Trends in prescription of psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018.

OBJECTIVE: To examine trends in prescribing psychotropic medications to children and adolescents in Australian primary care from 2011 to 2018. METHOD: A retrospective cohort study examined prescriptions written by general practitioners using MedicineInsight, a large Australian primary care database, covering approximately 9% of all general practitioner practices. Numbers of patients receiving prescriptions for five main classes of psychotropics (antipsychotics, antidepressants, attention deficit hyperactivity disorder medications, anxiolytics, and hypnotics/sedatives [including benzodiazepines and Z-drugs, but excluding melatonin]) were examined annually by age-group (0-4, 5-9, 10-14, 15-18 years). Melatonin was analysed separately. RESULTS: The number of patients prescribed any psychotropic increased from 25.6 to 36.2 per 1000 individuals from 2011 to 2018 (average annual increase +4.5%, 95% confidence interval [4.1%, 4.9%]; overall +41.4%). Among the five main classes, the largest annual increase was for attention deficit hyperactivity disorder medications (+9.6%, 95% confidence interval [8.8%, 10.5%]; overall +95.8%), followed by antipsychotics (+6.2%, 95% confidence interval [5.0%, 7.3%]; overall +62.8%) and antidepressants (+4.5%, 95% confidence interval [4.0%, 5.0%]; overall +42.8%). Hypnotic/sedative prescribing decreased on average 6.5% per year (95% confidence interval [-8.0%, -5.0%]; overall -40.2%). Anxiolytic prescribing remained steady. Melatonin prescriptions showed the highest increase of all (+24.7%, 95% confidence interval [23.7%, 25.8%]; overall +606.7%). The largest annual increase in antipsychotic, antidepressant or attention deficit hyperactivity disorder medication prescribing occurred in 10- to 14-year-olds (+7.5%, +6.5% and +10.4%, respectively). The largest point prevalence occurred in 2018 among 15- to 18-year-olds, with 98.5 per 1000 prescribed antidepressants. Antidepressants were more frequently prescribed to females; antipsychotics, attention deficit hyperactivity disorder medications and melatonin more often to males. The most prescribed antipsychotics were risperidone (<15 years) and quetiapine (15- to 18-year-olds). Fluoxetine was the most prescribed antidepressant in those aged 5+ years and amitriptyline in 0- to 4-year-olds. CONCLUSION: General practitioner prescribing of melatonin, antipsychotics, antidepressants and attention deficit hyperactivity disorder medications to under-19-year-olds increased markedly from 2011 to 2018. Although benzodiazepine and Z-drug prescriptions declined, this was offset by a substantial increase in melatonin prescribing.

Burden and health state utility values of eating disorders: results from a population-based survey.

BACKGROUND: There are no published estimates of the health state utility values (HSUVs) for a broad range of eating disorders (EDs). HSUVs are used in economic evaluations to determine quality-adjusted life years or as a measure of disorder burden. The main objective of the current study is to present HSUVs for a broad range of EDs based on DSM-5 diagnoses. METHODS: We used pooled data of two Health Omnibus Surveys (2015 and 2016) including representative samples of individuals aged 15 + years living in South Australia. HSUVs were derived from the SF-6D (based on the SF-12 health-related quality of life questionnaire) and analysed by ED classification, ED symptoms (frequency of binge-eating or distress associated to binge eating) and weight status. Multiple linear regression models, adjusted for socio-demographics, were used to test the differences of HSUVs across ED groups. RESULTS: Overall, 18% of the 5609 individuals met criteria for ED threshold and subthreshold. EDs were associated with HSUV decrements, especially if they were severe disorders (compared to non-ED), binge ED: -0.16 (95% CI -0.19 to -0.13), bulimia nervosa: -0.12, (95% CI -0.16 to -0.08). There was an inverse relationship between distress related binge eating and HSUVs. HSUVs were lower among people with overweight/obese compared to those with healthy weight regardless of ED diagnosis. CONCLUSIONS: EDs were significantly associated with lower HSUVs compared to people without such disorders. This study, therefore, provides new insights into the burden of EDs. The derived HSUVs can also be used to populate future economic models.

Education and Income Levels are Associated With Energy and Micronutrient Intake.

