The future burden of type 2 diabetes in Belgium: a microsimulation model.

OBJECTIVE: To forecast the annual burden of type 2 diabetes and related socio-demographic disparities in Belgium until 2030. METHODS: This study utilized a discrete-event transition microsimulation model. A synthetic population was created using 2018 national register data of the Belgian population aged 0-80 years, along with the national representative prevalence of diabetes risk factors obtained from the latest (2018) Belgian Health Interview and Examination Surveys using Multiple Imputation by Chained Equations (MICE) as inputs to the Simulation of Synthetic Complex Data (simPop) model. Mortality information was obtained from the Belgian vital statistics and used to calculate annual death probabilities. From 2018 to 2030, synthetic individuals transitioned annually from health to death, with or without developing type 2 diabetes, as predicted by the Finnish Diabetes Risk Score, and risk factors were updated via strata-specific transition probabilities. RESULTS: A total of 6722 [95% UI 3421, 11,583] new cases of type 2 diabetes per 100,000 inhabitants are expected between 2018 and 2030 in Belgium, representing a 32.8% and 19.3% increase in T2D prevalence rate and DALYs rate, respectively. While T2D burden remained highest for lower-education subgroups across all three Belgian regions, the highest increases in incidence and prevalence rates by 2030 are observed for women in general, and particularly among Flemish women reporting higher-education levels with a 114.5% and 44.6% increase in prevalence and DALYs rates, respectively. Existing age- and education-related inequalities will remain apparent in 2030 across all three regions. CONCLUSIONS: The projected increase in the burden of T2D in Belgium highlights the urgent need for primary and secondary preventive strategies. While emphasis should be placed on the lower-education groups, it is also crucial to reinforce strategies for people of higher socioeconomic status as the burden of T2D is expected to increase significantly in this population segment.

Understanding the contribution of lifestyle in breast cancer risk prediction: a systematic review of models applicable to Europe.

BACKGROUND: Breast cancer (BC) is a significant health concern among European women, with the highest prevalence rates among all cancers. Existing BC prediction models account for major risks such as hereditary, hormonal and reproductive factors, but research suggests that adherence to a healthy lifestyle can reduce the risk of developing BC to some extent. Understanding the influence and predictive role of lifestyle variables in current risk prediction models could help identify actionable, modifiable, targets among high-risk population groups. PURPOSE: To systematically review population-based BC risk prediction models applicable to European populations and identify lifestyle predictors and their corresponding parameter values for a better understanding of their relative contribution to the prediction of incident BC. METHODS: A systematic review was conducted in PubMed, Embase and Web of Science from January 2000 to August 2021. Risk prediction models were included if (i) developed and/or validated in adult cancer-free women in Europe, (ii) based on easily ascertained information, and (iii) reported models' final predictors. To investigate further the comparability of lifestyle predictors across models, estimates were standardised into risk ratios and visualised using forest plots. RESULTS: From a total of 49 studies, 33 models were developed and 22 different existing models, mostly from Gail (22 studies) and Tyrer-Cuzick and co-workers (12 studies) were validated or modified for European populations. Family history of BC was the most frequently included predictor (31 models), while body mass index (BMI) and alcohol consumption (26 and 21 models, respectively) were the lifestyle predictors most often included, followed by smoking and physical activity (7 and 6 models respectively). Overall, for lifestyle predictors, their modest predictive contribution was greater for riskier lifestyle levels, though highly variable model estimates across different models. CONCLUSIONS: Given the increasing BC incidence rates in Europe, risk models utilising readily available risk factors could greatly aid in widening the population coverage of screening efforts, while the addition of lifestyle factors could help improving model performance and serve as intervention targets of prevention programmes.

A retrospective database study of the demographic features and glycemic control of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo.

BACKGROUND: The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients' follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention. METHODS: We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model. RESULTS: Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5-3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years). CONCLUSION: In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients' follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

Ultra-processed food consumption in adults across Europe.

