Web-Based Digital Health Interventions for Weight Loss and Lifestyle Habit Changes in Overweight and Obese Adults: Systematic Review and Meta-Analysis.

BACKGROUND: Obesity is a highly prevalent condition with important health implications. Face-to-face interventions to treat obesity demand a large number of human resources and time, generating a great burden to individuals and health system. In this context, the internet is an attractive tool for delivering weight loss programs due to anonymity, 24-hour-accessibility, scalability, and reachability associated with Web-based programs. OBJECTIVE: We aimed to investigate the effectiveness of Web-based digital health interventions, excluding hybrid interventions and non-Web-based technologies such as text messaging, short message service, in comparison to nontechnology active or inactive (wait list) interventions on weight loss and lifestyle habit changes in individuals with overweight and obesity. METHODS: We searched PubMed or Medline, SciELO, Lilacs, PsychNet, and Web of Science up to July 2018, as well as references of previous reviews for randomized trials that compared Web-based digital health interventions to offline interventions. Anthropometric changes such as weight, body mass index (BMI), waist, and body fat and lifestyle habit changes in adults with overweight and obesity were the outcomes of interest. Random effects meta-analysis and meta-regression were performed for mean differences (MDs) in weight. We rated the risk of bias for each study and the quality of evidence across studies using the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS: Among the 4071 articles retrieved, 11 were included. Weight (MD -0.77 kg, 95% CI -2.16 to 0.62; 1497 participants; moderate certainty evidence) and BMI (MD -0.12 kg/m2; 95% CI -0.64 to 0.41; 1244 participants; moderate certainty evidence) changes were not different between Web-based and offline interventions. Compared to offline interventions, digital interventions led to a greater short-term (<6 months follow-up) weight loss (MD -2.13 kg, 95% CI -2.71 to -1.55; 393 participants; high certainty evidence), but not in the long-term (MD -0.17 kg, 95% CI -2.10 to 1.76; 1104 participants; moderate certainty evidence). Meta-analysis was not possible for lifestyle habit changes. High risk of attrition bias was identified in 5 studies. For weight and BMI outcomes, the certainty of evidence was moderate mainly due to high heterogeneity, which was mainly attributable to control group differences across studies (R2=79%). CONCLUSIONS: Web-based digital interventions led to greater short-term but not long-term weight loss than offline interventions in overweight and obese adults. Heterogeneity was high across studies, and high attrition rates suggested that engagement is a major issue in Web-based interventions.

Thyroid Function and Sarcopenia: Results from the ELSA-Brasil Study.

OBJECTIVES: We aimed to investigate the association of subclinical thyroid disease and thyroid hormone levels with sarcopenia and its defining components in community-dwelling middle-aged and older adults without overt thyroid dysfunction. DESIGN: Cross-sectional study. SETTING: Active and retired employees from public institutions located in six Brazilian cities. PARTICIPANTS: A total of 6974 participants from the ELSA-Brasil study's second wave, aged 50 years and older, without overt thyroid dysfunction and with complete data for exposure, outcome, and covariates. METHODS: Serum levels of thyrotropin (TSH), free thyroxine, and free triiodothyronine (FT3) were measured and divided in quintiles for the analyses. Participants were classified with euthyroidism, subclinical hypothyroidism, and subclinical hyperthyroidism. Muscle mass was assessed by bioelectrical impedance analysis and muscle strength by handgrip strength. Sarcopenia was defined according to the Foundation for the National Institutes of Health criteria. Possible confounders included sociodemographic characteristics, clinical conditions, and lifestyle. Analyses were performed separately for middle-aged and older adults (≥65 y). RESULTS: The frequencies of sarcopenia, low muscle mass, low muscle strength, subclinical hypothyroidism, and subclinical hyperthyroidism were 1.5%, 20.8%, 3.8%, 9.1%, and .9%, respectively. Subclinical thyroid dysfunction was not associated with sarcopenia and its defining components. Among older adults, TSH had a U-shaped association with sarcopenia and low muscle strength. The odds ratios (ORs) (95% confidence intervals [CIs]) for the associations of the first, second, fourth, and fifth quintile with sarcopenia, respectively, were 5.18 (1.47-18.28), 6.28 (1.82-21.73), 4.12 (1.15-14.76), and 4.81 (1.35-17.10), and with low muscle strength was (OR (95% CI) for the first, second, and fifth quintiles, respectively: 1.43 (1.16-5.07), 2.07 (1.24-4.70), and 2.18 (1.03-4.60). Additionally, FT3 had a negative association with muscle mass in both age strata. CONCLUSION: Subtle thyroid hormone alterations are associated with sarcopenia or its defining components in middle-aged and older adults without overt thyroid dysfunction. J Am Geriatr Soc 68:1545-1553, 2020.

Association between diabetes and cognitive function at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA- Brasil).

