Effects of inappropriate cause-of-death certification on mortality from cardiovascular disease and diabetes mellitus in Tonga.

BACKGROUND: Cardiovascular disease (CVD) and diabetes mellitus are major health issues in Tonga and other Pacific countries, although mortality levels and trends are unclear. We assess the impacts of cause-of-death certification on coding of CVD and diabetes as underlying causes of death (UCoD). METHODS: Tongan records containing cause-of-death data (2001-2018), including medical certificates of cause-of-death (MCCD), had UCoD assigned according to International Classification of Diseases 10th revision (ICD-10) coding rules. Deaths without recorded cause were included to ascertain total mortality. Diabetes and hypertension causes were reallocated from Part 1 of the MCCD (direct cause) to Part 2 (contributory cause) if potentially fatal complications were not recorded, and an alternative UCoD was assigned. Proportional mortality by cause based on the alternative UCoD were applied to total deaths then mortality rates calculated by age and sex using census/intercensal population estimates. CVD and diabetes mortality rates for unaltered and alternative UCoD were compared using Poisson regression. RESULTS: Over 2001-18, in ages 35-59 years, alternative CVD mortality was higher than unaltered CVD mortality in men (p = 0.043) and women (p = 0.15); for 2010-18, alternative versus unaltered measures in men were 3.3/103 (95%CI: 3.0-3.7/103) versus 2.9/103 (95%CI: 2.6-3.2/103), and in women were 1.1/103 (95%CI: 0.9-1.3/103) versus 0.9/103 (95%CI: 0.8-1.1/103). Conversely, alternative diabetes mortality rates were significantly lower than the unaltered rates over 2001-18 in men (p < 0.0001) and women (p = 0.013); for 2010-18, these measures in men were 1.3/103 (95%CI: 1.1-1.5/103) versus 1.9/103 (95%CI: 1.6-2.2/103), and in women were 1.4/103 (95%CI: 1.2-1.7/103) versus 1.7/103 (95%CI: 1.5-2.0/103). Diabetes mortality rates increased significantly over 2001-18 in men (unaltered: p < 0.0001; alternative: p = 0.0007) and increased overall in women (unaltered: p = 0.0015; alternative: p = 0.014). CONCLUSIONS: Diabetes reporting in Part 1 of the MCCD, without potentially fatal diabetes complications, has led to over-estimation of diabetes, and under-estimation of CVD, as UCoD in Tonga. This indicates the importance of controlling various modifiable risks for atherosclerotic CVD (including stroke) including hypertension, tobacco use, and saturated fat intake, besides obesity and diabetes. Accurate certification of diabetes as a direct cause of death (Part 1) or contributory factor (Part 2) is needed to ensure that valid UCoD are assigned. Examination of multiple cause-of-death data can improve understanding of the underlying causes of premature mortality to better inform health planning.

Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis.

BACKGROUND: The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades. The challenge is to translate them into routine clinical settings. The objective of this review is to determine whether lifestyle interventions delivered to high-risk adult patients in routine clinical care settings are feasible and effective in achieving reductions in risk factors for diabetes. DATA SOURCES: MEDLINE (PubMed), EMBASE, CINAHL, The Cochrane Library, Google Scholar, and grey literature were searched for English-language articles published from January 1990 to August 2009. The reference lists of all articles collected were checked to ensure that no relevant suitable studies were missed. STUDY SELECTION: We included RCTs, before/after evaluations, cohort studies with or without a control group and interrupted time series analyses of lifestyle interventions with the stated aim of diabetes risk reduction or diabetes prevention, conducted in routine clinical settings and delivered by healthcare providers such as family physicians, practice nurses, allied health personnel, or other healthcare staff associated with a health service. Outcomes of interest were weight loss, reduction in waist circumference, improvement of impaired fasting glucose or oral glucose tolerance test (OGTT) results, improvements in fat and fibre intakes, increased level of engagement in physical activity and reduction in diabetes incidence. RESULTS: Twelve from 41 potentially relevant studies were included in the review. Four studies were suitable for meta-analysis. A significant positive effect of the interventions on weight was reported by all study types. The meta-analysis showed that lifestyle interventions achieved weight and waist circumference reductions after one year. However, no clear effects on biochemical or clinical parameters were observed, possibly due to short follow-up periods or lack of power of the studies meta-analysed. Changes in dietary parameters or physical activity were generally not reported. Most studies assessing feasibility were supportive of implementation of lifestyle interventions in routine clinical care. CONCLUSION: Lifestyle interventions for patients at high risk of diabetes, delivered by a variety of healthcare providers in routine clinical settings, are feasible but appear to be of limited clinical benefit one year after intervention. Despite convincing evidence from structured intensive trials, this systematic review showed that translation into routine practice has less effect on diabetes risk reduction.