PURPOSE: The purpose of this study is to describe ultra-processed food and drinks (UPFDs) consumption, and associations with intake of total sugar and dietary fibre, and high BMI in adults across Europe. METHODS: Using food consumption data collected by food records or 24-h dietary recalls available from the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database, the foods consumed were classified by the level of processing using the NOVA classification. Diet quality was assessed by data linkage to the Dutch food composition tables (NEVO) and years lived with disability for high BMI from the Global Burden of Disease Study 2019. Bivariate groupings were carried out to explore associations of UPFDs consumption with population intake of sugar and dietary fibre, and BMI burden, visualised by scatterplots. RESULTS: The energy share from UPFDs varied markedly across the 22 European countries included, ranging from 14 to 44%, being the lowest in Italy and Romania, while the highest in the UK and Sweden. An overall modest decrease (2-15%) in UPFDs consumption is observed over time, except for Finland, Spain and the UK reporting increases (3-9%). Fine bakery wares and soft drinks were most frequently ranked as the main contributor. Countries with a higher sugar intake reported also a higher energy share from UPFDs, as most clearly observed for UPF (r = 0.57, p value = 0.032 for men; and r = 0.53, p value = 0.061 for women). No associations with fibre intake or high BMI were observed. CONCLUSION: Population-level UPFDs consumption substantially varied across Europe, although main contributors are similar. UPFDs consumption was not observed to be associated with country-level burden of high BMI, despite being related to a higher total sugar intake.

Cardiometabolic Profile and Outcomes in Migrant Populations: A Review of Comparative Evidence from Migrants in Europe in Relation to Their Country of Origin.

BACKGROUND: The potential effect of migration on increasing cardiometabolic risk factors remains partially understood. We aim to synthesize the evidence comparing the burden of diabetes and adiposity of migrating populations in Europe, with that of their country of origin. METHODS: We conducted a scoping literature review. We searched PubMed for studies investigating the effect of migration on diabetes or adiposity outcomes among migrants in countries from the European Union or the United Kingdom compared to the population in the country of origin. Studies were qualitatively synthesized in evidence tables and the demographic characteristics, study design, risk factors investigated, and outcomes were quantitatively summarized using measures of central tendency. FINDINGS: Of 1175 abstracts retrieved, 28 studies were eligible. Most of the studies included migrating populations residing in Western (50%), Northern (39%), and Southern Europe (11%) originating from countries in Africa (46%), Asia (29%), or European overseas (25%) regions of which 85% were classified as low-middle-income countries. Most of the studies (93%) had a cross-sectional design. The median number of individuals in the country of origin was greater [917; IQR: 231-1378] than in the receiving country [249; 150-883]. Thirty-five percent of the studies investigated migration as an independent risk factor, whereas 28% contextualized migration into lifestyle changes. The majority of the studies (57%) reported both diabetes and adiposity outcomes. Within the limited evidence available, controversial results were found as some studies showed poorer outcomes for the migrating populations, while others showed the opposite. CONCLUSION: Studies assessing the impact of migration by comparing migrating populations and the population of origin on diabetes and adiposity outcomes have gained interest. So far, the available evidence is highly heterogeneous to inform public health strategies in the receiving countries. We recommend further research including a more robust methodology and in-depth characterization of the migrant populations.

Improving health and carbon footprints of European diets using a benchmarking approach.

OBJECTIVE: This study aimed to identify diets with improved nutrient quality and environmental impact within the boundaries of dietary practices. DESIGN: We used Data Envelopment Analysis to benchmark diets for improved adherence to food-based dietary guidelines (FBDG). We then optimised these diets for dietary preferences, nutrient quality and environmental impact. Diets were evaluated using the Nutrient Rich Diet score (NRD15.3), diet-related greenhouse gas emission (GHGE) and a diet similarity index that quantified the proportion of food intake that remained similar as compared with the observed diet. SETTING: National dietary surveys of four European countries (Denmark, Czech Republic, Italy and France). SUBJECTS: Approximately 6500 adults, aged 18-64 years. RESULTS: When dietary preferences were prioritised, NRD15·3 was ~6 % higher, GHGE was ~4 % lower and ~85 % of food intake remained similar. This diet had higher amounts of fruit, vegetables and whole grains than the observed diet. When nutrient quality was prioritised, NRD15·3 was ~16 % higher, GHGE was ~3 % lower and ~72 % of food intake remained similar. This diet had higher amounts of legumes and fish and lower amounts of sweetened and alcoholic beverages. Finally, when environmental impact was prioritised, NRD15·3 was ~9 % higher, GHGE was ~21 % lower and ~73 % of food intake remained similar. In this diet, red and processed meat partly shifted to either eggs, poultry, fish or dairy. CONCLUSIONS: Benchmark modelling can generate diets with improved adherence to FBDG within the boundaries of dietary practices, but fully maximising health and minimising GHGE cannot be achieved simultaneously.

