Lifestyle predictors of colorectal cancer in European populations: a systematic review.

Background: Colorectal cancer (CRC) is the second most prevalent cancer in Europe, with one-fifth of cases attributable to unhealthy lifestyles. Risk prediction models for quantifying CRC risk and identifying high-risk groups have been developed or validated across European populations, some considering lifestyle as a predictor. Purpose: To identify lifestyle predictors considered in existing risk prediction models applicable for European populations and characterise their corresponding parameter values for an improved understanding of their relative contribution to prediction across different models. Methods: A systematic review was conducted in PubMed and Web of Science from January 2000 to August 2021. Risk prediction models were included if (1) developed and/or validated in an adult asymptomatic European population, (2) based on non-invasively measured predictors and (3) reported mean estimates and uncertainty for predictors included. To facilitate comparison, model-specific lifestyle predictors were visualised using forest plots. Results: A total of 21 risk prediction models for CRC (reported in 16 studies) were eligible, of which 11 were validated in a European adult population but developed elsewhere, mostly USA. All models but two reported at least one lifestyle factor as predictor. Of the lifestyle factors, the most common predictors were body mass index (BMI) and smoking (each present in 13 models), followed by alcohol (11), and physical activity (7), while diet-related factors were less considered with the most commonly present meat (9), vegetables (5) or dairy (2). The independent predictive contribution was generally greater when they were collected with greater detail, although a noticeable variation in effect size estimates for BMI, smoking and alcohol. Conclusions: Early identification of high-risk groups based on lifestyle data offers the potential to encourage participation in lifestyle change and screening programmes, hence reduce CRC burden. We propose the commonly shared lifestyle predictors to be further used in public health prediction modelling for improved uptake of the model.

The future burden of type 2 diabetes in Belgium: a microsimulation model.

OBJECTIVE: To forecast the annual burden of type 2 diabetes and related socio-demographic disparities in Belgium until 2030. METHODS: This study utilized a discrete-event transition microsimulation model. A synthetic population was created using 2018 national register data of the Belgian population aged 0-80 years, along with the national representative prevalence of diabetes risk factors obtained from the latest (2018) Belgian Health Interview and Examination Surveys using Multiple Imputation by Chained Equations (MICE) as inputs to the Simulation of Synthetic Complex Data (simPop) model. Mortality information was obtained from the Belgian vital statistics and used to calculate annual death probabilities. From 2018 to 2030, synthetic individuals transitioned annually from health to death, with or without developing type 2 diabetes, as predicted by the Finnish Diabetes Risk Score, and risk factors were updated via strata-specific transition probabilities. RESULTS: A total of 6722 [95% UI 3421, 11,583] new cases of type 2 diabetes per 100,000 inhabitants are expected between 2018 and 2030 in Belgium, representing a 32.8% and 19.3% increase in T2D prevalence rate and DALYs rate, respectively. While T2D burden remained highest for lower-education subgroups across all three Belgian regions, the highest increases in incidence and prevalence rates by 2030 are observed for women in general, and particularly among Flemish women reporting higher-education levels with a 114.5% and 44.6% increase in prevalence and DALYs rates, respectively. Existing age- and education-related inequalities will remain apparent in 2030 across all three regions. CONCLUSIONS: The projected increase in the burden of T2D in Belgium highlights the urgent need for primary and secondary preventive strategies. While emphasis should be placed on the lower-education groups, it is also crucial to reinforce strategies for people of higher socioeconomic status as the burden of T2D is expected to increase significantly in this population segment.

Understanding the contribution of lifestyle in breast cancer risk prediction: a systematic review of models applicable to Europe.

