presence or absence of metabolic abnormalities.”

He adds: “At the populationlevel, so-called metabolically healthy obesity is not a harmless condition and perhaps it is better not to use this term to describe an obese person, regardless of how many metabolic complications they have.”

Large studies find screening reduces mortality for those with detectable type 2 diabetes but not for general population


Three large trials published today in Diabetologia (the journal of the European Association for the Study of Diabetes) show that screening for type 2 diabetes and cardiovascular risk factors may not reduce mortality and cardiovascular disease in the general population. However, for individuals diagnosed with diabetes, screening is associated with a reduction in mortality and cardiovascular disease risk.

Health checks including diabetes risk assessment have been introduced in a number of countries. However, there are few population-based trials assessing the benefi ts and harms of these screening programmes, and these have shown mixed results. The fi rst two studies, both led by Dr Rebecca Simmons of the Department of Public Health, Aarhus University, Denmark, and the MRC Epidemiology Unit, University of Cambridge, UK, used data from ADDITION-Denmark, part of the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes In Primary Care.

Between 2001 and 2006, a populationbased cardiovascular and diabetes screening programme was introduced in fi ve out of sixteen Danish counties. Over 150,000 individuals registered with 181 practices participating in the ADDITIONDenmark study were sent a diabetes risk score questionnaire, and if their score indicated moderate to high risk they were invited to attend for a diabetes test and cardiovascular risk assessment with their family doctor.

More than 27,000 attended for screening, and 1533 were diagnosed with diabetes during screening. A further 1,760,000 individuals were identifi ed for a matched no-screening control group. Participants were followed for approximately 9.5 years to 31 December 2012, when national registers were searched for vital status and cardiovascular disease (CVD) events – CVD death, non-fatal ischaemic heart disease and non-fatal stroke.

The researchers found that in the overall populations in the screening and no-screening groups, a single round of screening for type 2 diabetes and cardiovascular risk assessment was not associated with a reduction in mortality or in cardiovascular events between 2001 and 2012. Similarly, rates of cardiovascular, cancer or diabetes-related mortality were not reduced by invitation to screening.

However, the sister study, which focused on those who were diagnosed with type 2 diabetes – either at the time of screening (2001–2006) or subsequently (2007–2009) – yielded different results. Individuals with clinically-diagnosed diabetes were identifi ed on average 2.2 years later than individuals whose diabetes was detected in the screening practices. A single round of diabetes screening and cardiovascular risk assessment was associated with a 21% reduction in all-cause mortality rate and a 16% reduction in CVD events between 2001 and 2012 in individuals diagnosed with diabetes between 2001 and 2009.

The authors note that as only 10% of individuals with diabetes in the screening group were actually diagnosed by screening, it is likely that the programme had wider effects in this cohort. For example, general practitioners in the screening group may have provided lifestyle advice and delayed development of diabetes among those found to be at risk. They may also have increased vigilance and the likelihood of early detection even after screening. Healthy behaviour change might also have impacted the fi ndings – for example one third of screen-detected individuals reported that they had stopped smoking at five-year follow up, and this cohort lost an average of 2 kg in weight.

The authors suggest that benefi ts to the general population might be increased by identifi cation of non-attenders, targeting of screening to those at greatest risk, strategies to maximise uptake of screening, use of repeated rounds of screening, and optimal treatment of detected disease.

In the third article published on this subject, researchers identified 1024 screendetected and 8642 clinically-detected cases of type 2 diabetes in a population of over 140,000 individuals eligible for screening at 10-year intervals (at age 30, 40, 50 and 60 years) between 1992 and 2013. Screening was undertaken as part of the Västerbotten Intervention Programme (VIP), a large community- and individualbased intervention in Västerbotten County, Sweden. Screen- and clinicallydetected diabetes cases were followed up in national registries for mortality, CVD events, renal disease and retinopathy for on average 8.7 and 7.2 years after diagnosis, respectively.

The authors, led by Dr Adina Feldman and Professor Olov Rolandsson from the VIPCAM collaboration between the University of Cambridge, UK, and Umeå University, Sweden, say: “We found that individuals with screen-detected diabetes were diagnosed on average 4.6 years earlier than those who were clinically-detected, and that when followed up after their diagnosis, they had markedly lower rates of all-cause mortality, CVD, renal disease and retinopathy. Although we cannot fullydisentangle the contribution of length time bias in particular, these data suggest a positive effect on survival and health outcomes if diabetes is detected earlier through screening than it would have been in clinical practice.”