Geographic and socioeconomic diversity of food and nutrient intakes: a comparison of four European countries.

PURPOSE: Public health policies and actions increasingly acknowledge the climate burden of food consumption. The aim of this study is to describe dietary intakes across four European countries, as baseline for further research towards healthier and environmentally-friendlier diets for Europe. METHODS: Individual-level dietary intake data in adults were obtained from nationally-representative surveys from Denmark and France using a 7-day diet record, Italy using a 3-day diet record, and Czech Republic using two replicates of a 24-h recall. Energy-standardised food and nutrient intakes were calculated for each subject from the mean of two randomly selected days. RESULTS: There was clear geographical variability, with a between-country range for mean fruit intake from 118 to 199 g/day, for vegetables from 95 to 239 g/day, for fish from 12 to 45 g/day, for dairy from 129 to 302 g/day, for sweet beverages from 48 to 224 ml/day, and for alcohol from 8 to 15 g/day, with higher intakes in Italy for fruit, vegetables and fish, and in Denmark for dairy, sweet beverages and alcohol. In all countries, intakes were low for legumes (< 20 g/day), and nuts and seeds (< 5 g/day), but high for red and processed meat (> 80 g/day). Within countries, food intakes also varied by socio-economic factors such as age, gender, and educational level, but less pronounced by anthropometric factors such as overweight status. For nutrients, intakes were low for dietary fibre (15.8-19.4 g/day) and vitamin D (2.4-3.0 µg/day) in all countries, for potassium (2288-2938 mg/day) and magnesium (268-285 mg/day) except in Denmark, for vitamin E in Denmark (6.7 mg/day), and for folate in Czech Republic (212 µg/day). CONCLUSIONS: There is considerable variation in food and nutrient intakes across Europe, not only between, but also within countries. Individual-level dietary data provide insight into the heterogeneity of dietary habits beyond per capita food supply data, and this is crucial to balancing healthy and environmentally-friendly diets for European citizens.

FFQ versus repeated 24-h recalls for estimating diet-related environmental impact.

BACKGROUND: There is an increasing interest in estimating environmental impact of individuals' diets by using individual-level food consumption data. However, like assessment of nutrient intakes, these data are prone to substantial measurement errors dependent on the method of dietary assessment, and this often result in attenuation of associations. PURPOSE: To investigate the performance of a food frequency questionnaire (FFQ) for estimating the environmental impact of the diet as compared to independent 24-h recalls (24hR), and to study the association between environmental impact and dietary quality for the FFQ and 24hR. METHODS: We analysed cross-sectional data from 1169 men and women, aged 20-76 years, who participated in the NQplus study, the Netherlands. They completed a 216-item FFQ and two replicates of web-based 24hR. Life cycle assessments of 207 food products were used to calculate greenhouse gas emissions, fossil energy and land use, summarised into an aggregated score, pReCiPe. Validity of the FFQ was evaluated against 24hRs using correlation coefficients and attenuation coefficients. Associations with dietary quality were based on Dutch Healthy Diet 15-index (DHD15-index) and Nutrient Rich Diet score (NRD9.3). RESULTS: For pReCiPe, correlation coefficient between FFQ and 24hR was 0.33 when adjusted for covariates age, gender and BMI, and increased to 0.76 when de-attenuated for within-subject variation in the 24hR. Energy-adjustment slightly reduced these correlations (r = 0.71 for residuals of observed values and 0.59 for residuals of density values). Covariate-adjusted attenuation coefficient for the FFQ was 0.56 (ʎ1 = 0.56 and ʎ1 = 0.65 for observed and density residuals), slightly lower than without covariate adjustment. Diet-related environmental impact was inversely associated with the food-based DHD15-index for both FFQ and 24hR, while associations with the nutrient-based NRD9.3 were inconsistent. CONCLUSIONS: The FFQ slightly underestimated environmental impact when compared to 24hR. Associations with dietary quality are highly dependent on the diet score used, and less dependent on the method of dietary assessment.

Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: evidence from the Caerphilly Prospective Study.

PURPOSE: Epidemiological findings indicate that higher adherence to a healthy diet may lower cardiovascular disease (CVD) risk. The present study aimed to investigate whether adherence to a healthy diet, assessed by the Healthy Diet Indicator (HDI), Dietary Approaches to Stop Hypertension (DASH) score, and Alternative Healthy Eating Index 2010 (AHEI-2010), was associated with CVD incidence and risk markers. METHODS: Included in the present analyses were data from 1867 middle-aged men, aged 56.7 ± 4.5 years at baseline, recruited into the Caerphilly Prospective Study. Adherence to a healthy diet was examined in relation to CVD, coronary heart disease (CHD), and stroke incidence (Cox regression), and risk markers (linear regression) with adjustment for relevant confounders. RESULTS: The DASH score was inversely associated with CVD [hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.66, 0.99], and stroke (HR 0.61; 95% CI 0.42, 0.88) incidence, but not with CHD after an average of 16.6 year follow-up, and with diastolic blood pressure, after 12 year follow-up. The AHEI-2010 was inversely associated with stroke (HR 0.66; 95% CI 0.42, 0.88) incidence, aortic pulse wave velocity, and C-reactive protein. The HDI was not associated with any single outcome. CONCLUSIONS: Higher DASH and AHEI-2010 scores were associated with lower CVD and stroke risk, and favourable cardiovascular health outcomes, suggesting that encouraging middle-aged men to comply with the dietary recommendations for a healthy diet may have important implications for future vascular disease and population health.

Operationalising the health aspects of sustainable diets: a review.

OBJECTIVE: Shifting towards a more sustainable food consumption pattern is an important strategy to mitigate climate change. In the past decade, various studies have optimised environmentally sustainable diets using different methodological approaches. The aim of the present review was to categorise and summarise the different approaches to operationalise the health aspects of environmentally sustainable diets. DESIGN: Conventional keyword and reference searches were conducted in PubMed, Scopus, Web of Knowledge and CAB Abstracts. Inclusion criteria were: (i) English-language publication; (ii) published between 2005 and October 2015; (iii) dietary data collected for the diet as a whole at the national, household or individual level; (iv) comparison of the current diet with dietary scenarios; and (v) for results to consider the health aspect in some way. SETTING: Consumer diets. SUBJECTS: Adult population. RESULTS: We reviewed forty-nine studies that combined the health and environmental aspects of consumer diets. Hereby, five approaches to operationalise the health aspect of the diet were identified: (i) food item replacements; (ii) dietary guidelines; (iii) dietary quality scores; (iv) diet modelling techniques; and (v) diet-related health impact analysis. CONCLUSIONS: Although the sustainability concept is increasingly popular and widely advocated by nutritional and environmental scientists, the journey towards designing sustainable diets for consumers has only just begun. In the context of operationalising the health aspects, diet modelling might be considered the preferred approach since it captures the complexity of the diet as a whole. For the future, we propose SHARP diets: environmentally Sustainable (S), Healthy (H), Affordable (A), Reliable (R) and Preferred from the consumer's perspective (P).

Lifestyle predictors of colorectal cancer in European populations: a systematic review.

Background: Colorectal cancer (CRC) is the second most prevalent cancer in Europe, with one-fifth of cases attributable to unhealthy lifestyles. Risk prediction models for quantifying CRC risk and identifying high-risk groups have been developed or validated across European populations, some considering lifestyle as a predictor. Purpose: To identify lifestyle predictors considered in existing risk prediction models applicable for European populations and characterise their corresponding parameter values for an improved understanding of their relative contribution to prediction across different models. Methods: A systematic review was conducted in PubMed and Web of Science from January 2000 to August 2021. Risk prediction models were included if (1) developed and/or validated in an adult asymptomatic European population, (2) based on non-invasively measured predictors and (3) reported mean estimates and uncertainty for predictors included. To facilitate comparison, model-specific lifestyle predictors were visualised using forest plots. Results: A total of 21 risk prediction models for CRC (reported in 16 studies) were eligible, of which 11 were validated in a European adult population but developed elsewhere, mostly USA. All models but two reported at least one lifestyle factor as predictor. Of the lifestyle factors, the most common predictors were body mass index (BMI) and smoking (each present in 13 models), followed by alcohol (11), and physical activity (7), while diet-related factors were less considered with the most commonly present meat (9), vegetables (5) or dairy (2). The independent predictive contribution was generally greater when they were collected with greater detail, although a noticeable variation in effect size estimates for BMI, smoking and alcohol. Conclusions: Early identification of high-risk groups based on lifestyle data offers the potential to encourage participation in lifestyle change and screening programmes, hence reduce CRC burden. We propose the commonly shared lifestyle predictors to be further used in public health prediction modelling for improved uptake of the model.