The relationship between obesity and blood pressure differs by ethnicity in Sydney school children.

BACKGROUND: The objective of this study was to investigate the relationship between obesity and high systolic blood pressure (SBP) in Southeast Asian (SEAsian) and Australian children living in Australia. METHODS: SBP, country of birth, and obesity indices (body mass index (BMI), waist circumference (WC), and percent body fat (%TBF)) were recorded in 1,232 9-year-old children from Sydney schools and remeasured 3 years later (n = 628). The relationship between SBP and obesity (both at baseline and longitudinally) was investigated by regression analyses. RESULTS: Children of SEAsian origin had a significantly higher risk of high SBP with increases in obesity indices compared to those of Australian origin. At 9 years old, SBP increased 1.51 mm Hg for each of BMI increase for SEAsian children compared to 1.05 mm Hg for Australian children (P(interaction) = 0.03). These same significant analysis of variance (ANOVA) interactions were seen with WC (P(interaction) = 0.02) and %TBF (P(interaction) = 0.04) as predictors of SBP. These differences by ethnic background were also reflected in the 3-year longitudinal analysis where SEAsian children showed higher risk of increasing SBP with BMI increase (SBP increased 1.70 mm Hg for each unit of BMI increase for SEAsian children compared to 0.80 mm Hg for Australian children (P(interaction) = 0.02)) or with WC increase (P(interaction) = 0.01), whereas these increases were small and nonsignificant in Australian children. CONCLUSION: These findings suggest that SEAsian children living in Australia are at higher risk of increasing SBP than their Australian counterparts when they become overweight or obese.

Cervical cancer screening in a Vietnamese nominal cohort.

BACKGROUND: In New South Wales (NSW) information on migrant status is not collected in routinely recorded cervical screening data, yet some migrant groups, particularly Vietnamese-born women, have a higher incidence of cervical cancer and, purportedly, lower cervical screening rates than Australian-born women. To investigate this, screening rates in a cohort of women with Vietnamese surnames were estimated and compared with survey data. METHODS: A cohort of women with common Vietnamese surnames was extracted from the NSW electoral roll and matched over three periods with data held on the NSW Pap Test Register (PTR), and estimates of cervical screening in the cohort derived. Screening rates for each of the three periods were pro-rated to biennial rates, and time-related changes compared. Screening rates in the cohort were also compared to those in Vietnamese migrant respondents to a population-based health interview survey. RESULTS: Estimated biennial screening rates in the overall Vietnamese nominal cohort of women aged 20-69 years were significantly and substantially lower than those for NSW overall, by 10-12 percentage points. Screening rates in the Vietnamese cohort were found to increase over the study period, from 44% for 1997/98 to 47% for 1998/99. While the biennial screening rate for 1998 in the nominal cohort was 19 percentage points lower than the self-reported surveyed screening rate of 63%, the relative screening ratios between Vietnamese and all NSW women were similar for both data sources. CONCLUSION: This study demonstrates the feasibility of estimating and monitoring cervical screening participation in minority groups with distinctive names using a Pap Test Register and information from a population register.