Introduction: According to the literature, education and income are determinants factors of diet quality and consequently of micronutrient intake. However, this association is still little known among adults who live in middle-income countries. Objective: To estimate energy and micronutrients intake by men and women living in a capital city in southern Brazil, according to education and income levels, and to identify prevalence of inadequate micronutrient intake according also to education and income levels. Method: This is a second wave cross-sectional analysis of a population-based longitudinal study, the EpiFloripa Adultos, including 1,222 individuals of 22-63 years. Data on food consumption were obtained through applying two 24-hour dietary recalls, and the prevalence of inadequate micronutrient intake, following the recommendations of the Institute of Medicine and from the National Research Council. Results: A tendency of increased intake with an increase in income (calcium, vitamins C, E) and education levels (calcium, vitamins A, C, D) was observed for most of the micronutrients analyzed (p<0.05 in all cases); still, a prevalence of inadequacy according to Estimated Average Requirement (EAR) between 85.5-100% in intake of vitamins A, D and E were found for the whole sample. Iron inadequate intake was associated with education level and among women less than 50 years of age (p=0.018). Conclusion: The results showed an influence of the education and income levels on micronutrient intake, point to the need of daily food consumption, of minimally processed and in natura foods (as fruits, vegetables, whole grains, milk and its derivatives) as a means to reduce the encountered inadequacies.

Multimorbidity, health-related quality of life and health service use among individuals with mental health problems: Urban-rural differences in South Australia.

OBJECTIVE: To investigate urban-rural differences in the relationship between the coexistence of multiple physical health conditions, health-related quality of life and health service use among individuals with mental health problems. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: Random sample of 2977 South Australians aged 15+ years. Analyses restricted to 535 individuals self-reporting a "current" mental health problem (anxiety, depression, another mental condition). EXPOSURE: Number of physical health conditions (none, 1-2, 3+ conditions) based on a list of 16 self-reported chronic diseases. MAIN OUTCOME MEASURES: Physical and mental health-related quality of life, frequently visited a GP (3+ times), visited a mental health specialist, visited an emergency department, was hospitalised in the last 3 months. RESULTS: The mean age of the participants was 57.3 ± 13.9 years (51.9% females) with 10.6% of them living in inner regional and 14.9% in outer/remote locations. Mental health problems had similar prevalence in major cities (15.4%; 95% confidence intervals [CI]: 13.5-17.4), inner regional (19.3%; 95% CI: 14.8-24.7) and outer/remote areas (16.8%; 95% CI: 14.4-17.7). The remoteness of residence did not affect the relationship between the number of physical health conditions with health-related quality of life or visits to the emergency department/hospitalisations. Individuals without a physical health condition living in major cities were five times more likely to have frequently visited a GP than their counterparts in outer/remote South Australia (35% and 7%, respectively), but these differences were less marked among those with multiple co-morbidities. CONCLUSION: The coexistence of multiple physical health conditions among patients with a mental health problem is associated with less urban-rural disparities in terms of visiting a GP.

Bullying and sexual abuse and their association with harmful behaviours, antidepressant use and health-related quality of life in adulthood: a population-based study in South Australia.

BACKGROUND: Few representative sample studies have reported estimates of bullying and sexual abuse in Australia. By using face-to-face interviews and self-labelling questions, we investigated the prevalence of these forms of abuse and their relationship with current harmful behaviours (smoking dependence, excessive alcohol intake, binge eating), antidepressant use, and the physical (PCS) and mental (MCS) components of health-related quality of life. METHODS: This study was a population-based survey that investigated 2873 South Australians in 2015 (48.8 ± 18.1 years; 49.3% males). Bullying and sexual abuse (age of onset and duration) and their outcomes were investigated through household interviews. Associations were adjusted for sociodemographic variables by using regression models. RESULTS: 45.6% (95% CI 43.3-47.9) of the participants were bullied, and 10.4% (95% CI 9.1-11.9) sexually abused; 7.3% (95% CI 6.2-8.5) reported experiencing both forms of abuse. Moreover, 15.8% of those bullied and 15.0% of those sexually abused suffered from these forms of abuse for > 24 months. Smoking dependence (7.8%) was twice as frequent among those who experienced bullying for > 24 months or when sexual abuse occurred in childhood (< 10 years) or adulthood (20+ years) or lasted ≥1 month. Excessive alcohol intake (14.3%) was more frequent when bullying occurred in childhood or lasted > 24 months. Binge eating (8.1%) was more frequent among those bullied or sexually abused in adulthood, but duration did not show a clear pattern. Antidepressant use was up to four times more likely, and PCS or MCS lower among those who were bullied or sexually abused, independent of when these forms of abuse started or their duration. The cumulative adverse relationship of bullying and sexual abuse with the investigated outcomes was more evident for smoking dependence, binge eating, PCS, and MCS than for antidepressant use, but no association was observed with alcohol intake. CONCLUSIONS: The use of self-labelling questions to investigate sensitive areas such as bullying and sexual abuse in a survey is feasible. Such questions provided estimates that are consistent with findings from studies using more detailed instruments. Bullying and sexual abuse have an additive adverse association with various outcomes. Identifying survivors of both forms of abuse is important to avoid more serious consequences.