BACKGROUND: Breast cancer (BC) is a significant health concern among European women, with the highest prevalence rates among all cancers. Existing BC prediction models account for major risks such as hereditary, hormonal and reproductive factors, but research suggests that adherence to a healthy lifestyle can reduce the risk of developing BC to some extent. Understanding the influence and predictive role of lifestyle variables in current risk prediction models could help identify actionable, modifiable, targets among high-risk population groups. PURPOSE: To systematically review population-based BC risk prediction models applicable to European populations and identify lifestyle predictors and their corresponding parameter values for a better understanding of their relative contribution to the prediction of incident BC. METHODS: A systematic review was conducted in PubMed, Embase and Web of Science from January 2000 to August 2021. Risk prediction models were included if (i) developed and/or validated in adult cancer-free women in Europe, (ii) based on easily ascertained information, and (iii) reported models' final predictors. To investigate further the comparability of lifestyle predictors across models, estimates were standardised into risk ratios and visualised using forest plots. RESULTS: From a total of 49 studies, 33 models were developed and 22 different existing models, mostly from Gail (22 studies) and Tyrer-Cuzick and co-workers (12 studies) were validated or modified for European populations. Family history of BC was the most frequently included predictor (31 models), while body mass index (BMI) and alcohol consumption (26 and 21 models, respectively) were the lifestyle predictors most often included, followed by smoking and physical activity (7 and 6 models respectively). Overall, for lifestyle predictors, their modest predictive contribution was greater for riskier lifestyle levels, though highly variable model estimates across different models. CONCLUSIONS: Given the increasing BC incidence rates in Europe, risk models utilising readily available risk factors could greatly aid in widening the population coverage of screening efforts, while the addition of lifestyle factors could help improving model performance and serve as intervention targets of prevention programmes.

Comparing self-reported health interview survey and pharmacy billing data in determining the prevalence of diabetes, hypertension, and hypercholesterolemia in Belgium.

BACKGROUND: Administrative and health surveys are used in monitoring key health indicators in a population. This study investigated the agreement between self-reported disease status from the Belgian Health Interview Survey (BHIS) and pharmaceutical insurance claims extracted from the Belgian Compulsory Health Insurance (BCHI) in ascertaining the prevalence of diabetes, hypertension, and hypercholesterolemia. METHODS: Linkage was made between the BHIS 2018 and the BCHI 2018, from which chronic condition was ascertained using the Anatomical Therapeutic Chemical (ATC) classification and defined daily dose. The data sources were compared using estimates of disease prevalence and various measures of agreement and validity. Multivariable logistic regression was performed for each chronic condition to identify the factors associated to the agreement between the two data sources. RESULTS: The prevalence estimates computed from the BCHI and the self-reported disease definition in BHIS, respectively, are 5.8% and 5.9% diabetes cases, 24.6% and 17.6% hypertension cases, and 16.2% and 18.1% of hypercholesterolemia cases. The overall agreement and kappa coefficient between the BCHI and the self-reported disease status is highest for diabetes and is equivalent to 97.6% and 0.80, respectively. The disagreement between the two data sources in ascertaining diabetes is associated with multimorbidity and older age categories. CONCLUSION: This study demonstrated the capability of pharmacy billing data in ascertaining and monitoring diabetes in the Belgian population. More studies are needed to assess the applicability of pharmacy claims in ascertaining other chronic conditions and to evaluate the performance of other administrative data such as hospital records containing diagnostic codes.

Predicting COVID-19 progression in hospitalized patients in Belgium from a multi-state model.

Objectives: To adopt a multi-state risk prediction model for critical disease/mortality outcomes among hospitalised COVID-19 patients using nationwide COVID-19 hospital surveillance data in Belgium. Materials and methods: Information on 44,659 COVID-19 patients hospitalised between March 2020 and June 2021 with complete data on disease outcomes and candidate predictors was used to adopt a multi-state, multivariate Cox model to predict patients' probability of recovery, critical [transfer to intensive care units (ICU)] or fatal outcomes during hospital stay. Results: Median length of hospital stay was 9 days (interquartile range: 5-14). After admission, approximately 82% of the COVID-19 patients were discharged alive, 15% of patients were admitted to ICU, and 15% died in the hospital. The main predictors of an increased probability for recovery were younger age, and to a lesser extent, a lower number of prevalent comorbidities. A patient's transition to ICU or in-hospital death had in common the following predictors: high levels of c-reactive protein (CRP) and lactate dehydrogenase (LDH), reporting lower respiratory complaints and male sex. Additionally predictors for a transfer to ICU included middle-age, obesity and reporting loss of appetite and staying at a university hospital, while advanced age and a higher number of prevalent comorbidities for in-hospital death. After ICU, younger age and low levels of CRP and LDH were the main predictors for recovery, while in-hospital death was predicted by advanced age and concurrent comorbidities. Conclusion: As one of the very few, a multi-state model was adopted to identify key factors predicting COVID-19 progression to critical disease, and recovery or death.

Cardiometabolic Profile and Outcomes in Migrant Populations: A Review of Comparative Evidence from Migrants in Europe in Relation to Their Country of Origin.

