How effective and efficient are different exercise patterns in reducing back pain?

BACKGROUND: Exercise is considered an effective intervention to relieve chronic back pain. However, it is still unknown whether specific exercise patterns vary in terms of their efficiency and effectiveness. AIM: To investigate the differential health and economic effects of intensity, specificity and degree of subjective perceived physical exertion across five exercise patterns (endurance, gymnastics, fitness, back gymnastics, multimodal back exercise) in adults with back pain. DESIGN: Longitudinal observational cohort study over a period of 24 months. SETTING: Various non-therapeutic exercise facilities (e.g. outdoor, fitness centers, health insurance programs, sports clubs) across one federal state of Germany (Baden-Wuerttemberg). POPULATION: Adults with back pain (N.=2,542, Mean =46.9 years, 66% females, graded chronic back pain [GCPS] 1=40.5%, GCPS 2=27.3%, GCPS 3=20.7%, GCPS 4=11.5%). METHODS: Self-reported back pain (functional restrictions and pain = back pain function score, [BPFS]) and characteristics of exercising behavior (frequency, duration, type, physical exertion) were assessed at baseline and at 6, 12, 18 and 24 months. Direct medical costs for back disorders (international classification of diseases, dorsopathies: M40-M54) were compiled from health insurance records. RESULTS: Moderate- to high-intensity exercise patterns were effective in reducing back pain, particularly at lower levels of subjective perceived physical exertion. At these intensity levels, multimodal back exercise (i.e. exercising the spine-stabilizing muscles specifically, ergonomic training) was 14.5 times more effective than non-back specific fitness exercise in reducing BPFS. The beneficial effects of both exercise types increased with the initial severity of back pain. However, only multimodal back exercise (moderate- to high-intensity/high back specificity) was associated with a significant decrease in direct medical costs for back pain. CONCLUSIONS: Targeted exercise of the spine-stabilizing musculature at moderate to high intensities without maximum perceived exertion is effective and efficient in reducing back pain. CLINICAL REHABILITATION IMPACT: The combination of high-intensity and high-specificity exercises yielded a significant reduction in medical costs. However, the intensities in terms of muscular load in endurance training and gymnastics may not be sufficient to reduce back pain effectively.

Taxation of unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes.

