More talk than action: gender and ethnic diversity in leading public health universities.

Improving the career progression of women and ethnic minorities in public health universities has been a longstanding challenge, which we believe might be addressed by including staff diversity data in university rankings. We present findings from a mixed methods investigation of gender-related and ethnicity-related differences in career progression at the 15 highest ranked social sciences and public health universities in the world, including an analysis of the intersection between sex and ethnicity. Our study revealed that clear gender and ethnic disparities remain at the most senior academic positions, despite numerous diversity policies and action plans reported. In all universities, representation of women declined between middle and senior academic levels, despite women outnumbering men at the junior level. Ethnic-minority women might have a magnified disadvantage because ethnic-minority academics constitute a small proportion of junior-level positions and the proportion of ethnic-minority women declines along the seniority pathway.

A systematic review of community nursing interventions focusing on improving outcomes for individuals exhibiting risk factors of cardiovascular disease.

OBJECTIVE: To examine the role of community-based nursing interventions in improving outcomes for community-dwelling individuals exhibiting risk factors of cardiovascular disease (CVD). DESIGN: A systematic review and narrative synthesis. DATA SOURCES: Seven electronic databases (MEDLINE, CINAHL, Global Health, LILACS, Africa-Wide Information, IMEMR, and WPRIM) were searched from inception to 16 March 2018. REVIEW METHODS: This review included outcomes from studies that were led by or delivered primarily by nurses for individuals exhibiting risk factors of CVD in community settings. At least two independent reviewers performed study selection, data extraction and risk of bias. RESULTS: 46 studies met the eligibility criteria. Community nursing interventions were found to be effective in improving clinical outcomes of symptom control, symptom awareness, symptom management, and social outcomes. Effective interventions were found to be facilitated by a community-centric approach, participant empowerment, reinforcement strategies, a targeted approach towards underserved populations, and home visits. These resulted in positive outcomes such as significant reductions in HbA1c for diabetic patients, attainment of blood pressure targets for hypertensive patients and greater improvement in self-reported dietary intake for patients with hyperlipidaemia. CONCLUSION: Community-based nurse-led interventions can result in positive outcomes for patients with risk factors of CVD. However, the success of such interventions needs to be facilitated by appropriate funding, thoughtful intervention design and training opportunities for nurses. IMPACT: Community-based nursing interventions are largely effective in improving clinical and social outcomes for community-dwelling individuals with risk factors of CVD.

The social determinants of chronic disease management: perspectives of elderly patients with hypertension from low socio-economic background in Singapore.

BACKGROUND: In Singapore, the burden of hypertension disproportionately falls on the elderly population of low socio-economic status. Despite availability of effective treatment, studies have shown high prevalence of sub-optimal blood pressure control in this group. Poor hypertension management can be attributed to a number of personal factors including awareness, management skills and overall adherence to treatment. However, these factors are also closely linked to a broader range of community and policy factors. This paper explores the perceived social and physical environments of low socio-economic status and elderly patients with hypertension; and how the interplay of factors within these environments influences their ability to mobilise resources for hypertension management. METHODS: In-depth interviews were conducted in English, Chinese, Chinese dialects and Malay with 20 hypertensive patients of various ethnic backgrounds. Purposive sampling was adopted for recruitment of participants from a previous community health screening campaign. Interviews were translated into English and transcribed verbatim. We deductively analysed leveraging on the Social Model of Health to identify key themes, while inductive analysis was used simultaneously to allow sub-themes to emerge. RESULTS AND DISCUSSION: Our finding shows that financing is an overarching topic embedded in most themes. Despite the availability of multiple safety nets, some patients were left out and lacked capital to navigate systems effectively, which resulted in delayed treatment or debt. The built environment played a significant role in enabling patients to access care easily and lead a more active lifestyle. A closer look is needed to enhance the capacity of patients with mobility challenges to enjoy equitable access. Furthermore, the establishment of community based elderly centres has enabled patients to engage in meaningful and healthy social activities. In contrast, participants' descriptions showed that their communication with healthcare professionals remained brief, and that personalised and meaningful interactions that are context and culturally specific are essential to advocate for patients' overall treatment adherence and lifestyle modification. CONCLUSION: Elderly patients with hypertension from lower socio-economic background have various unmet needs in managing their hypertension and other comorbidities. These needs are closely related to broader societal factors such as socio-demographic characteristics, support systems, urban planning and public policies, and health systems factors. Policy decisions to address these needs require an integrated multi-sectoral approach grounded in the principles of health equity.