BACKGROUND: The potential effect of migration on increasing cardiometabolic risk factors remains partially understood. We aim to synthesize the evidence comparing the burden of diabetes and adiposity of migrating populations in Europe, with that of their country of origin. METHODS: We conducted a scoping literature review. We searched PubMed for studies investigating the effect of migration on diabetes or adiposity outcomes among migrants in countries from the European Union or the United Kingdom compared to the population in the country of origin. Studies were qualitatively synthesized in evidence tables and the demographic characteristics, study design, risk factors investigated, and outcomes were quantitatively summarized using measures of central tendency. FINDINGS: Of 1175 abstracts retrieved, 28 studies were eligible. Most of the studies included migrating populations residing in Western (50%), Northern (39%), and Southern Europe (11%) originating from countries in Africa (46%), Asia (29%), or European overseas (25%) regions of which 85% were classified as low-middle-income countries. Most of the studies (93%) had a cross-sectional design. The median number of individuals in the country of origin was greater [917; IQR: 231-1378] than in the receiving country [249; 150-883]. Thirty-five percent of the studies investigated migration as an independent risk factor, whereas 28% contextualized migration into lifestyle changes. The majority of the studies (57%) reported both diabetes and adiposity outcomes. Within the limited evidence available, controversial results were found as some studies showed poorer outcomes for the migrating populations, while others showed the opposite. CONCLUSION: Studies assessing the impact of migration by comparing migrating populations and the population of origin on diabetes and adiposity outcomes have gained interest. So far, the available evidence is highly heterogeneous to inform public health strategies in the receiving countries. We recommend further research including a more robust methodology and in-depth characterization of the migrant populations.

The effectiveness of lifestyle interventions on type 2 diabetes and gestational diabetes incidence and cardiometabolic outcomes: A systematic review and meta-analysis of evidence from low- and middle-income countries.

Background: As lifestyle modification offers a unique strategy to prevent diabetes, we evaluated the effectiveness of lifestyle interventions in the prevention of type 2 diabetes and gestational diabetes in low- and middle-income countries (LMICs). Methods: We did a systematic literature review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and Cochrane Library for randomised controlled trials published in English, Spanish, French, and Portuguese between 1 January 2000 and 15 June 2022, evaluating multi-target and multi-component lifestyle interventions in at-risk populations conducted in LMICs. The main outcomes were incidence of type 2 diabetes and gestational diabetes, and indicators of glycaemic control. We assessed the methodological quality of the studies using the Cochrane risk of bias tool. Inverse-variance random-effects meta-analyses estimated the overall effect sizes. Sources of heterogeneity and study bias were evaluated. The study protocol was registered in PROSPERO (CRD42021279174). Findings: From 14 330 abstracts, 48 (0·3%) studies with 50 interventions were eligible of which 56% were conducted in lower-middle-income countries, 44% in upper-middle, and none in low-income. 54% of the studies were assessed as moderate risk of bias and 14% as high risk. A median of 246 (IQR 137-511) individuals participated in the interventions with a median duration of 6 (3-12) months. Lifestyle interventions decreased the incidence risk ratio of type 2 diabetes by 25% (0·75 [95% CI 0·61 to 0·91]), and reduced the levels of HbA1c by 0·15% [-0·25 to -0·05], fasting plasma glucose by 3·44 mg/dL [-4·72 to -2·17], and 2-hr glucose tolerance by 4·18 mg/dL [-7·35 to -1·02]. No publication bias was suggested for these outcomes. High levels of heterogeneity (I²≥ 81%) were found in most meta-analyses. Exploration using meta-regressions could not identify any explanatory variable, except for fasting glucose for which the quality score of the articles seems to be an effect modifier decreasing slightly the heterogeneity (72%) in the low risk of bias pooled estimate. The effect on gestational diabetes could not be evaluated due to the scarcity of available studies. Interpretation: Comprehensive lifestyle interventions are effective strategies to prevent type 2 diabetes among at-risk populations in LMICs. The heterogeneity identified in our results should be considered when using these interventions to address the onset of type 2 diabetes. Funding: None.

A retrospective database study of the demographic features and glycemic control of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo.

BACKGROUND: The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients' follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention. METHODS: We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model. RESULTS: Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5-3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years). CONCLUSION: In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients' follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

Food Choice Motives and COVID-19 in Belgium.