Patient-reported GP health assessments rather than individual cardiovascular risk burden are associated with the engagement in lifestyle changes: population-based survey in South Australia.

BACKGROUND: Little is known about whether a more comprehensive health assessment, performed by a general practitioner (GP) during a clinical encounter, could influence patients' lifestyle. We aimed to investigate whether health assessments, performed by GPs, are more important than the presence of cardiovascular disease (CVD) or cardiometabolic risk factors (obesity, diabetes, hypertension, dyslipidaemia) for engagement in lifestyle change. METHODS: Cross-sectional, population-based survey conducted in South Australia (September-December 2017) using face-to-face interviews and self-reported data of 2977 individuals aged 15+ years. The main outcome was engagement in four lifestyle changes: 1) increasing fruit/vegetable intake, 2) increasing physical activity level, 3) reducing alcohol consumption, and 4) attempts to stop smoking. Health assessments performed by a GP in the last 12 months included clinical/laboratory investigations (weight/waist circumference, blood pressure, glucose levels, lipid levels) and questions about lifestyle/wellbeing (current diet, physical activity, smoking status, alcohol intake, mental health, sleeping problems). Results were restricted to individuals aged 35+ years because of the low prevalence of CVD or their risk factors among younger participants. Logistic regression was used in all associations, adjusted for sociodemographic, lifestyle, mental health, and clinical variables. RESULTS: Of the 2384 investigated adults (mean age 57.3 ± 13.9 years; 51.9% females), 10.2% had CVD and 49.1% at least one cardiometabolic risk factor. Clinical/laboratory assessments performed by the GP were 2-3 times more frequent than assessments of lifestyle, mental health status, or sleeping problems, especially among those with CVD. Individuals with CVD or a cardiometabolic risk factor were no more likely to be increasing their fruit/vegetable consumption (33.6%), physical activity level (40.9%), reducing alcohol consumption (31.1%), or trying to quit smoking (34.0%) than 'healthy' participants. However, lifestyle changes were between 30 and 100% more likely when GPs performed three or more health assessments (either clinical/laboratory or questions about lifestyle/wellbeing) than when individuals did not visit the GP or when GPs performed no any assessment during these clinical encounters (p < 0.05 in all cases). CONCLUSION: More frequent and comprehensive CVD-related assessments by GPs were more important in promoting a healthier lifestyle than the presence of CVD or cardiometabolic risk factors by themselves.

Epidemiology of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis among 1.5 million patients in Australian general practice: NPS MedicineWise MedicineInsight dataset.

BACKGROUND: Previous estimates for the prevalence of musculoskeletal conditions (MSK) and chronic pain in Australia have been based on self-report. We aimed to determine the prevalence and distribution of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis and current consultations for chronic pain among adults attending Australian general practice, and describe their distribution according to sociodemographic characteristics and presence of co-morbidities. METHODS: We investigated 1,501,267 active adult patients (57.6% females; 22.5% ≥65y) evaluated between 2013 and 2016 and included in the MedicineInsight database (a National Prescribing Service MedicineWise program), a large general practice data program that extracts longitudinal de-identified electronic medical record data from 'active' patients in over 550 practices. Three main groups of outcomes were investigated: 1) "prevalence" of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies, and/or rheumatoid arthritis between 2000 and 2016; 2) "current" diagnosis/encounter for the same conditions occurring between 2013 and 2016, and; 3) "current" consultations for chronic pain of any type occurring between 2013 and 2016. RESULTS: The combined "prevalence" of the investigated MSK (diagnosis between 2000 and 2016) among adults attending Australian general practice was 16.8% (95%CI 15.9;17.7) with 21.3% (95%CI 20.2;22.4) of the sample consulting for chronic pain between 2013 and 2016. The investigated MSK with the highest "prevalence" were arthritis (9.5%) and chronic back pain (6.7%). Patients with some of these MSK attended general practices more frequently than those without these conditions (median 2.0 and 1.0 contacts/year, respectively). The "prevalence" of the investigated MSK and "current" consultations for chronic pain increased with age, especially in women, but chronic pain remained stable at 22% for males aged > 40 years. The investigated MSK and chronic pain were more frequent among those in lower socioeconomic groups, veterans, Aboriginal and Torrent Strait Islanders, current and ex-smokers, and patients with chronic obstructive pulmonary disease or heart failure. CONCLUSIONS: The investigated MSK are more frequent among lower socioeconomic groups and the elderly. Based on information collected from adults attending Australian general practices, MedicineInsight provided similar estimates to those obtained from population-based studies, with the advantage of being based on medical diagnosis and including a national sample.

