Cost-effectiveness and return on investment of school-based health promotion programmes for chronic disease prevention.

BACKGROUND: While school-based health prevention programmes are effective in addressing unhealthy diet and physical inactivity, little is known about their economic implications. We conducted an economic evaluation of the programmes that were previously identified as feasible, acceptable, and sustainable in the Canadian context. METHODS: This study builds on a meta-analysis of the effectiveness of feasible, acceptable, and sustainable school-based health promotion programmes. A micro-simulation model incorporated intervention effects on multiple risk factors to estimate incremental cost-effectiveness and return on investment (ROI) of comprehensive school health (CSH), multicomponent, and physical education (PE) curriculum modification programmes. Cost-effectiveness was expressed as the programme costs below which the programme would be cost-effective at a CA$50 000 threshold level. RESULTS: The estimated costs below which interventions were cost-effective per quality-adjusted life year gained were CA$682, CA$444, and CA$416 per student for CSH, multicomponent, and PE curriculum modification programmes, respectively. CSH programmes remained cost-effective per year of chronic disease prevented for costs of up to CA$3384 per student, compared to CA$1911 and CA$1987 for multicomponent and PE curriculum modification interventions, respectively. If the interventions were implemented at total discounted intervention costs of CA$100 per student, ROI through the avoidance of direct healthcare costs related to the treatment and management of chronic diseases would be 824% for CSH, 465% for multicomponent interventions, and 484% for PE curriculum modification interventions. CONCLUSIONS: Whereas each examined intervention types showed favourable economic benefits, CSH programmes appeared to be the most cost-effective and to have the highest ROI.

Adherence to Life-Style Recommendations and Attention-Deficit/Hyperactivity Disorder: A Population-Based Study of Children Aged 10 to 11 Years.

OBJECTIVE: The incidence of attention-deficit/hyperactivity disorder (ADHD) among children and youth is high, and temporal increases have been paralleled by deteriorating life-styles. Poor diet quality, physical inactivity, poor sleep habits, and sedentary behaviors have all been associated with ADHD. However, no earlier prospective study has examined the independent and combined importance of meeting established life-style recommendations in childhood for ADHD in adolescence. We examined the associations of adherence to life-style recommendations with the incidence of ADHD and the utilization of health services associated with ADHD. METHODS: Life-style survey among 10- and 11-year-old students (N = 3436) was linked to administrative health data. Associations between adherence to nine established life-style recommendations with ADHD diagnosis and number of physician visits for ADHD until age 14 years were examined using Cox proportional hazard and negative binomial regression. RESULTS: Before age 14 years, 10.8% of students received an ADHD diagnosis. Meeting recommendations for vegetables and fruit, meat and alternatives, saturated fat, added sugar, and physical activity was associated with fewer ADHD diagnoses. Compared with children who met one to three recommendations, meeting seven to nine recommendations was associated with substantially lower incidence of ADHD and fewer physician visits related to ADHD (hazard ratio = 0.42 [95% confidence interval = 0.28-0.61]; rate ratio = 0.38 [95% confidence interval = 0.22-0.65]). CONCLUSIONS: Life-style recommendations exist to benefit development and physical health. Their promotion comes at no harm and may have benefits for ADHD. Experimental evidence is needed to clarify the potential bidirectional relationship between ADHD and adverse health behaviors.

Exposure to HIV risks among young people who use drugs (YPUD) in three cities in Vietnam: time to develop targeted interventions.

INTRODUCTION: The aim of this study is to identify the profiles of young people who use drugs (YPUD) and their exposure to HIV risks in the 3 main cities of Vietnam, Haiphong, Hanoi, and Ho Chi Minh City (HCMC), in order to design a community-based intervention to prevent HIV. METHODS: A survey using respondent-driven sampling (RDS) was conducted among YPUD aged 16-24. Participants were eligible if they reported drug use, confirmed by a urine test. After obtaining informed consent, they were screened for HIV/HCV and assessed using face-to-face questionnaires and self-report. A cluster analysis was conducted, taking into account risk behaviors and confirmed HIV-positive status. RESULTS: Seven hundred and three YPUD aged 16-24 were recruited between October 2016 and February 2017, 584 of whom were included in the final analysis. Median age was 21 (17.7, 23.0); 79% were male, 18% female, and 2% transgender. Methamphetamines use was reported by 77%, followed by cannabis (51%) and heroin (17%); polydrug use was common; 15% had "ever" injected drugs. HIV prevalence was 7%. Among all participants, 48% reported non-consistent condom use and 1% reported needle/syringe sharing during the previous month. Four distinct profiles of HIV risk behaviors were identified: The high multiple-risk group mixed unsafe drug use with unsafe sexual practices and had higher prevalence of HIV; the second group practiced high-risk sex with non-consistent condom combined with methamphetamine use; the third group was a moderate-risk group with limited unsafe sexual practices; and the fourth was considered at "low-risk" as reportedly, most never had sex and never injected. The highest risk group included more female YPUD, living in HCMC, who used heroin and had unsafe sex with their regular partners. The second high-risk group included most of the MSM and all transgender people and frequently reported mental health disorders. CONCLUSIONS: The profiles of YPUD who are at risk of HIV vary according to age, location, and population group. Injecting YPUD are the most exposed to risk and need immediate attention. Sexual exposure to HIV is very common. Mental health is a major concern. Interventions need to be integrated in a differentiated but holistic approach.