BACKGROUND: Global prevalence of overweight and obesity are alarming. For tackling this public health problem, preventive public health and policy actions are urgently needed. Some countries implemented food taxes in the past and some were subsequently abolished. Some countries, such as Norway, Hungary, Denmark, Bermuda, Dominica, St. Vincent and the Grenadines, and the Navajo Nation (USA), specifically implemented taxes on unprocessed sugar and sugar-added foods. These taxes on unprocessed sugar and sugar-added foods are fiscal policy interventions, implemented to decrease their consumption and in turn reduce adverse health-related, economic and social effects associated with these food products. OBJECTIVES: To assess the effects of taxation of unprocessed sugar or sugar-added foods in the general population on the consumption of unprocessed sugar or sugar-added foods, the prevalence and incidence of overweight and obesity, and the prevalence and incidence of other diet-related health outcomes. SEARCH METHODS: We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase and 15 other databases and trials registers on 12 September 2019. We handsearched the reference list of all records of included studies, searched websites of international organisations and institutions, and contacted review advisory group members to identify planned, ongoing or unpublished studies. SELECTION CRITERIA: We included studies with the following populations: children (0 to 17 years) and adults (18 years or older) from any country and setting. Exclusion applied to studies with specific subgroups, such as people with any disease who were overweight or obese as a side-effect of the disease. The review included studies with taxes on or artificial increases of selling prices for unprocessed sugar or food products that contain added sugar (e.g. sweets, ice cream, confectionery, and bakery products), or both, as intervention, regardless of the taxation level or price increase. In line with Cochrane Effective Practice and Organisation of Care (EPOC) criteria, we included randomised controlled trials (RCTs), cluster-randomised controlled trials (cRCTs), non-randomised controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series (ITS) studies. We included controlled studies with more than one intervention or control site and ITS studies with a clearly defined intervention time and at least three data points before and three after the intervention. Our primary outcomes were consumption of unprocessed sugar or sugar-added foods, energy intake, overweight, and obesity. Our secondary outcomes were substitution and diet, expenditure, demand, and other health outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all eligible records for inclusion, assessed the risk of bias, and performed data extraction.Two review authors independently assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We retrieved a total of 24,454 records. After deduplicating records, 18,767 records remained for title and abstract screening. Of 11 potentially relevant studies, we included one ITS study with 40,210 household-level observations from the Hungarian Household Budget and Living Conditions Survey. The baseline ranged from January 2008 to August 2011, the intervention was implemented on September 2011, and follow-up was until December 2012 (16 months). The intervention was a tax - the so-called 'Hungarian public health product tax' - on sugar-added foods, including selected foods exceeding a specific sugar threshold value. The intervention includes co-interventions: the taxation of sugar-sweetened beverages (SSBs) and of foods high in salt or caffeine. The study provides evidence on the effect of taxing foods exceeding a specific sugar threshold value on the consumption of sugar-added foods. After implementation of the Hungarian public health product tax, the mean consumption of taxed sugar-added foods (measured in units of kg) decreased by 4.0% (standardised mean difference (SMD) -0.040, 95% confidence interval (CI) -0.07 to -0.01; very low-certainty evidence). The study was at low risk of bias in terms of performance bias, detection bias and reporting bias, with the shape of effect pre-specified and the intervention unlikely to have any effect on data collection. The study was at unclear risk of attrition bias and at high risk in terms of other bias and the independence of the intervention. We rated the certainty of the evidence as very low for the primary and secondary outcomes. The Hungarian public health product tax included a tax on sugar-added foods but did not include a tax on unprocessed sugar. We did not find eligible studies reporting on the taxation of unprocessed sugar. No studies reported on the primary outcomes of consumption of unprocessed sugar, energy intake, overweight, and obesity. No studies reported on the secondary outcomes of substitution and diet, demand, and other health outcomes. No studies reported on differential effects across population subgroups. We could not perform meta-analyses or pool study results. AUTHORS' CONCLUSIONS: There was very limited evidence and the certainty of the evidence was very low. Despite the reported reduction in consumption of taxed sugar-added foods, we are uncertain whether taxing unprocessed sugar or sugar-added foods has an effect on reducing their consumption and preventing obesity or other adverse health outcomes. Further robustly conducted studies are required to draw concrete conclusions on the effectiveness of taxing unprocessed sugar or sugar-added foods for reducing their consumption and preventing obesity or other adverse health outcomes.

Cost-effectiveness of a mindfulness-based mental health promotion program: economic evaluation of a nonrandomized controlled trial with propensity score matching.

BACKGROUND: Mental health promotion programs have been shown to reduce the burden associated with mental distress and prevent the onset of mental disorders, but evidence of cost-effectiveness is scarce. OBJECTIVE: To evaluate the cost-effectiveness of a mindfulness-based mental health prevention program provided by health coaches in a multi-site field setting in Germany. METHODS: The single-study based economic evaluation was conducted as part of a nonrandomized controlled trial, comparing the effects of a group-based prevention program to usual care based on propensity score matching. Participants (N = 1166) were recruited via a large statutory health insurance fund. Health outcome was assessed with the Hospital Anxiety and Depression Scale (HADS). Cost outcomes were actually incurred costs compiled from the health insurance' records. Incremental cost-effectiveness ratios (ICER) were analyzed from a societal and a health care perspective for a 12-month time horizon with sampling uncertainty being handled using nonparametric bootstrapping. A cost-effectiveness acceptability curve was graphed to determine the probability of cost-effectiveness at different willingness-to-pay ceiling ratios. RESULTS: From a societal perspective, prevention was cost-effective compared to usual-care by providing larger effects of 1.97 units on the HADS (95% CI [1.14, 2.81], p < 0.001) at lower mean incremental total costs of €-57 (95% CI [- 634, 480], p = 0.84), yielding an ICER of €-29 (savings) per unit improvement. From a health care perspective, the incremental health benefits were achieved at additional direct costs of €181 for prevention participants (95% CI [40, 318], p = 0.01) with an ICER of €91 per unit improvement on the HADS. Willingness-to-pay for the prevention program to achieve a 95% probability of being cost-effective compared to usual-care, was estimated at €225 per unit improvement on the HADS score from a societal, and €191 from a health care perspective respectively. Sensitivity analyses suggested differential cost-effect-ratios depending on the initial distress of participants. LIMITATIONS: Due to the complexity of the field trial, it was not feasible to randomize participants and offer an active control condition. This limitation was met by applying a rigorous matching procedure. CONCLUSIONS: Our results indicate that universal mental health promotion programs in community settings might be a cost-effective strategy to enhance well-being. Differences between the societal and health care perspective underline the call for joint funding in the dissemination of preventive services. TRIAL REGISTRATION: German Clinical Trials Registration ID: DRKS00006216 (2014/06/11, retrospective registration).

