Area-level inequalities in the provision of NHS orthodontic care in England from 2016 to 2019.

Objective To investigate geographic inequalities in the provision of NHS orthodontic care in England at the area level.Methods NHS dental activity data were analysed for the three financial years April 2016 to March 2019. The measures used were units of dental activity (UDA), units of orthodontic activity (UOA) and commencement of orthodontic treatment. Two orthodontic activity indices were created to assess relative volumes of care. Deprivation was measured using the index of multiple deprivations. Slope and relative inequality indices were used to assess inequality.Results Nearly 12.4 million UOA and 572,987 courses of treatment in England were reported under NHS arrangements in the three years studied. There were significant variations in the rates of UOA (0-716) and UDA (148-918) provided per 100 children (0-17 years) at the local authority level. The variation was not associated with deprivation at the local authority level.Conclusions There were significant disparities in the provision of NHS orthodontic treatment at the local authority level, but this was not associated with area-level measures of deprivation. Inequality in the uptake of orthodontic care may not be due to area-level disparities in service provision.

Area-level deprivation and oral cancer in England 2012-2016.

BACKGROUND: The relationship between deprivation and oral cancer is complex. We examined magnitude and shape of deprivation-related inequalities in oral cancer in England 2012-2016. METHODS: Oral cancer was indicated by cancers of the lip and oral cavity (ICD10 C00-C06) and lip, oral cavity and pharynx (C00-C14) and deprivation by the Index of Multiple Deprivation. Deprivation inequality in incidence and mortality rates of oral cancer outcomes was measured using the Relative Index of Inequality (RII). Fractional polynomial regression was used to explore the shape of the relationships between deprivation and oral cancer outcomes. Multivariate regression models were fitted with the appropriate functions to examine the independent effect of deprivation on cancer adjusting for smoking, alcohol and ethnicity. RESULTS: Incidence rate ratios (IRRs) and mortality rate ratios (MRRs) were greater for more deprived areas. The RII values indicated significant inequalities for oral cancer outcomes but the magnitude of inequalities were greater for mortality. The relationships between deprivation and oral cancer outcomes were curvilinear. Deprivation, Asian ethnicity and alcohol consumption were associated with higher incidence and mortality rates of oral cancer. CONCLUSION: This is the first study, to our knowledge, exploring the shape of socioeconomic inequalities in oral cancer at neighbourhood level. Deprivation-related inequalities were present for all oral cancer outcomes with a steeper rise at the more deprived end of the deprivation spectrum. Deprivation predicted oral cancer even after accounting for other risk factors.

Loss-Framed Financial Incentives and Personalized Goal-Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial.

BACKGROUND: Regular physical activity reduces the risk of cardiovascular events, but most ischemic heart disease (IHD) patients do not obtain enough. METHODS AND RESULTS: ACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) was a 24-week home-based, remotely monitored, randomized trial with a 16-week intervention (8-week ramp-up incentive phase and 8-week maintenance incentive phase) and an 8-week follow-up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks. In the ramp-up incentive phase, daily step goals increased weekly by 15% from baseline with a maximum of 10 000 steps and then remained fixed. Each week, $14 was allocated to a virtual account; $2 could be lost per day for not achieving step goals. The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase. Ischemic heart disease patients had a mean (SD) age of 60 (11) years and 70% were male. Compared with control, patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp-up (1388 versus 385; adjusted difference, 1061 [95% confidence interval, 386-1736]; P<0.01), maintenance (1501 versus 264; adjusted difference, 1368 [95% confidence interval, 571-2164]; P<0.001), and follow-up (1066 versus 92; adjusted difference, 1154 [95% confidence interval, 282-2027]; P<0.01). CONCLUSIONS: Loss-framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16-week intervention, and effects were sustained during the 8-week follow-up. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02531022.

Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes: A Randomized Clinical Trial.

Importance: Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life. Objective: To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes. Design, Setting, and Participants: The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A1c [HbA1c] >8.0%) were recruited from the Diabetes Center for Children at the Children's Hospital of Philadelphia. Interventions: All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued. Main Outcomes and Measures: The primary outcome was change in HbA1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA1c levels at 6 months. All analyses were by intention to treat. Results: Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, -2.0% to 9.9%; P = .20). The change in HbA1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, -0.08%; 95% CI, -0.69% to 0.54%; P = .80) or 6 months (adjusted difference, 0.03%; 95% CI, -0.55% to 0.60%; P = .93). Conclusions and Relevance: Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control. Trial Registration: clinicaltrials.gov Identifier: NCT02568501.

Adipose triglyceride lipase-null mice are resistant to high-fat diet-induced insulin resistance despite reduced energy expenditure and ectopic lipid accumulation.

Adipose triglyceride lipase (ATGL) null (-/-) mice store vast amounts of triacylglycerol in key glucoregulatory tissues yet exhibit enhanced insulin sensitivity and glucose tolerance. The mechanisms underpinning these divergent observations are unknown but may relate to the reduced availability of circulating fatty acids. The aim of this study was to determine whether the enhancements in insulin stimulated glucose metabolism in ATGL-/- mice persist when challenged with a high-fat diet. ATGL-/- mice fed a low-fat diet exhibit improved whole-body insulin sensitivity and glucose tolerance compared with wild-type mice. Wild-type mice became hyperlipidemic and insulin-resistant when challenged with a high-fat diet (HFD, 60% fat) for 4 wk. ATGL-/- mice fed a HFD had elevated circulating fatty acids but had reduced fasting glycemia compared to pre-high-fat diet levels and were refractory to glucose intolerance and insulin resistance. This protection from high-fat diet-induced metabolic perturbations was associated with a preference for fatty acid utilization but reduced energy expenditure and no change in markers of mitochondrial capacity or density. The protection from high-fat diet-induced insulin resistance in ATGL-/- mice was due to increased cardiac and liver insulin-stimulated glucose clearance despite increased lipid content in these tissues. Additionally, there was no difference in skeletal muscle insulin-stimulated glucose disposal, but there was a reduction observed in brown adipose tissue. Overall, these results show that ATGL-/- mice are protected from HFD-induced insulin resistance and reveal a tissue specific disparity between lipid accumulation and insulin sensitivity.