Diabetes has been associated with cognitive changes and an increased risk of vascular dementia and Alzheimer's disease, but it is unclear whether there are associations between diabetes and early alterations in cognitive performance. The present study consisted of a cross-section analysis of 14,444 participants aged 35-74 years and from a developing country at baseline in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil); these participants were recruited between 2008 and 2010. We investigated whether there was an association between diabetes and early changes in the cognitive performance of this Brazilian population. To assess cognitive domains, we used the word-list learning, word-list delayed recall and word recognition tests along. Phonemic verbal fluency tests included semantic phonemic test (animals) and a phonemic test (words beginning with the letter F). Executive functions associated with attention, concentration and psychomotor speed were evaluated using the Trail Making Test B. The exposure variable in the study was defined as diabetes. Multiple linear regression was used to estimate the association between diabetes and cognitive performance. The results were adjusted for age, sex, education, hypertension, coronary disease, depression, physical activity, smoking, alcohol consumption, and the cholesterol/HDL-C ratio. We found a significant association between diabetes and decreased memory, language and executive function (attention, concentration and psychomotor speed) performance in this population from a country with a distinct epidemiological profile, even after adjusting for the main intervening variables.

Using the Behaviour Change Wheel for Designing an Online Platform for Healthy Weight Loss - "POEmaS".

INTRODUCTION: Behaviour change is a key point in weight management. Digital health interventions are attractive tools to deliver behaviour interventions for weight loss, due to the potential to reach a large number of people. We aimed to report how the Behaviour Change Wheel (BCW) was used to develop and implement a web platform to promote weight loss in Brazilian adults with overweight and obesity. Moreover, we aimed to describe the first 12 weeks of usage of the platform in a randomized controlled trial. METHODS: The BCW framework was used to define intake of fruit/vegetables, ultra-processed products and sweetened beverages, leisure physical activity and sitting time as target behaviours. The BCW components of behaviour-capability, opportunity and motivation were used to make a behaviour diagnosis of the population and BCW second layer oriented the selection of information, goal setting, self-monitoring, feedback, social support and incentives as behaviour techniques. Using these behaviour techniques, a 24-week behaviour intervention delivered by seven different platform functionalities was developed. The platform was tested in a three-arm parallel (basic platform versus enhanced platform versus minimal intervention control group) randomized controlled trial from September 2017 to April 2018. In the present analysis, we classified the platform functionalities according to the BCW behaviour component (capability, opportunity and behaviour) and used descriptive statistics and Spearman correlations to report functionalities usage according to the BCW behaviour component over the first 12 weeks of the trial. The study was approved by the Ethics Committee of the Federal University of Minas Gerais, Brazil and was registered under NCT 03435445. RESULTS: Over the first 12 weeks of the RCT, the 809 participants (619, 76.5% women; mean age 33.7 years, SD 10.3; mean BMI 29.9 kg/m2, SD 4.3) were enrolled for use of the basic and enhance versions of the platform. Capability-driven functionalities were accessed by 455 (56.2%) users with median access of 1 (IQR 1-6) times, whereas opportunity-driven platform functionalities were accessed by 592 participants with 8 (IQR 1-27) median access times and motivation-driven functionalities were accessed by 560 (69.2%) participants with 13 (IQR 1-30) median times of access. Spearman correlations between the use of capability and opportunity functionalities, capability and motivation functionalities and opportunity and motivation functionalities were 0.74 (95% CI 0.70-0.77), 0.74 (95% CI 0.70-0.78), 0.89 (95% CI 0.87-0.91), respectively. DISCUSSION: BCW provided a systematic approach to planning, designing and implementing a complex weight loss intervention based on behaviour change. Moreover, it promoted a clear understanding of the relation between platform functionalities and behaviour determinants. The low use of the capability-driven functionalities might have been related to lack of accuracy in the behaviour diagnosis, as well as to implementation issues. The high correlation between the functionalities use suggests that the BCW approach did not determine the platform usage profile. CONCLUSION: The BCW provided a framework for an evidence-based intervention on weight loss delivered by a web platform. Using the framework led to a clear understanding of the behaviour determinants and their relation to the platform features.

Insulin resistance is associated with carotid intima-media thickness in non-diabetic subjects. A cross-sectional analysis of the ELSA-Brasil cohort baseline.

BACKGROUND AND AIMS: Epidemiological studies have analyzed the association between carotid intima-media thickness (CIMT) and insulin resistance, glucose levels or glycated hemoglobin with mixed results. We aimed to evaluate the association between CIMT and homeostasis model assessment - insulin resistance (HOMA-IR), fasting and post-load plasma glucose and glycated hemoglobin in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. METHODS: We included 8028 participants (aged 35-74 years) without diabetes or overt cardiovascular disease who had complete CIMT data at baseline. We built crude and adjusted linear and binary logistic models to evaluate the association between CIMT and (a) HOMA-IR; (b) fasting plasma glucose; (c) post-load plasma glucose; and (d) glycated hemoglobin. We also built post-hoc models, stratified by sex. RESULTS: In the fully-adjusted linear models, only the association between CIMT (in mm) and HOMA-IR remained significant (ß = 0.004; 95% confidence interval [95%CI]:0.001 to 0.006). Consistent with these results, only the association between the highest age- sex- and race-specific CIMT quartile and HOMA-IR was significant in the adjusted logistic model (odds ratio [OR]:1.10; 95% CI:1.04-1.17). The association between HOMA-IR and the highest CIMT quartile remained significant in sex-specific analyses (OR:1.10; 95% CI:1.02-1.20 for men and OR:1.10; 95% CI:1.02-1.20 for women). We did not find an independent association between CIMT and glucose or glycated hemoglobin. CONCLUSIONS: We found a direct association between HOMA-IR and CIMT in a large sample of non-diabetic participants. Mechanisms unrelated to glucose homeostasis, as a direct effect of insulin on atherosclerosis, or medial hypertrophy, may be involved.