Prenatal Alcohol Exposure and the Associated Risk of Elevated Blood Pressure: A Cross-sectional Analysis of 3- to 17-Year-Olds in Germany.

BACKGROUND: As the prevalence of obesity and high blood pressure increases among the population, early action is needed to reduce blood pressure. Certain lifestyles during pregnancy have negative effects resulting in high blood pressure for children and adolescents. Using data from the "German Health Interview and Examination Survey for Children and Adolescents" (KiGGS), this study analyzed: (i) the association between low-to-moderate prenatal alcohol exposure (PAE) and the risk of increased systolic and diastolic blood pressure and (ii) whether associations were modified by socioeconomic status (SES), prenatal smoke exposure (PSE), and body mass index (BMI) of the children and adolescents. METHODS: We applied multivariate logistic regression analyses and stratified analyses by SES, PSE, and BMI with cross-sectional data from the KiGGS study (N = 14,253) to examine the association between PAE and prehypertension or hypertension in 3- to 17-year-olds. RESULTS: Of the surveyed children and adolescents, 13.7% had a systolic prehypertension and 11.5% had a diastolic prehypertension. A further 7.5% were identified as having systolic hypertension and 6.0% diastolic hypertension. In the regression analyses, PAE resulted in a decreased risk of systolic prehypertension (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.70, 0.99) and diastolic prehypertension (OR: 0.82, 95% CI: 0.68, 0.98). Risk reductions were not significant in surveyed children and adolescents with hypertension. Interactions between PAE and SES, PSE, and offspring BMI were not significant. CONCLUSIONS: Contrary to our initial hypothesis, PAE reduces the risk of prehypertension. Animal studies suggest that vasodilation is induced by nitric oxide in small quantities of PAE.

Therapeutic and economic effects of multimodal back exercise: A controlled multicentre study.

To compare the cost-effectiveness of a multimodal back exercise programme for non-specific back pain with that of standard treatment. Medical costs were measured in euros (EUR) and effectiveness was measured using Graded Chronic Pain Status (GCPS). A controlled multicentre study (39 sites) with a 6-month intervention phase and follow-up at 6, 12 and 18 months. The study included 1,829 participants in an intervention group and 495 individuals in a control group. The multimodal back exercise programme comprises 36 exercise sessions for optimizing the spine stabilizing muscles and everyday motor func-tions. The patients were given a home training programme at the end of the intervention programme. The back exercise programme resulted in a significant reduction, of 0.4, in back pain grade on the GCPS after 2 years, compared with standard treat-ment, and reduced medical costs by 763 EUR. The exercise programme was therapeutically effective for GCPS back pain grades 1-4 and produced cost savings in the case of grade 4 GCPS. The multimodal back exercise programme was therapeutically effective for back pain (grades 1-2) and pain-related functional impairment (grades 3-4). It resulted in reduced costs for chronic back pain causing high pain-induced functional impairment (grade 4). The therapeutic and economic effects of the programme increase with the grade of back pain.

Changes in Sports Participation across Transition to Retirement: Modification by Migration Background and Acculturation Status.