To investigate the main motives driving dietary intake changes potentially introduced by preventive measures to address the pandemic, an online survey, using a 36-item Food Choice Questionnaire applied for the period before (the year 2019) and during (2020-2021) the pandemic, was distributed between July and October 2021 among adult residents from Belgium. A total of 427 eligible respondents, the majority Dutch-speaking, were included for analyses. The importance of nine motives for food choices, including health, mood, convenience, sensory appeal, natural content, price, weight control, familiarity and ethical concerns, was assessed by scoring from 1 to 5, and comparing mean scores from the during period with the before period. Sensory appeal was the most important food choice motive before (mean score of 4.02 ± 0.51) and during (3.98 ± 0.48) the pandemic. Convenience and health also ranked among the main motives, with health observed to become more important during the pandemic (3.69 ± 0.60 during vs. 3.64 ± 0.59 before). Additionally, mean scores of mood (3.41 ± 0.71 vs. 3.32 ± 0.58), natural content (3.35 ± 0.84 vs. 3.26 ± 0.85) and weight control (3.33 ± 0.79 vs. 3.25 ± 0.76) were significantly higher during as compared to before. The extent of change in the level of importance for natural content was smaller with increasing age, and for health larger for urban areas, but for other motives there were no significant differences across population subgroups. Changes in the level of importance were observed in both directions, while a moderate share of respondents declared no change, suggesting some persistence of food choice motives. Further activities within public health monitoring should be considered to fully understand the COVID-19 implications on food choice motives together with people's food behaviors and consumption.

Ultra-processed food consumption in adults across Europe.

PURPOSE: The purpose of this study is to describe ultra-processed food and drinks (UPFDs) consumption, and associations with intake of total sugar and dietary fibre, and high BMI in adults across Europe. METHODS: Using food consumption data collected by food records or 24-h dietary recalls available from the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database, the foods consumed were classified by the level of processing using the NOVA classification. Diet quality was assessed by data linkage to the Dutch food composition tables (NEVO) and years lived with disability for high BMI from the Global Burden of Disease Study 2019. Bivariate groupings were carried out to explore associations of UPFDs consumption with population intake of sugar and dietary fibre, and BMI burden, visualised by scatterplots. RESULTS: The energy share from UPFDs varied markedly across the 22 European countries included, ranging from 14 to 44%, being the lowest in Italy and Romania, while the highest in the UK and Sweden. An overall modest decrease (2-15%) in UPFDs consumption is observed over time, except for Finland, Spain and the UK reporting increases (3-9%). Fine bakery wares and soft drinks were most frequently ranked as the main contributor. Countries with a higher sugar intake reported also a higher energy share from UPFDs, as most clearly observed for UPF (r = 0.57, p value = 0.032 for men; and r = 0.53, p value = 0.061 for women). No associations with fibre intake or high BMI were observed. CONCLUSION: Population-level UPFDs consumption substantially varied across Europe, although main contributors are similar. UPFDs consumption was not observed to be associated with country-level burden of high BMI, despite being related to a higher total sugar intake.

Microsimulation Modeling in Food Policy: A Scoping Review of Methodological Aspects.

Food policies for the prevention and management of diet-related noncommunicable diseases (NCDs) have been increasingly relying on microsimulation models (MSMs) to assess effectiveness. Given the increased uptake of MSMs, this review aims to provide an overview of the characteristics of MSMs that link diets with NCDs. A comprehensive review was conducted in PubMed and Web of Knowledge. Inclusion criteria were: 1) findings from an MSM; 2) diets, foods, or nutrients as the main exposure of interest; and 3) NCDs, such as overweight/obesity, type 2 diabetes, coronary heart disease, stroke, or cancer, as the disease outcome for impact assessment. This review included information from 33 studies using MSM in analyzing diet and diverse food policies on NCDs. Hereby, most models employed stochastic, discrete-time, dynamic microsimulation techniques to calculate anticipated (cost-)effectiveness of strategies based on food pricing, food reformulation, or dietary (lifestyle) interventions. Currently available models differ in the methodology used for quantifying the effect of the dietary changes on disease, and in the method for modeling the disease incidence and mortality. However, all studies provided evidence that the models were sufficiently capturing the close-to-reality situation by justifying their choice of model parameters and validating externally their modeled disease incidence and mortality with observed or predicted event data. With the increasing use of various MSMs, between-model comparisons, facilitated by open access models and good reporting practices, would be important for judging a model's accuracy, leading to continued improvement in the methodologies for developing and applying MSMs and, subsequently, a better understanding of the results by policymakers.

Mapping the nutritional value of diets across Europe according to the Nutri-Score front-of-pack label.