Are we reducing the risk of cardiovascular disease and improving the quality of life through preventive health care? Results of a population-based study in South Australia.

This study investigated the achievement of lifestyle recommendations and use of preventive medication in people who 1) are obese, 2) or have metabolic risk factors (hypertension, dyslipidaemia, and/or diabetes), 3) or have cardiovascular disease (CVD), 4) or are healthy, and the impact this preventive health care had on their 'Health-Related Quality of Life' (HRQoL). Cross-sectional survey conducted in 2015 with 2379 South Australian adults (57.1±14years; 51.7% females). Physical (PCS) and mental components scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Although adequate fruit/vegetable intake was lower among individuals with CVD (29.8%; p=0.049), this behaviour was associated with a better MCS. Adequate physical activity level was lower among those with metabolic risk factors (29.5%) or CVD (31.0%; p=0.008), but independent of their clinical condition, this behaviour was associated with a higher PCS. Individuals with CVD were less likely to have adequate alcohol consumption (63.4%; p=0.026), but those achieving this recommendation had poorer PCS. Non-smoking was similar in all groups (85%; p=0.768) and was associated with a better MCS only among healthy individuals and those with CVD. In all the groups, individuals achieving all the lifestyle recommendations had a better PCS. Only 48.2% of individuals with CVD reported combined use of antithrombotic, antihypertensive, and antilipidemic drugs, but the use of these medications was not associated with HRQoL. In conclusion, the vast majority of individuals at risk of or with CVD did not achieve preventive recommendations, and only the adequacy of uptake of all recommended lifestyle behaviours showed consistent benefits for PCS and MCS.

Individual diseases or clustering of health conditions? Association between multiple chronic diseases and health-related quality of life in adults.

BACKGROUND: Chronic diseases are highly prevalent and cluster in individuals (multimorbidity). This study investigated the association between multimorbidity and Health-Related Quality of Life (HRQoL), assessing the combination of chronic diseases highly correlated with this outcome. METHODS: We conducted a household survey in 2015 in a random sample of 2912 South Australian adults (48.9 ± 18.1 years; 50.9% females), obtaining information on sociodemographics, lifestyle, and 17 chronic conditions clustered in four different groups (metabolic, cardiovascular, gastrointestinal, and musculoskeletal). Information on physical (PCS) and mental components scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Multivariable linear regression models considering individual diseases (mutually adjusted) and clusters within- and between-groups were used to test the associations. RESULTS: Only 41% of the sample was negative for all the investigated diseases. The most prevalent conditions were osteoarthritis, obesity and hypertension, which affected one in every four individuals. PCS was markedly lower among those reporting stroke, heart failure, and osteoarthritis, but they were not associated with MCS. Direct-trend relationships were observed between the number of chronic conditions (clusters within- and between-groups) and PCS, but not with MCS. The strongest association with PCS was for musculoskeletal conditions (difference between those affected by 2+ conditions and those free of these conditions -6.7 95%CI -8.5;-5.4), and lower PCS were observed in any combination of clusters between-group including musculoskeletal diseases. CONCLUSION: In the context of multimorbidity, musculoskeletal diseases are a key determinant group of PCS, amplifying the association of other chronic conditions on physical but not on mental health.

Lower educational level and unemployment increase the impact of cardiometabolic conditions on the quality of life: results of a population-based study in South Australia.