While total physical activity decreases over the life course, sports and leisure-time physical activity (LTPA) have shown to increase after transition to retirement. This paper aimed to investigate whether this change in sports participation differs (1) between non-migrant persons (NMP) versus persons with a migrant background (PMB), and (2) by acculturation status. Data was drawn from 16 waves of the German Socio-Economic Panel Study (SOEP) including 2664 NMP and 569 PMB. PMB were grouped according to acculturation status (integrated, assimilated, marginalised, separated), assessed regarding three dimensions (language, social interaction and identification). We applied multilevel logistic regression models, adjusting for sex, retirement age, socioeconomic status, health status and body mass index. Our results show that (1) transition to retirement led to an increase in the sports participation of NMP during the first 5 years and the subsequent 5 years after retirement. Changes in sports participation were modified by migration status: In PMB sports participation increased to a lesser extent than in NMP. (2) While sports participation of integrated PMB was not significantly different from NMP in the preretirement phase, sports participation among integrated PMB increased less after retirement compared with NMP. Marginalized and assimilated PMB did not show consistent sports participation patterns before retirement, but seemingly increased their sports participation less than NMP over the retirement transition. Separated PMB had particularly low levels of sports participation. Considering that LTPA is a key factor for healthy ageing, the increasing gap in levels of sports participation after transition to retirement indicates the need for interventions targeting physical activity of the older migrant population.

The effects of iodine blocking following nuclear accidents on thyroid cancer, hypothyroidism, and benign thyroid nodules: design of a systematic review.

BACKGROUND: One of the most efficient radiation protection methods to reduce the risk of adverse health outcomes in case of accidental radioactive iodine release is the administration of potassium iodine (KI). Although KI administration is recommended by WHO's guidelines for iodine prophylaxis following nuclear accidents and is also widely implemented in most national guidelines, the scientific evidence for the guidelines lacks as the guidelines are mostly based on expert opinions and recommendations. Therefore, this study will provide evidence by systematically reviewing the effects of KI administration in case of accidental radioactive iodine release on thyroid cancer, hypothyroidism, and benign nodules. METHODS: We will apply standard systematic review methodology for the identification of eligible studies, data extraction, assessment of risk of biases, heterogeneity, and data synthesis. The electronic database search will be conducted in MEDLINE (via PubMed) and EMBASE, and covers three search blocks with terms related to the health condition, intervention, and occurrence/location. We have no date or language restrictions, but restrictions to humans only. We will include studies comparing the effects of KI administration on thyroid cancer, hypothyroidism, and benign thyroid nodules in a population exposed to radioactive iodine release. The quality of the studies will be graded. If feasible, a meta-analysis will be conducted. DISCUSSION: This proposed systematic review will update the existing WHO guideline from 1999. New evidence on the efficacy of KI administration to reduce thyroid cancer, hypothyroidism, and benign thyroid nodules in the event of an accidental release of radioactive iodine to the environment will provide the basis for an update of the WHO guideline for iodine prophylaxis following nuclear accidents. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015024340.

Anthropometric and health-related behavioral factors in the explanation of social inequalities in low birth weight in children with prenatal alcohol exposure.

There is evidence for social inequalities in the health status of children with prenatal alcohol exposure (PAE). This study aimed to describe social inequalities in low birth weight (LBW) in children/adolescents with PAE and to examine the contribution of anthropometric and health-related behavioral factors to the explanation of social inequalities. A total of 2,159 participants with parental self-reported moderate to regular PAE (enrolled in the cross-sectional German Health Interview and Examination Survey for Children and Adolescents) were examined. At similar levels of PAE, the risk of LBW was significantly increased in subjects with a low socioeconomic status (SES) (adjusted odds ratio (OR) 2.78, 95% confidence interval (CI) 1.59, 4.86) and middle SES (adjusted OR 2.04, 95% CI 1.28, 3.24). Maternal height, maternal body mass index (BMI) and smoking during pregnancy mediated the association. The mediating effect of maternal height was 12.5% to 33.7%. Maternal BMI explained 7.9% of the socioeconomic difference in LBW between the high and low SES groups in children with PAE. The mediating effect of smoking during pregnancy was 17.3% to 31.5%. Maternal height, maternal BMI and smoking during pregnancy together explained 24.4% to 60.1% of the socioeconomic differences in LBW in children with PAE. A large proportion of the socioeconomic differences in LBW in children with PAE can be attributed to anthropometric and health-related behavioral factors.

Educational differences in continuing or restarting drinking in early and late pregnancy: role of psychological and physical problems.