Perspectives on decision making amongst older people with end-stage renal disease and caregivers in Singapore: A qualitative study.

BACKGROUND: End-stage renal disease (ESRD) is increasing both globally and in Asia. Singapore has the fifth highest incidence of ESRD worldwide, a trend that is predicted to rise. Older patients with ESRD are faced with a choice of haemodialysis, peritoneal dialysis or conservative management, all of which have their risks and benefits. OBJECTIVE: This study seeks to explore perspectives on decision making amongst older (≥70) Singaporean ESRD patients and their caregivers to undergo (or not to undergo) dialysis. DESIGN: Qualitative study design using semi-structured interviews. SETTING AND PARTICIPANTS: Twenty-three participants were recruited from the largest tertiary hospital in Singapore: seven peritoneal dialysis patients, five haemodialysis patients, four patients on conservative management and seven caregivers. RESULTS: While some patients believed that they had made an independent treatment decision, others reported feeling like they had no choice in the matter or that they were strongly persuaded by their doctors and/or family members to undergo dialysis. Patients reported decision-making factors including loss of autonomy in daily life, financial burden (on themselves or on their families), caregiving burden, alternative medicine, symptoms and disease progression. Caregivers also reported concerns about financial and caregiving burden. DISCUSSION AND CONCLUSION: This study has identified several factors that should be considered in the design and implementation of decision aids to help older ESRD patients in Singapore make informed treatment decisions, including patients' and caregivers' decision-making factors as well as the relational dynamics between patients, caregivers and doctors.

Biopsychosocial experiences and coping strategies of elderly ESRD patients: a qualitative study to inform the development of more holistic and person-centred health services in Singapore.

BACKGROUND: As the incidence and prevalence rates of end stage renal disease (ESRD) rise globally, a disproportionate increase has been observed in the elderly population. Singapore has the fifth highest incidence of treated ESRD worldwide, with the upward trend of ESRD being most apparent among those aged 70 years and older. Although it is well-documented that ESRD patients suffer an impaired quality of life compared to the general population, there is limited research focusing on the unique experiences and needs of elderly ESRD patients in Asian populations. To address the knowledge gap, this study seeks to explore the impact of ESRD and dialysis on the quality of life of elderly (≥70 years old) ESRD patients in Singapore and examine the coping strategies utilised by these patients. METHODS: This qualitative study involved semi-structured, in-depth interviews with 7 peritoneal dialysis patients, 5 haemodialysis patients, 4 patients on non-dialysis supportive care and 7 caregivers in Singapore. Interviews were conducted in English, Chinese, and Malay and fully transcribed. QSR NVivo 11 software was used for analysis. RESULTS: Participants reported that ESRD and dialysis had an impact on three highly interconnected areas of their quality of life: (a) biological/physical (general symptoms, neuromuscular problems, skin problems and poor sleep quality); (b) psychological (depressive symptoms, anxiety and fears, stress and negative self-perceptions); and (c) social (increased dependence on family and loss of social life). There were four key strategies that participants used to cope with these biopsychosocial challenges: (a) family support (financial, practical and emotional support); (b) religious/spiritual support (experiencing gratitude/contentment, the power of prayer and belonging to a faith community); (c) avoidance (cognitive avoidance and distraction techniques); and (d) acceptance (positive thinking and problem solving). CONCLUSIONS: This study has provided insights into the biopsychosocial impact of ESRD and dialysis, as well as cultural and religious factors that shape the experiences and coping mechanisms of elderly ESRD patients and caregivers in Singapore, which can be used to further the development and implementation of more holistic and person-centred services to help each patient achieve a better quality of life.