PURPOSE: To investigate if sociodemographic characteristics increase the adverse effects of cardiovascular diseases (CVD) and cardiometabolic risk factors (CMRF) on health-related quality of life (HRQoL). METHODS: Cross-sectional, face-to-face survey investigating 2379 adults living in South Australia in 2015 (57.1 ± 14 years; 51.7% females). Questions included diagnosis of CMRF (obesity, diabetes, hypertension, dyslipidaemia) and CVD. Physical and mental HRQoL were assessed using the SF-12v1 questionnaire. Multiple linear regression models including confounders (sociodemographic, lifestyle, use of preventive medication) and interaction terms between sociodemographic variables and cardiometabolic conditions were used in adjusted analysis. RESULTS: The prevalence of CMRF (one or more) was 54.6% and CVD was 13.0%. The physical HRQoL reduced from 50.8 (95%CI 50.2-51.4) in healthy individuals to 45.1 (95%CI 44.4-45.9) and 39.1 (95%CI 37.7-40.5) among those with CMRF and CVD, respectively. Adjustment for sociodemographic variables reduced these differences in 33%, remaining stable after controlling for lifestyle and use of preventive medications (p < 0.001). Differences in physical HRQoL according to cardiometabolic conditions were twice as high among those with lower educational level, or if they were not working. Among unemployed, having a CMRF or a CVD had the same impact on the physical HRQoL (9.7 lower score than healthy individuals). The inverse association between cardiometabolic conditions and mental HRQoL was subtle (p = 0.030), with no evidence of disparities due to sociodemographic variables. CONCLUSIONS: A lower educational level and unemployment increase the adverse effects of cardiometabolic conditions on the physical HRQoL. Targeted interventions for reducing CMRF and/or CVD in these groups are necessary to improve HRQoL.

Severe obesity increases the prevalence but not the incidence of depressive symptoms in the elderly-population-based cohort in Southern Brazil.

BACKGROUND: The relation between body weight status and depressive symptoms in the elderly differs according to age and country of origin. The goal of this study was to analyze the cross-sectional and longitudinal relationship between body mass index (BMI), waist circumference (WC) and depressive symptoms in the elderly. METHODS: A population-based cohort study of 1,702 elderly individuals (70.6+8.0 years) in Southern Brazil evaluated in 2009/10 and 2013/14 was accessed. The body weight status was assessed using measured data of BMI and WC. The Geriatric Depression Scale (GDS-15) was used to determine depressive symptoms. Logistic regression analysis adjusted for sociodemographic and behavioral variables was performed. RESULTS: The prevalence of depressive symptoms in 2009/10 was 23.3% (95% CI 20.3-26.6) and the cumulative incidence in the 4-years period was 10.9% (95% CI 8.7-13.6). Elderly people with obesity class II-III and WC in the highest quartile had higher prevalence odds ratio of being depressed than individuals with normal weight or WC in the lower quartile (OR 2.34; 95% CI 1.42-3.87 and OR 1.73; 95% CI 1.13-2.65, respectively). Meanwhile, intermediary values of BMI and WC were associated with a lower prevalence. When evaluating the incidence of depressive symptoms, overweight individuals and those in the second quartile of WC had a lower risk (58% and 57%, respectively), but severely obese individuals had the same risk compared to those with normal BMI/WC. CONCLUSIONS: Severely obese individuals presented a similar incidence of depressive symptoms compared to those with normal BMI/WC, but higher prevalence. Intermediary values of body weight status decrease the risk of depressive symptoms.

Anthropometric measures change and quality of life in elderly people: a longitudinal population-based study in Southern Brazil.

PURPOSE: To analyze the effects of anthropometric measures change on quality of life (QoL) in elderly, using measured anthropometric data on body mass index (BMI) and waist circumference (WC). METHOD: Population-based cohort study investigating a sample of elderly (≥60) assessed in 2009 (n = 1705) and followed up in 2013 (n = 1197). QoL was evaluated in 2013 using the CASP-19. Variables evaluated as exposure including BMI and WC in 2009 (both standardized), categories of anthropometric measures change from 2009 to 2013 (excess weight = BMI ≥ 25.0 kg/m2; large WC = top quartile), and the absolute BMI and WC change in same period. Multivariate linear regressions adjusted for possible confounding factors and mediators were used. RESULTS: Both BMI and WC at baseline were associated with lower QoL scores, even after adjustment for confounding variables (ß BMI = -0.9; 95 % CI -1.5; -0.3 and ß WC = -1.0; 95 % CI -1.7; -0.4). Additionally, QoL scores were lower among elderly with excess weight (ß = -1.4; 95 % CI -2.9; 0.0) or large WC (ß = -3.3; 95 % CI -5.2; -1.4) in both waves than among those whose BMI and WC were always normal, but changes in anthropometric measures did not affect QoL. The presence of chronic diseases was a partial mediator of these associations, especially for effects of BMI change. Anthropometric measures change treated as a continuous variable was not associated with QoL. CONCLUSIONS: Having excess weight and large WC in both waves was associated with lower QoL scores in elderly, but changing the anthropometric measures did not affect this outcome. Maintaining weight and WC within normal limits during aging can help to preserve QoL.