Background: Front-of-pack labels, such as Nutri-Score, aim to offer clear information on the overall nutritional quality of foods and beverages to consumers, allowing them to make healthier food choices. Using the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database, the present study aims to map out European food consumption patterns by applying the Nutri-Score as a benchmark for nutritional value. Methods: Country-specific food consumption data, collected by multiple 24-h dietary recalls or food records available from EFSA, were linked to the Dutch Food Composition Database (NEVO). Foods and beverages consumed by adolescents (10-17 years), adults (18-64 years), and the elderly (65-74 years) were graded following the modified Food Standard Agency Nutrient Profiling System (FSAm-NPS) and classified according to Nutri-Score grading, from A to E. Subsequently, a dietary index score (FSAm-NPS-DI) was calculated for each country-specific diet by age-groups and sex as an energy-weighted mean of the FSAm-NPS score of all foods and beverages consumed, with lower scores for a diet of greater overall nutritional quality. Results: On average, the daily energy intake of adults across the European countries studied is distributed in 27.6% of A-, 12.9% of B-, 17% of C-, 30.0% of D-, and 12.5% of E-classified foods and beverages. This energy distribution, according to the Nutri-Score, corresponded to a median FSAm-NPS-DI score of 6.34 (interquartile range: 5.92, 7.19). For both adult males and females, Estonia reported the highest energy share from A-classified products, scoring the lowest on the FSAm-NPS-DI. On the other hand, Latvia reported the highest energy share from E-classified products, along with the highest FSAm-NPS-DI. Females and the elderly group reported, in general, a greater energy share from A- and a lower share from E-classified products, and had the lowest FSAm-NPS-DI scores. No sex-related difference was observed for adolescents whose share of energy was predominantly from A- and D-classified products, such as for adults and the elderly. Conclusion: Our analyses leveraging the secondary use of country-specific databases on dietary intakes found considerable variation in the nutritional value of European diets, with an overall agreement across all countries on a modestly healthier dietary profile for the elderly and among females.

Unravelling data for rapid evidence-based response to COVID-19: a summary of the unCoVer protocol.

INTRODUCTION: unCoVer-Unravelling data for rapid evidence-based response to COVID-19-is a Horizon 2020-funded network of 29 partners from 18 countries capable of collecting and using real-world data (RWD) derived from the response and provision of care to patients with COVID-19 by health systems across Europe and elsewhere. unCoVer aims to exploit the full potential of this information to rapidly address clinical and epidemiological research questions arising from the evolving pandemic. METHODS AND ANALYSIS: From the onset of the COVID-19 pandemic, partners are gathering RWD from electronic health records currently including information from over 22 000 hospitalised patients with COVID-19, and national surveillance and screening data, and registries with over 1 900 000 COVID-19 cases across Europe, with continuous updates. These heterogeneous datasets will be described, harmonised and integrated into a multi-user data repository operated through Opal-DataSHIELD, an interoperable open-source server application. Federated data analyses, without sharing or disclosing any individual-level data, will be performed with the objective to reveal patients' baseline characteristics, biomarkers, determinants of COVID-19 prognosis, safety and effectiveness of treatments, and potential strategies against COVID-19, as well as epidemiological patterns. These analyses will complement evidence from efficacy/safety clinical trials, where vulnerable, more complex/heterogeneous populations and those most at risk of severe COVID-19 are often excluded. ETHICS AND DISSEMINATION: After strict ethical considerations, databases will be available through a federated data analysis platform that allows processing of available COVID-19 RWD without disclosing identification information to analysts and limiting output to data aggregates. Dissemination of unCoVer's activities will be related to the access and use of dissimilar RWD, as well as the results generated by the pooled analyses. Dissemination will include training and educational activities, scientific publications and conference communications.

Quantification of disparities in the distribution of lifestyle and metabolic risk factors, prevalence of non-communicable diseases and related mortality: the Belgian Health Interview Surveys 1997-2018.