Does the ingestion of a 24 hour low glycaemic index Asian mixed meal diet improve glycaemic response and promote fat oxidation? A controlled, randomized cross-over study.

BACKGROUND: The health benefits of consuming a low glycaemic index (GI) diet to reduce the risk of type 2 Diabetes are well recognized. In recent years the GI values of various foods have been determined. Their efficacy in constructing and consuming a low GI diet over 24 h in modulating glycaemic response has not been fully documented. The translation of using single-point GI values of foods to develop a 24 h mixed meal diet can provide valuable information to consumers, researchers and dietitians to optimize food choice for glycaemic control. By using GI values of foods to develop mixed meals, our study is the first to determine how both blood glucose and substrate oxidation may be modulated over 24 h. METHODS: The study included 11 Asian men with a BMI between 17-24 kg/m2 who followed both a 1-day low GI and 1-day high GI diet in a randomized, controlled cross-over design. Test meals included breakfast, lunch, snack and dinner. Glycaemic response was measured continuously for over 24 h and postprandial substrate oxidation for 10 h inside a whole body calorimeter. RESULTS: The low GI diet resulted in lower 24 h glucose iAUC (860 ± 440 vs 1329 ± 614 mmol/L.min; p = 0.014) with lower postprandial glucose iAUC after breakfast (p < 0.001), lunch (p = 0.009), snack (p = 0.012) and dinner (p = 0.003). Moreover, 24 h mean amplitude of glycaemic excursion was lower during the low GI vs high GI diet (1.44 ± 0.63 vs 2.33 ± 0.82 mmol/L; p < 0.001). Simultaneously, decrease in 10 h fat oxidation was less during the low vs high GI diet (-0.033 ± 0.021 vs -0.050 ± 0.017 g/min; p < 0.001), specifically after breakfast (p < 0.001) and lunch (p < 0.001). CONCLUSIONS: Our study corroborates that using low GI local foods to construct a 24 h low GI diet, is able to reduce glycaemic response and variability as recorded by continuous glucose monitoring. Our observations also confirm that a low GI diet promotes fat oxidation over carbohydrate oxidation when compared to a high GI diet. These observations provide public health support for the encouragement of healthier nutrition choices by consuming low GI foods. TRIAL REGISTRATION: NCT 02631083 (Clinicaltrials.gov).

Glycemic potency of muffins made with wheat, rice, corn, oat and barley flours: a comparative study between in vivo and in vitro.

PURPOSE: Muffins made with wheat flour are a popular snack consumed in western and emerging countries. This study aimed to examine the content of amylose, glycemic response (GR) and glycemic index (GI) of muffins baked with refined wheat and rice flours, as well as wholegrain corn, oat and barley flours. METHODS: This study adopted a randomized, controlled, crossover, non-blind design. Twelve healthy participants consumed wheat, rice, corn, oat and barley muffins once and the reference glucose solution three times in a random order on non-consecutive day. Capillary blood samples were taken every 15 min in the first 60 min and every 30 min for the remaining 60 min for blood glucose analysis. The Megazyme amylose/amylopectin assay procedure was employed to measure amylose content. RESULTS: The GR elicited from the consumption of wheat, rice and corn muffins was comparable between these samples but significantly greater when compared with oat and barley muffins. Consumption of wholegrain muffins, apart from corn muffin, blunted postprandial GR when compared with muffins baked with refined cereal flours. Muffins baked with wheat, rice, corn, oat and barley flours gave rise to GI values of 74, 79, 74, 53 and 55, respectively. The content of amylose was significantly higher in corn, oat and barley muffins than wheat and rice muffins. CONCLUSIONS: The greater content of amylose and fibre may play a part in the reduced glycemic potency of oat and barley muffins. Wheat flour can be substituted with oat and barley flours for healthier muffins and other bakery products.