Comparing self-reported health interview survey and pharmacy billing data in determining the prevalence of diabetes, hypertension, and hypercholesterolemia in Belgium.

BACKGROUND: Administrative and health surveys are used in monitoring key health indicators in a population. This study investigated the agreement between self-reported disease status from the Belgian Health Interview Survey (BHIS) and pharmaceutical insurance claims extracted from the Belgian Compulsory Health Insurance (BCHI) in ascertaining the prevalence of diabetes, hypertension, and hypercholesterolemia. METHODS: Linkage was made between the BHIS 2018 and the BCHI 2018, from which chronic condition was ascertained using the Anatomical Therapeutic Chemical (ATC) classification and defined daily dose. The data sources were compared using estimates of disease prevalence and various measures of agreement and validity. Multivariable logistic regression was performed for each chronic condition to identify the factors associated to the agreement between the two data sources. RESULTS: The prevalence estimates computed from the BCHI and the self-reported disease definition in BHIS, respectively, are 5.8% and 5.9% diabetes cases, 24.6% and 17.6% hypertension cases, and 16.2% and 18.1% of hypercholesterolemia cases. The overall agreement and kappa coefficient between the BCHI and the self-reported disease status is highest for diabetes and is equivalent to 97.6% and 0.80, respectively. The disagreement between the two data sources in ascertaining diabetes is associated with multimorbidity and older age categories. CONCLUSION: This study demonstrated the capability of pharmacy billing data in ascertaining and monitoring diabetes in the Belgian population. More studies are needed to assess the applicability of pharmacy claims in ascertaining other chronic conditions and to evaluate the performance of other administrative data such as hospital records containing diagnostic codes.

Mapping the nutritional value of diets across Europe according to the Nutri-Score front-of-pack label.

Background: Front-of-pack labels, such as Nutri-Score, aim to offer clear information on the overall nutritional quality of foods and beverages to consumers, allowing them to make healthier food choices. Using the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database, the present study aims to map out European food consumption patterns by applying the Nutri-Score as a benchmark for nutritional value. Methods: Country-specific food consumption data, collected by multiple 24-h dietary recalls or food records available from EFSA, were linked to the Dutch Food Composition Database (NEVO). Foods and beverages consumed by adolescents (10-17 years), adults (18-64 years), and the elderly (65-74 years) were graded following the modified Food Standard Agency Nutrient Profiling System (FSAm-NPS) and classified according to Nutri-Score grading, from A to E. Subsequently, a dietary index score (FSAm-NPS-DI) was calculated for each country-specific diet by age-groups and sex as an energy-weighted mean of the FSAm-NPS score of all foods and beverages consumed, with lower scores for a diet of greater overall nutritional quality. Results: On average, the daily energy intake of adults across the European countries studied is distributed in 27.6% of A-, 12.9% of B-, 17% of C-, 30.0% of D-, and 12.5% of E-classified foods and beverages. This energy distribution, according to the Nutri-Score, corresponded to a median FSAm-NPS-DI score of 6.34 (interquartile range: 5.92, 7.19). For both adult males and females, Estonia reported the highest energy share from A-classified products, scoring the lowest on the FSAm-NPS-DI. On the other hand, Latvia reported the highest energy share from E-classified products, along with the highest FSAm-NPS-DI. Females and the elderly group reported, in general, a greater energy share from A- and a lower share from E-classified products, and had the lowest FSAm-NPS-DI scores. No sex-related difference was observed for adolescents whose share of energy was predominantly from A- and D-classified products, such as for adults and the elderly. Conclusion: Our analyses leveraging the secondary use of country-specific databases on dietary intakes found considerable variation in the nutritional value of European diets, with an overall agreement across all countries on a modestly healthier dietary profile for the elderly and among females.