OBJECTIVES: Comprehensively measure the trends in health disparities by sociodemographic strata in terms of exposure to lifestyle and metabolic risks, and prevalence and mortality of non-communicable diseases (NCDs) during the last 20 years in Belgium. DESIGN: Cross-sectional analysis of periodic national-representative health interview surveys and vital statistics. SETTING: Population-based study of adult residents in Belgium between 1997 and 2018. PARTICIPANTS: Adults aged 25-84 years and resident in Belgium in the years 1997 (7256 adults), 2001 (8665), 2004 (9054), 2008 (7343), 2013 (7704) and 2018 (8358). MAIN OUTCOME MEASURE: Age-standardised prevalence rates of modifiable lifestyle risks (poor diet, smoking, excessive alcohol use and leisure-time physical inactivity), metabolic risks (high body mass index (BMI), blood pressure and cholesterol levels) and major NCDs (type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVDs), cancer, asthma and chronic obstructive pulmonary disease (COPD)), with their relative health disparities across strata by age, sex, region of residence, nationality, education and income level, and according to high versus low engagement in the four lifestyle risks, calculated from a survey-weighted age-adjusted logistic regression. RESULTS: Greater avoidable disparities were observed between extremes of education and income strata. The most marked disparities were found for exposure to lifestyle risks (except excessive alcohol use), prevalence of high BMI as well as T2DM, asthma and COPD, with disparities of daily smoking and COPD worsening over time. Still, NCD-specific mortality rates were significantly higher among men (except asthma), residents of Wallonia and Brussels (except cerebrovascular disease), and among the native Belgians (except T2DM and asthma). High engagement in lifestyle risks was generally observed for men, residents of the region Wallonia, and among lower education and income strata. This subgroup (20%) had a worse health profile as compared with those who had a low-risk lifestyle (25%), shown by prevalence ratios varying between 1.1 and 1.6 for metabolic risks, and between 1.8 and 3.7 for CVD, asthma and COPD. CONCLUSIONS: Improving population health, including promoting greater health equity, requires approaches to be tailored to high-risk groups with actions tackling driving root causes of disparities seen by social factors and unhealthy lifestyle.

Evaluation of the Food Choice Motives before and during the COVID-19 Pandemic: A Cross-Sectional Study of 1232 Adults from Croatia.

The coronavirus disease 2019 pandemic brought changes to almost every segment of our lives, including dietary habits. We present one among several studies, and the first on the Croatian population, aiming at investigating changes of food choice motives before and during the pandemic. The study was performed in June 2021 as an online-based survey, using a 36-item Food Choice Questionnaire applied for both the periods before and during the pandemic. The final sample consisted of 1232 adults living in Croatia. Sensory appeal was ranked as the number one most important food choice motive before, whereas health was ranked as the number one most important food choice motive during the pandemic. Ethical concern was reported as the least important food choice motive both before and during the pandemic. In women, natural content (p = 0.002), health, convenience, price, weight control, familiarity, and ethical concern (all p < 0.001) became more important during the pandemic, while price (p = 0.009), weight control, familiarity, and ethical concern (all p < 0.001) became more relevant for men. All together, these can be considered favorable changes toward optimal diets and may result in beneficial influences on health and lifestyle. Education strategies and efficiently tackling misinformation are prerequisites for informed food choice, which will ensure long-lasting positive effects of such changes.

Insights into the association of ACEIs/ARBs use and COVID-19 prognosis: a multistate modelling study of nationwide hospital surveillance data from Belgium.

OBJECTIVES: The widespread use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) by patients with chronic conditions raised early concerns on the potential exacerbation of COVID-19 severity and fatality. Previous studies addressing this question have used standard methods that may lead to biased estimates when analysing hospital data because of the presence of competing events and event-related dependency. We investigated the association of ACEIs/ARBs' use with COVID-19 disease outcomes using time-to-event data in a multistate setting to account for competing events and minimise bias. SETTING: Nationwide surveillance data from 119 Belgian hospitals. PARTICIPANTS: Medical records of 10 866 patients hospitalised from 14 March 2020to 14 June 2020 with a confirmed SARS-CoV-19 infection and information about ACEIs/ARBs' use. PRIMARY OUTCOME MEASURE: Multistate, multivariate Cox-Markov models were used to estimate the hazards of patients transitioning through health states from admission to discharge or death, along with transition probabilities calculated by combining the baseline cumulative hazard and regression coefficients. RESULTS: After accounting for potential confounders, there was no discernable association between ACEIs/ARBs' use and transfer to intensive care unit (ICU). Contrastingly, for patients without ICU transfer, ACEIs/ARBs' use was associated with a modest increase in recovery (HR 1.07, 95% CI 1.01 to 1.13, p=0.027) and reduction in fatality (HR 0.83, 95% CI 0.75 to 0.93, p=0.001) transitions. For patients transferred to ICU admission, no evidence of an association between ACEIs/ARBs' use and recovery (HR 1.16, 95% CI 0.97 to 1.38, p=0.098) or in-hospital death (HR 0.91, 95% CI 0.73 to 1.12, p=0.381) was observed. Male gender and older age were significantly associated with higher risk of ICU admission or death. Chronic cardiometabolic comorbidities were also associated with less recovery. CONCLUSIONS: For the first time, a multistate model was used to address magnitude and direction of the association of ACEIs/ARBs' use on COVID-19 progression. By minimising bias, this study provided a robust indication of a protective, although modest, association with recovery and survival.