Taking these results together, Dr Simmons says: “Screening appears to offer benefi cial effects for all those diagnosed with diabetes, regardless of whether they were screen detected or clinically diagnosed but this benefi t is too small to have an impact on overall population risk of heart disease and stroke, for example, or on early death.”

Indeed, in the first of two comments published with these articles, Professor David Simmons, Western Sydney University, NSW, Australia, and Dr Janice C. Zgibor, University of South Florida, Tampa, FL, USA, say that “trials of screening for undiagnosed diabetes among asymptomatic individuals may no longer be feasible or ethical in many countries. The most efficient recommendation may be opportunistic screening, where patients already seeking care (including screening) for another condition are subsequently tested for diabetes or prediabetes. If screened positive, they are more likely to receive treatment, thus leading to improved outcomes. There is probably suffi cient evidence to conclude that this systematic approach to screening should occur in primary care and that focus should now shift to trials of how to screen, methods for implementing treatment earlier, and better risk factor control in those at highest risk.”

Professor Jonathan Shaw, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia, says: “The appropriate conclusion from the currently-available evidence is that community screening programmes cannot be justifi ed for type 2 diabetes in countries where opportunistic diabetes screening is functioning well, and management of cardiovascular risk factors is good. The large amounts of public money required for such screening programmes would be better spent on treating those with clinically diagnosed disease.”

Lower socioeconomic status linked to obesity through distress and emotional eating


New research presented at this year’s European Congress on Obesity in Porto, Portugal shows that lower socioeconomic status is associated with higher bodymass index (BMI) through its effects on distress and subsequent emotional eating.

The study is by Jade Stewart and Dr Charlotte Hardman, Department of Psychological Sciences, University of Liverpool, UK and colleagues.

Lower socioeconomic status is robustly associated with obesity; however, the underpinning psychological mechanisms remain unclear. According to a recent theoretical model*, socioeconomic disadvantage increases psychological distress which, in turn, promotes maladaptive coping behaviours, such as emotional eating, and ultimately obesity. Furthermore, resilience (an individual’s capacity to cope with stressors and ‘bounce back’) is thought to moderate the association between socio-economic disadvantage and distress thus providing a protective role. The current study sought to test these predictions.

A total of 150 adults aged 18 to 65 years and from a range of socioeconomic backgrounds reported their income and education level as an indicator of socioeconomic status. Psychological distress, emotional eating, and resilience were assessed using the Depression, Anxiety and Stress Scale, the Dutch Eating Behaviour Questionnaire, and the Brief Resilience Scale, respectively. Selfreported height and weight were also obtained to calculate body mass index (BMI).

As predicted, the data (adjusted for age and sex) indicated a signifi cant indirect effect of socioeconomic status on BMI via psychological distress and increased emotional eating; specifi cally, lower socioeconomic status was associated with higher distress, higher distress was associated with higher emotional eating, and higher emotional eating was associated with higher BMI. An increase by 1 scale point on the emotional eating scale (scale 1-5) was associated with an increase in BMI of 1.9 kg/m2. Mean BMI at the lowest point on the emotional eating scale was 23.3 kg/m2. At the highest point it was 30.9 kg/m2. However, contrary to prediction, resilience was not found to moderate this effect.

The authors conclude: “These findings provide a novel insight into the relationship between socioeconomic status and obesity, suggesting that it may be partly explained by psychological distress and subsequent emotional eating as a coping strategy. Targeting these maladaptive coping behaviours in response to distress may be a way of reducing obesity in low-income populations.”

They add: “One way of doing this would be to teach people to implement more positive coping strategies when they are in a state of distress for example going for a walk instead of eating chocolate.”

“The association between low SES and access to cheap energy-dense foods and subsequent obesity is already well-documented. What this study does is to shed light on a psychological explanation for the association between SES and obesity and this has received little consideration in research to date.”

*Hemmingsson, E. (2014). A new model of the role of psychological and emotional distress in promoting obesity: conceptual review with implications for treatment and prevention. Obesity Reviews, 16, 769 -779.



Date of upload: 19th Nov 2017

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