Microsimulation Modeling in Food Policy: A Scoping Review of Methodological Aspects.

Food policies for the prevention and management of diet-related noncommunicable diseases (NCDs) have been increasingly relying on microsimulation models (MSMs) to assess effectiveness. Given the increased uptake of MSMs, this review aims to provide an overview of the characteristics of MSMs that link diets with NCDs. A comprehensive review was conducted in PubMed and Web of Knowledge. Inclusion criteria were: 1) findings from an MSM; 2) diets, foods, or nutrients as the main exposure of interest; and 3) NCDs, such as overweight/obesity, type 2 diabetes, coronary heart disease, stroke, or cancer, as the disease outcome for impact assessment. This review included information from 33 studies using MSM in analyzing diet and diverse food policies on NCDs. Hereby, most models employed stochastic, discrete-time, dynamic microsimulation techniques to calculate anticipated (cost-)effectiveness of strategies based on food pricing, food reformulation, or dietary (lifestyle) interventions. Currently available models differ in the methodology used for quantifying the effect of the dietary changes on disease, and in the method for modeling the disease incidence and mortality. However, all studies provided evidence that the models were sufficiently capturing the close-to-reality situation by justifying their choice of model parameters and validating externally their modeled disease incidence and mortality with observed or predicted event data. With the increasing use of various MSMs, between-model comparisons, facilitated by open access models and good reporting practices, would be important for judging a model's accuracy, leading to continued improvement in the methodologies for developing and applying MSMs and, subsequently, a better understanding of the results by policymakers.

Predicting COVID-19 progression in hospitalized patients in Belgium from a multi-state model.

Objectives: To adopt a multi-state risk prediction model for critical disease/mortality outcomes among hospitalised COVID-19 patients using nationwide COVID-19 hospital surveillance data in Belgium. Materials and methods: Information on 44,659 COVID-19 patients hospitalised between March 2020 and June 2021 with complete data on disease outcomes and candidate predictors was used to adopt a multi-state, multivariate Cox model to predict patients' probability of recovery, critical [transfer to intensive care units (ICU)] or fatal outcomes during hospital stay. Results: Median length of hospital stay was 9 days (interquartile range: 5-14). After admission, approximately 82% of the COVID-19 patients were discharged alive, 15% of patients were admitted to ICU, and 15% died in the hospital. The main predictors of an increased probability for recovery were younger age, and to a lesser extent, a lower number of prevalent comorbidities. A patient's transition to ICU or in-hospital death had in common the following predictors: high levels of c-reactive protein (CRP) and lactate dehydrogenase (LDH), reporting lower respiratory complaints and male sex. Additionally predictors for a transfer to ICU included middle-age, obesity and reporting loss of appetite and staying at a university hospital, while advanced age and a higher number of prevalent comorbidities for in-hospital death. After ICU, younger age and low levels of CRP and LDH were the main predictors for recovery, while in-hospital death was predicted by advanced age and concurrent comorbidities. Conclusion: As one of the very few, a multi-state model was adopted to identify key factors predicting COVID-19 progression to critical disease, and recovery or death.

The effectiveness of lifestyle interventions on type 2 diabetes and gestational diabetes incidence and cardiometabolic outcomes: A systematic review and meta-analysis of evidence from low- and middle-income countries.