Effectiveness of workplace wellness programmes for dietary habits, overweight, and cardiometabolic health: a systematic review and meta-analysis.

BACKGROUND: The workplace offers a unique opportunity for effective health promotion. We aimed to comprehensively study the effectiveness of multicomponent worksite wellness programmes for improving diet and cardiometabolic risk factors. METHODS: We did a systematic literature review and meta-analysis, following PRISMA guidelines. We searched PubMed-MEDLINE, Embase, the Cochrane Library, Web of Science, and Education Resources Information Center, from Jan 1, 1990, to June 30, 2020, for studies with controlled evaluation designs that assessed multicomponent workplace wellness programmes. Investigators independently appraised the evidence and extracted the data. Outcomes were dietary factors, anthropometric measures, and cardiometabolic risk factors. Pooled effects were calculated by inverse-variance random-effects meta-analysis. Potential sources of heterogeneity and study biases were evaluated. FINDINGS: From 10 169 abstracts reviewed, 121 studies (82 [68%] randomised controlled trials and 39 [32%] quasi-experimental interventions) met the eligibility criteria. Most studies were done in North America (57 [47%]), and Europe, Australia, or New Zealand (36 [30%]). The median number of participants was 413·0 (IQR 124·0-904·0), and median duration of intervention was 9·0 months (4·5-18·0). Workplace wellness programmes improved fruit and vegetable consumption (0·27 servings per day [95% CI 0·16 to 0·37]), fruit consumption (0·20 servings per day [0·11 to 0·28]), body-mass index (-0·22 kg/m2 [-0·28 to -0·17]), waist circumference (-1·47 cm [-1·96 to -0·98]), systolic blood pressure (-2·03 mm Hg [-3·16 to -0·89]), and LDL cholesterol (-5·18 mg/dL [-7·83 to -2·53]), and to a lesser extent improved total fat intake (-1·18% of daily energy intake [-1·78 to -0·58]), saturated fat intake (-0·70% of daily energy [-1·22 to -0·18]), bodyweight (-0·92 kg [-1·11 to -0·72]), diastolic blood pressure (-1·11 mm Hg [-1·78 to -0·44]), fasting blood glucose (-1·81 mg/dL [-3·33 to -0·28]), HDL cholesterol (1·11 mg/dL [0·48 to 1·74]), and triglycerides (-5·38 mg/dL [-9·18 to -1·59]). No significant benefits were observed for intake of vegetables (0·03 servings per day [95% CI -0·04 to 0·10]), fibre (0·26 g per day [-0·15 to 0·67]), polyunsaturated fat (-0·23% of daily energy [-0·59 to 0·13]), or for body fat (-0·80% [-1·80 to 0·21]), waist-to-hip ratio (-0·00 ratio [-0·01 to 0·00]), or lean mass (1·01 kg [-0·82 to 2·83]). Heterogeneity values ranged from 46·9% to 91·5%. Between-study differences in outcomes were not significantly explained by study design, location, population, or similar factors in heterogeneity analyses. INTERPRETATION: Workplace wellness programmes are associated with improvements in specific dietary, anthropometric, and cardiometabolic risk indicators. The heterogeneity identified in study designs and results should be considered when using these programmes as strategies to improve cardiometabolic health. FUNDING: National Heart, Lung, and Blood Institute.

Work Shift, Lifestyle Factors, and Subclinical Atherosclerosis in Spanish Male Workers: A Mediation Analysis.

(1) Background: Working night shifts has been associated with altered circadian rhythms, lifestyle habits, and cardiometabolic risks. No information on the potential association of working shift and the presence of atherosclerosis is available. The aim of this study was to quantify the association between different work shifts and the presence of subclinical atherosclerosis objectively measured by imaging. (2) Methods: Analyses were conducted on the baseline data of the Aragon Workers Health Study (AWHS) cohort, including information on 2459 middle-aged men. Categories of shift work included central day shift, rotating morning-evening or morning-evening-night shift, and night shift. The presence of atherosclerotic plaques was assessed by 2D ultrasound in the carotid and femoral vascular territories. Multivariable logistic models and mediation analysis were conducted to characterize and quantify the association between study variables. (3) Results: Participants working night or rotating shifts presented an overall worse cardiometabolic risk profile, as well as more detrimental lifestyle habits. Workers in the most intense (morning-evening-night) rotating shift presented higher odds of subclinical atherosclerosis (odds ratio: 1.6; 95% confidence interval: 1.12 to 2.27) compared to workers in the central shift, independently of the presence of lifestyle and metabolic risk factors. A considerable (21%) proportion of this association was found to be mediated by smoking, indicating that altered sleep-wake cycles have a direct relationship with the early presence of atherosclerotic lesions. (4) Conclusions: Work shifts should be factored in during workers health examinations, and when developing effective workplace wellness programs.