OBJECTIVE: Many women continue drinking alcohol during pregnancy. This study aimed to describe educational differences in continued drinking in early and late pregnancy and to examine the contribution of psychological and physical factors to the explanation of educational differences. METHOD: We examined 4,885 women enrolled in the Amsterdam Born Children and their Development study. Information on alcohol intake during pregnancy was based on self-reports at the 16th week of gestation and at 3 months postpartum. Only women who reported alcohol intake before pregnancy were included. Explanatory factors were alcohol intake before pregnancy, psychological problems, and physical problems. RESULTS: The risk of continued drinking in early pregnancy was increased in higher educated women (odds ratio [OR] = 1.41, 95% CI [1.25, 1.60]); in addition, in late pregnancy, higher educated women had an increased risk of restarting (OR = 1.67, 95% CI [1.37, 2.04]) and continuing drinking (OR = 1.77, 95% CI [1.36, 2.30]). The intensity of alcohol intake before pregnancy and all physical and psychological problems together explained 17.1% and 8.8% of the educational differences in continued drinking in early pregnancy, respectively. CONCLUSIONS: Higher educated women are more likely to continue drinking during pregnancy. The intensity of alcohol intake before pregnancy and physical and psychological problems contributed to the explanation of continued drinking. However, other factors may play a greater role, such as cultural factors and social norms.

Adolescents' use of alcohol, tobacco and illicit drugs in relation to prenatal alcohol exposure: modifications by gender and ethnicity.

AIMS: The study aimed to investigate (a) the association between low to moderate prenatal alcohol exposure (PAE) and the use of alcohol, tobacco and illicit drugs in adolescence and (b) whether the associations are modified by gender and ethnicity. METHODS: The subjects of the study were 5922 children and adolescents, aged from 11 to 17 years, enrolled in the cross-sectional German Health Interview and Examination Survey for Children and Adolescents (the KiGGS study). Information on PAE is based on parental self-report questionnaires. Use of alcohol, tobacco and illicit drugs was assessed through self-report questionnaires for adolescents. RESULTS: Low to moderate PAE was associated with an increased risk of drinking alcohol (adjusted odds ratio (OR) 1.73, 95% confidence interval (CI) 1.34, 2.18) and also of illicit drug use (adjusted OR 1.62, 95% CI 1.23, 2.14). The associations between PAE and the use of alcohol, tobacco and illicit drugs differed according to gender and ethnicity. Gender-stratified analyses resulted in adverse effects of PAE on drinking alcohol, smoking and illicit drug use in females; however, in German males, the associations disappeared. Stronger associations between PAE and the outcome measures were found in non-Germans. CONCLUSIONS: Our findings indicate that low to moderate levels of maternal alcohol intake during pregnancy are a risk factor for use of alcohol, tobacco and illicit drugs by the offspring, with stronger associations in females and non-Germans.

Preterm birth and small for gestational age in relation to alcohol consumption during pregnancy: stronger associations among vulnerable women? Results from two large Western-European studies.

BACKGROUND: Inconsistent data on the association between prenatal alcohol exposure and a range of pregnancy outcomes, such as preterm birth (PTB) and small for gestational age (SGA) raise new questions. This study aimed to assess whether the association between low-moderate prenatal alcohol exposure and PTB and SGA differs according to maternal education, maternal mental distress or maternal smoking. METHODS: The Amsterdam Born Children and their Development (ABCD) Study (N = 5,238) and the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) (N = 16,301) are both large studies. Women provide information on alcohol intake in early pregnancy, 3 months postpartum and up to 17 years retrospectively. Multivariate logistic regression analyses and stratified regression analyses were performed to examine the association between prenatal alcohol exposure and PTB and SGA, respectively. RESULTS: No association was found between any level of prenatal alcohol exposure (non-daily, daily, non-abstaining) and SGA. The offspring of daily drinkers and non-abstainers had a lower risk of PTB [ABCD: odds ratio (OR) 0.31, 95% confidence interval (CI) 0.13, 0.77; KiGGS: OR 0.75, 95% CI 0.57, 0.99]. Interactions with maternal education, maternal distress or maternal smoking were not significant. CONCLUSIONS: Although these results should be interpreted with caution, both studies showed no adverse effects of low-moderate prenatal alcohol exposure on PTB and SGA, not even in the offspring of women who were disadvantaged in terms of low education, high levels of distress, or smoking during pregnancy.