Economic Burden of Not Complying with Canadian Food Recommendations in 2018.

Poor diet has been identified as a major cause of chronic disease. In this study we estimated the 2018 economic burden of chronic disease attributable to not complying with Canadian food recommendations. We retrieved the chronic disease risk estimates for intakes of both protective (fruit, vegetables, milk, whole grains, nuts and seeds) and harmful foods (sugar-sweetened beverages, processed meat, red meat) from the Global Burden of Disease Study, and food intakes from the 2015 Canadian Community Health Survey 24-hour dietary recalls (n = 19,797). Population attributable fractions (PAFs) were calculated for all food-chronic disease combinations, and mathematically adjusted to estimate the 2018 annual direct (hospital, physician, drug) and indirect (human capital approach) economic burden for each disease. Not meeting the eight food recommendations was estimated to be responsible for CAD$15.8 billion/year in direct (CAD$5.9 billion) and indirect (CAD$9.9 billion) costs. The economic burden of Canadians under-consuming healthful foods exceeded the burden of overconsumption of harmful foods (CAD$12.5 billion vs. CAD$3.3 billion). Our findings suggest poor diet represents a substantial economic burden in Canada. Interventions may be more effective if they are wide in focus and promote decreased consumption of harmful foods alongside increased consumption of healthful foods, with emphasis on whole grains and nuts and seeds.

Lifestyle Behavior and Mental Health in Early Adolescence.

BACKGROUND AND OBJECTIVES: Mental illnesses affect >15% of Canadian adolescents. New preventive strategies are critically needed. We examined the associations of meeting established recommendations for diet, physical activity, sleep, and sedentary behavior in childhood with mental illness in adolescence. METHODS: Population-based prospective study (n = 3436) linking 2011 health behavior survey data of 10- to 11-year-olds with administrative health data from 2011 to 2014. Lifestyle behaviors were measured with the Harvard Food Frequency Questionnaire and self- and parental-proxy reports, expressed as meeting recommendations for vegetables and fruit, grain products, milk and alternatives, meat and alternatives, added sugar, saturated fat, sleep, screen time, and physical activity. Mental illness was defined by physician-diagnosed internalizing, externalizing, and other psychiatric conditions. Negative binomial regression was used to determine the independent and cumulative associations of meeting lifestyle recommendations with physician visits for mental illnesses. RESULTS: Of all participants, 12%, 67%, and 21% met 1 to 3, 4 to 6, and 7 to 9 recommendations, respectively, and 15% had a mental illness diagnosis during follow-up. Compared with meeting 1 to 3 recommendations, meeting 7 to 9 recommendations was associated with 56% (95% confidence interval: 38%-69%) fewer physician visits for mental illness during follow-up. Every additional recommendation met was associated with 15% fewer physician visits for mental illnesses (95% confidence interval: 9%-21%). CONCLUSIONS: Mental illness in adolescence is associated with compliance to lifestyle recommendations in childhood, with stronger associations seen when more recommendations are met. Emphasizing lifestyle recommendations in pediatric practice may reduce the future burden of mental illness.

The Effect of Serum 25-Hydroxyvitamin D on Serum Ferritin Concentrations: A Longitudinal Study of Participants of a Preventive Health Program.