Improving health and carbon footprints of European diets using a benchmarking approach.

OBJECTIVE: This study aimed to identify diets with improved nutrient quality and environmental impact within the boundaries of dietary practices. DESIGN: We used Data Envelopment Analysis to benchmark diets for improved adherence to food-based dietary guidelines (FBDG). We then optimised these diets for dietary preferences, nutrient quality and environmental impact. Diets were evaluated using the Nutrient Rich Diet score (NRD15.3), diet-related greenhouse gas emission (GHGE) and a diet similarity index that quantified the proportion of food intake that remained similar as compared with the observed diet. SETTING: National dietary surveys of four European countries (Denmark, Czech Republic, Italy and France). SUBJECTS: Approximately 6500 adults, aged 18-64 years. RESULTS: When dietary preferences were prioritised, NRD15·3 was ~6 % higher, GHGE was ~4 % lower and ~85 % of food intake remained similar. This diet had higher amounts of fruit, vegetables and whole grains than the observed diet. When nutrient quality was prioritised, NRD15·3 was ~16 % higher, GHGE was ~3 % lower and ~72 % of food intake remained similar. This diet had higher amounts of legumes and fish and lower amounts of sweetened and alcoholic beverages. Finally, when environmental impact was prioritised, NRD15·3 was ~9 % higher, GHGE was ~21 % lower and ~73 % of food intake remained similar. In this diet, red and processed meat partly shifted to either eggs, poultry, fish or dairy. CONCLUSIONS: Benchmark modelling can generate diets with improved adherence to FBDG within the boundaries of dietary practices, but fully maximising health and minimising GHGE cannot be achieved simultaneously.

The Burden of Malnutrition and Fatal COVID-19: A Global Burden of Disease Analysis.

Background: Although reasonable to assume, it is not yet clear whether malnourished countries are at higher risk for severe or fatal coronavirus disease 2019 (COVID-19). This study aims to identify the countries where prevalent malnutrition may be a driving factor for fatal disease after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods: Using estimates from the Global Burden of Disease 2019, country-level burden of malnutrition was quantified using four indicators: death rates for child growth failure (underweight, stunting, and/or wasting) and years lived with disability (YLD) attributed to iron and vitamin A deficiencies and high body mass index (BMI). Global mortality descriptors of the ongoing COVID-19 pandemic were extracted from the European Centre for Disease Prevention and Control, and case fatality ratios (CFRs) were calculated introducing a lag time of 10 weeks after the first death of a confirmed case. Bivariate analyses for 172 countries were carried out for malnutrition indicators and fatal COVID-19. Correlations between burden indicators were characterized by Spearman's rank correlation coefficients (ρ) and visually by scatterplots. Restricted cubic splines and underlying negative binomial regressions adjusted for countries' age-structure, prevalent chronic comorbidities related to COVID-19, population density, and income group were used to explore non-linear relationships. Results: Stratified by the World Bank income group, a moderate positive association between YLD rates for iron deficiency and CFRs for COVID-19 was observed for low-income countries (ρ = 0.60, p = 0.027), whereas no clear indications for the association with child growth failure, vitamin A deficiency, or high BMI were found (ρ < 0.30). Countries ranking high on at least three malnutrition indicators and presenting also an elevated CFR for COVID-19 are sub-Saharan African countries, namely, Angola, Burkina Faso, Chad, Liberia, Mali, Niger, Sudan, and Tanzania, as well as Yemen and Guyana. Conclusions: Population-level malnutrition appears to be related to increased rates of fatal COVID-19 in areas with an elevated burden of undernutrition, such as countries in the Sahel strip. COVID-19 response plans in malnourished countries, vulnerable to fatal COVID-19, should incorporate food security, nutrition, and social protection as a priority component in order to reduce COVID-19 fatality.