A glycaemic index compendium of non-western foods.

Current international tables published on the glycaemic index (GI) of foods represent valuable resources for researchers and clinicians. However, the vast majority of published GI values are of Western origin, notably European, Australian and North American. Since these tables focus on Western foods with minimal inclusion of other foods from non-Western countries, their application is of limited global use. The objective of this review is to provide the GI values for a variety of foods that are consumed in non-Western countries. Our review extends and expands on the current GI tables in an attempt to widen its application in many other regions of the world.

Chrononutrition in the management of diabetes.

Circadian rhythms are 24-h cycles regulated by endogeneous molecular oscillators called the circadian clock. The effects of diet on circadian rhythmicity clearly involves a relationship between factors such as meal timings and nutrients, known as chrononutrition. Chrononutrition is influenced by an individual's "chronotype", whereby "evening chronotypes" or also termed "later chronotype" who are biologically driven to consume foods later in the day. Research in this area has suggested that time of day is indicative of having an influence on the postprandial glucose response to a meal, therefore having a major effect on type 2 diabetes. Cross-sectional and experimental studies have shown the benefits of consuming meals early in the day than in the evening on postprandial glycaemia. Modifying the macronutrient composition of night meals, by increasing protein and fat content, has shown to be a simple strategy to improve postprandial glycaemia. Low glycaemic index (GI) foods eaten in the morning improves glycaemic response to a greater effect than when consumed at night. Timing of fat and protein (including amino acids) co-ingested with carbohydrate foods, such as bread and rice, can reduce glycaemic response. The order of food presentation also has considerable potential in reducing postprandial blood glucose (consuming vegetables first, followed by meat and then lastly rice). These practical recommendations could be considered as strategies to improve glycaemic control, rather than focusing on the nutritional value of a meal alone, to optimize dietary patterns of diabetics. It is necessary to further elucidate this fascinating area of research to understand the circadian system and its implications on nutrition that may ultimately reduce the burden of type 2 diabetes.

Are Asian foods as "fattening" as western-styled fast foods?

In Asia, the consumption of western-styled fast foods is widely perceived as the cause of the rise in obesity and chronic disease. Twenty-five of the most popular local Asian foods were compared for energy, total fat, saturated fat, sodium, and cholesterol with twenty-nine western-styled fast foods. The comparative analysis showed no significant difference in energy (p = 0.150) and total fat (p = 0.346) between the two food categories. These findings suggest that many local Asian foods contribute as much energy and total fat in a single meal as western-styled fast foods. Local Asian foods had greater amounts of sodium (p < 0.001), saturated fat (p = 0.007), and cholesterol (p = 0.009) than western-styled fast foods. The persistent presumption that the consumption of western-styled fast foods is the cause of obesity in Asia needs to be challenged. This observation that local Asian foods are as energy dense as western-styled fast foods, will enable us to redress the necessary strategies to address the Asian diet-health debate.

Effects of Cocoa Butter and Cocoa Butter Equivalent in a Chocolate Confectionery on Human Blood Triglycerides, Glucose and Insulin.

Given the rising trend in the consumption of chocolate confectioneries, the shortage in cocoa butter (CB) production remains a constant threat to food manufacturers. Therefore, exploring alternative plant sources of CB is essential. Sal fat, obtained from seed kernels of trees, has the potential to substitute CB in chocolate confectioneries. The primary aims of this randomised controlled, crossover trial was to compare the glycaemic, insulinaemic and lipidaemic response of two different oil types (CB and Sal fat) in people and the effects of these oils in two physical forms (liquid and oleogel). Seventeen healthy male participants (age 24.73 ± 2.63, height 173.81 ± 7.24 cm, weight 65.85 ± 8.06 kg, BMI 21.73 ± 1.65 kg/m2) completed the study. There were no significant differences in blood glucose iAUC (p = 0.995), plasma insulin (p = 0.760) and triglyceride (TG) (p = 0.129), regardless of oil type consumed. When comparing incremental area under the curve (iAUC) of insulin and TG between the different forms (liquid or oleogel), oleogel was found to be significantly lower (p = 0.014 and p = 0.024 respectively). Different types of oil transformed into oleogels are effective in reducing postprandial insulinaemia and lipidaemia. Sal fat, although not metabolically different from CB, can be an acceptable substitute for CB in the production of chocolate confectioneries.