Prediction of Areal Bone Mineral Density and Bone Mineral Content in Children and Adolescents Living With HIV Based on Anthropometric Variables.

Children and adolescents living with HIV have low bone mass for age. There are reliable and accurate methods for evaluation of bone mass, however, alternative methods are necessary, especially, for application in limited-resource scenarios. Anthropometry is a noninvasive and low cost method that can predict bone mass in healthy youths. The aim of the study was to develop predictive equations for bone mineral content and bone mineral density in children and adolescents living with HIV based on anthropometric variables. Forty-eight children and adolescents of both sexes (24 females) from 7 to 17 years, living in greater Florianopolis area, Santa Catarina, Brazil, who were under clinical follow-up at "Hospital Infantil Joana de Gusmão", participated in the study. Dual-energy X-ray absorptiometry was used to evaluate whole-body bone mineral content (BMC) and areal bone mineral density (aBMD). Height, body weight, bone diameters, arm circumference, and triceps skinfold were measured and the body mass index and arm muscle area were calculated. Multiple regression models were fitted to predict BMC and aBMD, using backward selection (p ≥ 0.05). Two predictive models with high R2 values (84%-94%) were developed. Model 1 to estimate aBMD [Y = -0.1450124 + (height × 0.0033807) + (age × 0.0146381) + (body mass index × 0.0158838) + (skin color × 0.0421068)], and model 2 to estimate BMC [Y = 1095.1 + (body weight × 45.66973) + (age × 31.36516) + (arm circumference × -53.27204) + (femoral diameter × -9.594018)].The predictive models using anthropometry provided reliable estimates and can be useful to monitor aBMD and BMC in children and adolescents living with human immunodeficiency virus where limited resources are available.

Sodium content on processed foods for snacks.

OBJECTIVE: To assess the Na content reported on the labels of processed foods sold in Brazil that are usually consumed as snacks by children and adolescents. DESIGN: Cross-sectional study that assessed Na content and serving size reporting on processed food labels. SETTING: A supermarket that is part of a large chain in Brazil. SUBJECTS: All foods available for sale at the study's location and reported in the literature as snacks present in the diets of Brazilian children and adolescents. RESULTS: Of the 2945 processed foods, 87 % complied with the reference serving sizes, although variability in reporting was observed in most of the food subgroups. In addition, 21 % of the processed foods had high Na levels (>600 mg/100 g) and 35 % had medium Na levels (>120 and ≤600 mg/100 g). The meats, oils, fats and seeds groups as well as the prepared dishes had higher percentages of foods classified as high Na (81 %, 58 % and 53 %, respectively). CONCLUSIONS: Most of the processed foods had high or medium Na content. We emphasize the importance of revising Brazilian nutrition labelling legislation to standardize reference serving sizes to avoid variation. Besides, we point out the potential for reducing Na levels in most processed foods, as evidenced by the variability in Na content within subgroups. Finally, we have identified the need to develop a method to classify Na levels in processed foods with specific parameters for children and adolescents.

Sodium content and labelling of processed and ultra-processed food products marketed in Brazil.

OBJECTIVE: To analyse the Na content and labelling of processed and ultra-processed food products marketed in Brazil. DESIGN: Cross-sectional study. SETTING: A large supermarket in Florianopolis, southern Brazil. SUBJECTS: Ingredient lists and Na information on nutrition labels of all processed and ultra-processed pre-prepared meals and prepared ingredients, used in lunch or dinner, available for sale in the supermarket. RESULTS: The study analysed 1416 products, distributed into seven groups and forty-one subgroups. Five products did not have Na information. Most products (58.8 %; 95 % CI 55.4, 62.2 %) had high Na content (>600 mg/100 g). In 78.0 % of the subgroups, variation in Na content was at least twofold between similar products with high and low Na levels, reaching 634-fold difference in the 'garnishes and others' subgroup. More than half of the products (52.0 %; 95 % CI 48.2, 55.6 %) had at least one Na-containing food additive. There was no relationship between the appearance of salt on the ingredients list (first to third position on the list) and a product's Na content (high, medium or low; P=0.08). CONCLUSIONS: Most food products had high Na content, with great variation between similar products, which presents new evidence for reformulation opportunities. There were inconsistencies in Na labelling, such as lack of nutritional information and incomplete ingredient descriptions. The position of salt on the ingredients list did not facilitate the identification of high-Na foods. We therefore recommend a reduction in Na in these products and a review of Brazilian legislation.