Background: As lifestyle modification offers a unique strategy to prevent diabetes, we evaluated the effectiveness of lifestyle interventions in the prevention of type 2 diabetes and gestational diabetes in low- and middle-income countries (LMICs). Methods: We did a systematic literature review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and Cochrane Library for randomised controlled trials published in English, Spanish, French, and Portuguese between 1 January 2000 and 15 June 2022, evaluating multi-target and multi-component lifestyle interventions in at-risk populations conducted in LMICs. The main outcomes were incidence of type 2 diabetes and gestational diabetes, and indicators of glycaemic control. We assessed the methodological quality of the studies using the Cochrane risk of bias tool. Inverse-variance random-effects meta-analyses estimated the overall effect sizes. Sources of heterogeneity and study bias were evaluated. The study protocol was registered in PROSPERO (CRD42021279174). Findings: From 14 330 abstracts, 48 (0·3%) studies with 50 interventions were eligible of which 56% were conducted in lower-middle-income countries, 44% in upper-middle, and none in low-income. 54% of the studies were assessed as moderate risk of bias and 14% as high risk. A median of 246 (IQR 137-511) individuals participated in the interventions with a median duration of 6 (3-12) months. Lifestyle interventions decreased the incidence risk ratio of type 2 diabetes by 25% (0·75 [95% CI 0·61 to 0·91]), and reduced the levels of HbA1c by 0·15% [-0·25 to -0·05], fasting plasma glucose by 3·44 mg/dL [-4·72 to -2·17], and 2-hr glucose tolerance by 4·18 mg/dL [-7·35 to -1·02]. No publication bias was suggested for these outcomes. High levels of heterogeneity (I²≥ 81%) were found in most meta-analyses. Exploration using meta-regressions could not identify any explanatory variable, except for fasting glucose for which the quality score of the articles seems to be an effect modifier decreasing slightly the heterogeneity (72%) in the low risk of bias pooled estimate. The effect on gestational diabetes could not be evaluated due to the scarcity of available studies. Interpretation: Comprehensive lifestyle interventions are effective strategies to prevent type 2 diabetes among at-risk populations in LMICs. The heterogeneity identified in our results should be considered when using these interventions to address the onset of type 2 diabetes. Funding: None.

Food Choice Motives and COVID-19 in Belgium.

To investigate the main motives driving dietary intake changes potentially introduced by preventive measures to address the pandemic, an online survey, using a 36-item Food Choice Questionnaire applied for the period before (the year 2019) and during (2020-2021) the pandemic, was distributed between July and October 2021 among adult residents from Belgium. A total of 427 eligible respondents, the majority Dutch-speaking, were included for analyses. The importance of nine motives for food choices, including health, mood, convenience, sensory appeal, natural content, price, weight control, familiarity and ethical concerns, was assessed by scoring from 1 to 5, and comparing mean scores from the during period with the before period. Sensory appeal was the most important food choice motive before (mean score of 4.02 ± 0.51) and during (3.98 ± 0.48) the pandemic. Convenience and health also ranked among the main motives, with health observed to become more important during the pandemic (3.69 ± 0.60 during vs. 3.64 ± 0.59 before). Additionally, mean scores of mood (3.41 ± 0.71 vs. 3.32 ± 0.58), natural content (3.35 ± 0.84 vs. 3.26 ± 0.85) and weight control (3.33 ± 0.79 vs. 3.25 ± 0.76) were significantly higher during as compared to before. The extent of change in the level of importance for natural content was smaller with increasing age, and for health larger for urban areas, but for other motives there were no significant differences across population subgroups. Changes in the level of importance were observed in both directions, while a moderate share of respondents declared no change, suggesting some persistence of food choice motives. Further activities within public health monitoring should be considered to fully understand the COVID-19 implications on food choice motives together with people's food behaviors and consumption.

Quantification of disparities in the distribution of lifestyle and metabolic risk factors, prevalence of non-communicable diseases and related mortality: the Belgian Health Interview Surveys 1997-2018.

OBJECTIVES: Comprehensively measure the trends in health disparities by sociodemographic strata in terms of exposure to lifestyle and metabolic risks, and prevalence and mortality of non-communicable diseases (NCDs) during the last 20 years in Belgium. DESIGN: Cross-sectional analysis of periodic national-representative health interview surveys and vital statistics. SETTING: Population-based study of adult residents in Belgium between 1997 and 2018. PARTICIPANTS: Adults aged 25-84 years and resident in Belgium in the years 1997 (7256 adults), 2001 (8665), 2004 (9054), 2008 (7343), 2013 (7704) and 2018 (8358). MAIN OUTCOME MEASURE: Age-standardised prevalence rates of modifiable lifestyle risks (poor diet, smoking, excessive alcohol use and leisure-time physical inactivity), metabolic risks (high body mass index (BMI), blood pressure and cholesterol levels) and major NCDs (type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVDs), cancer, asthma and chronic obstructive pulmonary disease (COPD)), with their relative health disparities across strata by age, sex, region of residence, nationality, education and income level, and according to high versus low engagement in the four lifestyle risks, calculated from a survey-weighted age-adjusted logistic regression. RESULTS: Greater avoidable disparities were observed between extremes of education and income strata. The most marked disparities were found for exposure to lifestyle risks (except excessive alcohol use), prevalence of high BMI as well as T2DM, asthma and COPD, with disparities of daily smoking and COPD worsening over time. Still, NCD-specific mortality rates were significantly higher among men (except asthma), residents of Wallonia and Brussels (except cerebrovascular disease), and among the native Belgians (except T2DM and asthma). High engagement in lifestyle risks was generally observed for men, residents of the region Wallonia, and among lower education and income strata. This subgroup (20%) had a worse health profile as compared with those who had a low-risk lifestyle (25%), shown by prevalence ratios varying between 1.1 and 1.6 for metabolic risks, and between 1.8 and 3.7 for CVD, asthma and COPD. CONCLUSIONS: Improving population health, including promoting greater health equity, requires approaches to be tailored to high-risk groups with actions tackling driving root causes of disparities seen by social factors and unhealthy lifestyle.