The role of community-based nursing interventions in improving outcomes for individuals with cardiovascular disease: A systematic review.

OBJECTIVE: To examine the role of community-based nursing interventions in improving outcomes for community-dwelling individuals with cardiovascular disease. DESIGN: A systematic review and narrative synthesis. DATA SOURCES: Seven electronic databases (MEDLINE, CINAHL, Global Health, LILACS, Africa-Wide Information, IMEMR and WPRIM) were searched from inception to 16 March 2018 without language restrictions. REVIEW METHODS: We included studies evaluating the outcomes of interventions led by, or primarily delivered by, nurses for individuals with cardiovascular disease in community settings. Study selection, data extraction and risk of bias assessments were performed by at least two independent reviewers. RESULTS: Twenty-eight studies met the inclusion criteria and were included in this review. Community-based nursing interventions improved outcomes in four key areas: (1) self-care, (2) health, (3) healthcare utilisation, and (4) quality of care. Significant improvements were reported in patients' knowledge and ability to self-manage, severity of disease, functional status, quality of life, risk of death, hospital readmission days, emergency department visits, healthcare costs and satisfaction with care. Facilitators to intervention effectiveness included the use of an individualised approach, multidisciplinary approach, specially trained nurses, family involvement and the home setting. Conversely, barriers to intervention success included limitations in nurses' time and skills, ineffective interdisciplinary collaboration and insufficient intervention intensity. CONCLUSIONS: The overall evidence is positive regarding the role of community-based nursing interventions in improving outcomes for individuals with cardiovascular disease. However, this review highlights the need for more robust research establishing definitive relationships between different types of interventions and outcomes as well as evaluating the cost-effectiveness of these interventions to aid the development of sustainable policy solutions.

A Low Glycaemic Index Diet Incorporating Isomaltulose Is Associated with Lower Glycaemic Response and Variability, and Promotes Fat Oxidation in Asians.

Low glycaemic index (GI) foods minimize large blood glucose fluctuations and have been advocated to enhance fat oxidation and may contribute to weight management. We determined whether the inclusion of isomaltulose compared to sucrose in a low/high GI meal sequence can modulate the glycaemic response and substrate oxidation in an Asian population. Twenty Chinese men (body mass index (BMI): 17-28 kg/m²) followed a 24 h low GI (isomaltulose, PalatinoseTM) or high GI (sucrose) diet in a randomized double-blind, controlled cross-over design. Treatment meals included dinner (day 1), breakfast, lunch, and snack (day 2). Continuous glucose monitoring provided incremental area under the curve (iAUC) and mean amplitude of glycaemic excursion (MAGE) and 10 h indirect calorimetry (whole body calorimeter) (day 2) provided energy expenditure and substrate oxidation. Our results demonstrated that the low GI diet resulted in lower 24 h glucose iAUC (502.5 ± 231.4 vs. 872.6 ± 493.1 mmol/L; p = 0.002) and lower 24 h glycaemic variability (MAGE: 1.67 ± 0.53 vs. 2.68 ± 1.13 mmol/L; p < 0.001). Simultaneously, 10 h respiratory quotient increased more during high GI (p = 0.014) and fat oxidation was higher after low GI breakfast (p = 0.026), lunch (p < 0.001) and snack (p = 0.013). This indicates that lower GI mixed meals incorporating isomaltulose are able to acutely reduce the glycaemic response and variability and promote fat oxidation.