Changes in total and central adiposity and body fat distribution among 7-10-year-old schoolchildren in Brazil.

OBJECTIVE: To describe changes in total and central adiposity and body fat distribution in children over a 5-year period by investigating variations in BMI, waist circumference (WC), waist-to-height ratio (WHtR) and skinfold thicknesses (SFT). DESIGN: A school-based sample of children from 2nd to 5th grades of elementary schools participated in two cross-sectional studies in 2002 (n 2936) and 2007 (n 1232). SETTING: Public and private schools of Florianopolis, Brazil. SUBJECTS: Schoolchildren aged 7-10 years had their weight, height, WC and SFT measured according to standard procedures. Body fat distribution was assessed by triceps, subscapular, suprailiac and medial calf skinfold measurements. Changes in BMI, WC, WHtR and SFT were analysed, adjusting for type of school and monthly family income. RESULTS: Adjusted mean differences between 2002 and 2007 for BMI and WC were always positive and of similar magnitude between boys and girls. However, a statistically significant increase was observed only for BMI (raw and Z-score values) in boys. WHtR remained stable in both sexes. Adjusted median values for SFT also increased in boys and girls, except for triceps skinfold. BMI, WC and SFT tended to increase across age classes in both sexes. The relative change observed for the median central skinfolds (subscapular and suprailiac) was greater than that of peripheral skinfolds (triceps and medial calf). CONCLUSIONS: The subcutaneous adipose tissue (SFT) appeared to increase at a faster rate than total adiposity (BMI). The increase in central SFT indicates that the relative change is due primarily to a rise in central adiposity.

Factors associated with 25-hydroxyvitamin D levels in patients with liver cirrhosis.

INTRODUCTION: Lower 25-hydroxyvitamin D [25(OH)D] levels have been observed in cirrhotic patients and have been related to disease severity. However, most previous studies included patients with very advanced disease, lacking an adequate control for other variables that could interfere with vitamin D levels. We sought to investigate the prevalence of hypovitaminosis D and the factors related to its occurrence. MATERIAL AND METHODS: This cross-sectional study included 133 cirrhotic patients and 30 healthy controls. Bivariate and multivariate analyses were performed to determine factors associated with 25(OH)D levels below the lower tertile. Thirty patients who had been recently hospitalized were compared in two time points. RESULTS: Mean 25(OH)D levels were 32.34 ± 11.38 in controls and 27.03 ± 6.22 ng/mL in patients (P = 0.018). 25(OH)D levels were < 30 ng/mL in 69.9% and < 20 ng/mL in 14.3% of the sample. Levels of 25(OH)D below the lower tertile (< 24 ng/mL) were independently associated with higher triceps skinfold and non-Caucasian race. Parathyroid hormone above the reference value (65 pg/mL) was found in 24.6% of patients without association with 25(OH)D or severity of liver disease. Significantly lower levels of 25(OH)D were found at the time of acute decompensation of cirrhosis. CONCLUSIONS: In conclusion, hypovitaminosis D was prevalent in cirrhotics and it was associated with adiposity and non-Caucasian race in stable patients with relatively well preserved liver function. However, significantly lower levels were observed during admission for acute decompensation suggesting an impact of systemic inflammation or liver dysfunction on 25(OH)D levels.

Accuracy and adequacy of waist circumference cut-off points currently recommended in Brazilian adults.

OBJECTIVE: To evaluate the adequacy and accuracy of cut-off values currently recommended by the WHO for assessment of cardiovascular risk in southern Brazil. DESIGN: Population-based study aimed at determining the predictive ability of waist circumference for cardiovascular risk based on the use of previous medical diagnosis for hypertension, diabetes mellitus and/or dyslipidaemia. Descriptive analysis was used for the adequacy of current cut-off values of waist circumference, receiver operating characteristic curves were constructed and the most accurate criteria according to the Youden index and points of optimal sensitivity and specificity were identified. SETTING: Pelotas, southern Brazil. SUBJECTS: Individuals (n 2112) aged ≥20 years living in the city were selected by multistage sampling, since these individuals did not report the presence of previous myocardial infarction, angina pectoris or stroke. RESULTS: The cut-off values currently recommended by WHO were more appropriate in men than women, with overestimation of cardiovascular risk in women. The area under the receiver operating characteristic curve showed moderate predictive ability of waist circumference in men (0.74, 95% CI 0.71, 0.76) and women (0.75, 95% CI 0.73, 0.77). The method of optimal sensitivity and specificity showed better performance in assessing the accuracy, identifying the values of 95 cm in men and 87 cm in women as the best cut-off values of waist circumference to assess cardiovascular risk. CONCLUSIONS: The cut-off values currently recommended for waist circumference are not suitable for women. Longitudinal studies should be conducted to evaluate the consistency of the findings.