Insights into the association of ACEIs/ARBs use and COVID-19 prognosis: a multistate modelling study of nationwide hospital surveillance data from Belgium.

OBJECTIVES: The widespread use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) by patients with chronic conditions raised early concerns on the potential exacerbation of COVID-19 severity and fatality. Previous studies addressing this question have used standard methods that may lead to biased estimates when analysing hospital data because of the presence of competing events and event-related dependency. We investigated the association of ACEIs/ARBs' use with COVID-19 disease outcomes using time-to-event data in a multistate setting to account for competing events and minimise bias. SETTING: Nationwide surveillance data from 119 Belgian hospitals. PARTICIPANTS: Medical records of 10 866 patients hospitalised from 14 March 2020to 14 June 2020 with a confirmed SARS-CoV-19 infection and information about ACEIs/ARBs' use. PRIMARY OUTCOME MEASURE: Multistate, multivariate Cox-Markov models were used to estimate the hazards of patients transitioning through health states from admission to discharge or death, along with transition probabilities calculated by combining the baseline cumulative hazard and regression coefficients. RESULTS: After accounting for potential confounders, there was no discernable association between ACEIs/ARBs' use and transfer to intensive care unit (ICU). Contrastingly, for patients without ICU transfer, ACEIs/ARBs' use was associated with a modest increase in recovery (HR 1.07, 95% CI 1.01 to 1.13, p=0.027) and reduction in fatality (HR 0.83, 95% CI 0.75 to 0.93, p=0.001) transitions. For patients transferred to ICU admission, no evidence of an association between ACEIs/ARBs' use and recovery (HR 1.16, 95% CI 0.97 to 1.38, p=0.098) or in-hospital death (HR 0.91, 95% CI 0.73 to 1.12, p=0.381) was observed. Male gender and older age were significantly associated with higher risk of ICU admission or death. Chronic cardiometabolic comorbidities were also associated with less recovery. CONCLUSIONS: For the first time, a multistate model was used to address magnitude and direction of the association of ACEIs/ARBs' use on COVID-19 progression. By minimising bias, this study provided a robust indication of a protective, although modest, association with recovery and survival.

Evaluation of the Food Choice Motives before and during the COVID-19 Pandemic: A Cross-Sectional Study of 1232 Adults from Croatia.

The coronavirus disease 2019 pandemic brought changes to almost every segment of our lives, including dietary habits. We present one among several studies, and the first on the Croatian population, aiming at investigating changes of food choice motives before and during the pandemic. The study was performed in June 2021 as an online-based survey, using a 36-item Food Choice Questionnaire applied for both the periods before and during the pandemic. The final sample consisted of 1232 adults living in Croatia. Sensory appeal was ranked as the number one most important food choice motive before, whereas health was ranked as the number one most important food choice motive during the pandemic. Ethical concern was reported as the least important food choice motive both before and during the pandemic. In women, natural content (p = 0.002), health, convenience, price, weight control, familiarity, and ethical concern (all p < 0.001) became more important during the pandemic, while price (p = 0.009), weight control, familiarity, and ethical concern (all p < 0.001) became more relevant for men. All together, these can be considered favorable changes toward optimal diets and may result in beneficial influences on health and lifestyle. Education strategies and efficiently tackling misinformation are prerequisites for informed food choice, which will ensure long-lasting positive effects of such changes.