C-reactive protein and B-type natriuretic peptide yield either a non-significant or a modest incremental value to traditional risk factors in predicting long-term overall mortality in older adults.

BACKGROUND: New biomarkers may aid in preventive and end-of-life decisions in older adults if they enhance the prognostic ability of traditional risk factors. We investigated whether C-reactive protein (CRP) and/or B-type natriuretic peptide (BNP) improve the ability to predict overall mortality among the elderly of the Bambuí, Brazil Study of Aging when added to traditional risk factors. METHODS: From 1997 to 2007, 1,470 community-dwelling individuals (≥60 years) were followed-up. Death was ascertained by continuous verification of death certificates. We calculated hazard ratios per 1 standard deviation change (HR) of death for traditional risk factors only (old model), and traditional risk factors plus CRP and/or BNP (new models) and assessed calibration of the models. Subsequently, we compared c-statistic of each of the new models to the old one, and calculated integrated discriminative improvement (IDI) and net reclassification improvement (NRI). RESULTS: 544 (37.0%) participants died in a mean follow-up time of 9.0 years. CRP (HR 1.28, 95% CI 1.17-1.40), BNP (HR 1.31 95% CI 1.19-1.45), and CRP plus BNP (HR 1.26, 95% CI 1.15-1.38, and HR 1.29, 95% CI 1.16-1.42, respectively) were independent determinants of mortality. All models were well-calibrated. Discrimination was similar among the old (c-statistic 0.78 [0.78-0.81]) and new models (p=0.43 for CRP; p=0.57 for BNP; and p=0.31 for CRP plus BNP). Compared to the old model, CRP, BNP, and CRP plus BNP models led to an IDI of 0.009 (p<0.001), -0.005 (p<0.001) and -0.003 (p=0.84), and a NRI of 0.04 (p=0.24), 0.07 (p=0.08) and 0.06 (p=0.10), respectively. CONCLUSIONS: Despite being independent predictors of long-term risk of death, compared to traditional risk factors CRP and/or BNP led to either a modest or non-significant improvement in the ability of predicting all-cause mortality in older adults.

Overweight and class I obesity are associated with lower 10-year risk of mortality in Brazilian older adults: the Bambuí Cohort Study of Ageing.

BACKGROUND: Prospective studies mostly with European and North-American populations have shown inconsistent results regarding the association of overweight/obesity and mortality in older adults. Our aim was to investigate the relationship between overweight/ obesity and mortality in an elderly Brazilian population. METHODS AND FINDINGS: Participants were 1,450 (90.2% from total) individuals aged 60 years and over from the community-based Bambuí (Brazil) Cohort Study of Ageing. From 1997 to 2007, 521 participants died and 89 were lost, leading to 12,905 person-years of observation. Body mass index (BMI) and waist circumference (WC) were assessed at baseline and at the 3rd and 5th years of follow-up. Multiple imputation was performed to deal with missing values. Hazard ratios (HR) of mortality for BMI or WC alone (continuous and categorical), and BMI and WC together (continuous) were estimated by extended Cox regression models, which were fitted for clinical, socioeconomic and behavioral confounders. Adjusted absolute rates of death at 10-year follow-up were estimated for the participants with complete data at baseline. Continuous BMI (HR 0.85; 95% CI 0.80-0.90) was inversely related to mortality, even after exclusion of smokers (HR 0.85; 0.80-0.90), and participants who had weight variation and died within the first 5 years of follow-up (HR 0.83; CI 95% 0.73-0.94). Overweight (BMI 25-30 kg/m(2)) was inversely (HR 0.76; 95%CI 0.61-0.93) and obesity (BMI ≥ 30 kg/m(2); HR 0.85; 95% CI 0.64-1.14) not significantly associated with mortality. Subjects with BMI between 25-35 kg/m(2) (23.8-25.9%) had the lowest absolute rates of death at 10-years follow-up. The association between WC and death was not significant, except after adjusting WC for BMI levels, when the relationship turned into marginally positive (HR 1.01; CI 95% 1.00-1.02). CONCLUSIONS: The usual BMI and WC cut-off points should not be used to guide public health and clinical weight control interventions in elderly in Brazil.