Trends in adiposity in Brazilian 7-10-year-old schoolchildren: evidence for increasing overweight but not obesity between 2002 and 2007.

BACKGROUND: The negative health consequences of childhood overweight/obesity (OW/OB) are well known. Therefore, an accurate monitoring of the OW/OB prevalence is essential. Anthropometry is the most practical and cost-effective method for nutritional status evaluation. AIM: To describe trends in the nutritional status among 7-10-year-old children by investigating changes in the prevalence of stunting, thinness, overweight, obesity, risk and excess abdominal adiposity, and to study changes in height-for-age, body mass index (BMI) and waist circumference (WC). SUBJECTS AND METHODS: A school-based sample of 7-10-year-old children participated in two cross-sectional studies in 2002 (n = 2936) and 2007 (n = 1232) in Florianopolis, southern Brazil. Prevalence of stunting, risk and excess abdominal adiposity and changes in the distribution of height-for-age, BMI-for-age, WC-for-age z-scores were evaluated. Three BMI-based references were used to define the prevalence of thinness, overweight and obesity. RESULTS: Between 2002-2007, the prevalence of stunting, thinness, obesity and excess abdominal adiposity remained stable, whereas overweight (including obesity) increased 10-23% in boys and 18-21% in girls, depending on the BMI reference used. The risk of abdominal adiposity increased in boys, but not in girls. No significant change was observed in mean height, BMI, WC-for-age z-scores. CONCLUSIONS: This study identified a potential levelling off in the prevalence of obesity and excess abdominal adiposity, but a continuing increase in the prevalence of overweight.

Management of physical and psychological trauma resulting from motor vehicle crashes in Australian general practice: a mixed-methods approach.

BACKGROUND: In Australia, motor vehicle crashes (MVC)-related health data are available from insurance claims and hospitals but not from primary care settings. This study aimed to identify the frequency of MVC-related consultations in Australian general practices, explore the pharmacological management of health conditions related to those crashes, and investigate general practitioners' (GPs) perceived barriers and enablers in managing these patients. METHODS: Mixed-methods study. The quantitative component explored annual MVC-related consultation rates over seven years, the frequency of chronic pain, depression, anxiety or sleep issues after MVC, and management with opioids, antidepressants, anxiolytics or sedatives in a sample of 1,438,864 patients aged 16 + years attending 402 Australian general practices (MedicineInsight). Subsequently, we used content analysis of 81 GPs' qualitative responses to an online survey that included some of our quantitative findings to explore their experiences and attitudes to managing patients after MVC. RESULTS: MVC-related consultation rates remained stable between 2012 and 2018 at around 9.0 per 10,000 consultations. In 2017/2018 compared to their peers, those experiencing a MVC had a higher frequency of chronic pain (48% vs. 26%), depression/anxiety (20% vs. 13%) and sleep issues (7% vs. 4%). In general, medications were prescribed more after MVC. Opioid prescribing was much higher among patients after MVC than their peers, whether they consulted for chronic pain (23.8% 95%CI 21.6;26.0 vs. 15.2%, 95%CI 14.5;15.8 in 2017/2018, respectively) or not (15.8%, 95%CI 13.9;17.6 vs. 6.7%, 95% CI 6.4;7.0 in 2017/2018). Qualitative analyses identified a lack of guidelines, local referral pathways and decision frameworks as critical barriers for GPs to manage patients after MVC. GPs also expressed interest in having better access to management tools for specific MVC-related consequences (e.g., whiplash/seatbelt injuries, acute/chronic pain management, mental health issues). CONCLUSION: Chronic pain, mental health issues and the prescription of opioids were more frequent among patients experiencing MVC. This reinforces the relevance of appropriate management to limit the physical and psychological impact of MVC. GPs identified a lack of available resources (e.g. education, checklists and management support tools) for managing MVC-related consequences, and the need for local referral pathways and specific guidelines to escalate treatments.