Various studies have suggested a role of vitamin D in inflammation. However, its effect on ferritin, a biomarker of inflammation, has received relatively little attention. Therefore, we aimed to assess the association of serum 25-hydroxyvitamin D (25(OH)D) with serum ferritin (SF) concentrations, and to examine whether temporal increases in serum 25(OH)D concentrations are paralleled by a reduction in SF concentrations. Data from a community sample of Canadian adults who participated in a preventive health program (n = 6812) were analyzed. During the follow-up, serum 25(OH)D concentrations increased from 80.7 to 115.0 nmol/L whereas SF concentrations decreased from 122.0 to 92.0 µg/L (median follow-up time was 11.67 months). Cross-sectional analyses revealed that compared to participants with 25(OH)D concentrations of <50 nmol/L, those with 25(OH)D concentrations of 75 to <100, 100 to <125, and ≥125 nmol/L had SF concentrations that were 13.00, 23.15, and 27.59 µg/L lower respectively (p < 0.001). Compared to those without temporal improvements in 25(OH)D concentrations between baseline and follow-up, participants who improved their 25(OH)D concentrations with ≥50 nmol/L decreased their SF concentrations with 5.71 µg/L. For participants for whom the increase in 25(OH)D concentrations was less than 50 nmol/L, decreases in SF concentrations were less pronounced and not statistically significant. These observations suggest that despite strong associations between 25(OH)D and SF concentrations, interventions aiming to lower SF concentrations through sun-exposure and vitamin D supplementation should target substantial increases in 25(OH)D concentrations.

The association of serum 25-hydroxyvitamin D concentrations with elevated serum ferritin levels in normal weight, overweight and obese Canadians.

In light of the growing body of literature suggesting a beneficial effect of vitamin D on inflammatory response, we hypothesized that vitamin D affects serum ferritin (SF), a biomarker of inflammation. The objective of the present study is to examine the association of serum 25-hydroxyvitamin D [25(OH)D] with elevated SF concentrations indicative of inflammation as no earlier study has done so. Data from 5550 Canadian adults who participated in the 2012/2013 and the 2014/2015 Canadian Health Measures Surveys were analysed. We observed that 9.4% of Canadian adults have elevated SF concentrations and that 35.6% were vitamin D insufficient. Among Canadians with under/normal body weights, those with serum 25(OH)D ≥ 75 nmol/L relative to those with serum 25(OH)D < 50 nmol/L, were substantially less at risk for elevated SF concentrations (OR = 0.24; 95% CI = 0.06, 0.89; p = 0.034). We did not observe this association for overweight and obese Canadians. Canadians of older age, non-white ethnicity, males, those with income above $100,000, those who consumed alcohol, and those with high total cholesterol concentrations and elevated blood pressures were more likely to have elevated SF concentrations. Serum 25(OH)D ≥ 75 nmol/L is likely to provoke anti-inflammatory benefits, but intervention studies that achieve high 25(OH)D concentrations and with long follow up are needed to establish the role of vitamin D on SF.

The combined impact of diet, physical activity, sleep and screen time on academic achievement: a prospective study of elementary school students in Nova Scotia, Canada.

BACKGROUND: Few studies have investigated the independent associations of lifestyle behaviors (diet, physical activity, sleep, and screen time) and body weight status with academic achievement. Even fewer have investigated the combined effect of these behaviors on academic achievement. We hypothesize that the combined effect of these behaviors will have a higher impact on academic achievement than any behavior alone, or that of body weight status. METHODS: In 2011, 4253 grade 5 (10-11 years old) students and their parents were surveyed about the child's diet, physical activity, screen time and sleep. Students' heights and weights were measured by research assistants. Academic achievement was measured using provincial standardized exams in mathematics, reading and writing, and was expressed as 'meeting' or 'not meeting' expectations as per standardized criterion. Exams were written 1 year following the measurement of lifestyle behaviors. Lifestyle behaviors were measured with self- and parental proxy reports and expressed as meeting recommendations (yes/no) for each behavior. Mixed effects logistic regression models adjusting for demographic confounders and caloric intake were used to determine the independent and combined associations. RESULTS: Meeting dietary recommendations was associated with increased likelihood of meeting academic expectations for each of math, reading and writing. Meeting recommendations for screen time and sleep was associated with meeting expectations for writing. For all three subjects, meeting additional lifestyle behavior recommendations was associated with higher likelihood of meeting expectations. Children who met 7-9 lifestyle behavior recommendations had greater than three-times the odds of meeting expectations for reading compared to those who met 0-3 recommendations (OR: 3.07, 95% CI: 2.09, 4.51), and 1.47 and 2.77 times the odds of meeting expectations in mathematics and writing, respectively. Body weight status was not associated with academic achievement. CONCLUSIONS: We found that lifestyle behaviors, not body weight status, are strongly associated with student academic performance. Promoting compliance with established healthy lifestyle recommendations could improve both the health and educational outcomes of school-aged children. School-based health promotion initiatives that target multiple lifestyle behaviors may have a greater effect on academic achievement than those that focus on a single behavior.

Vitamin D deficiency and sufficiency among Canadian children residing at high latitude following the revision of the RDA of vitamin D intake in 2010.

Recently, countries at high latitudes have updated their vitamin D recommendations to ensure adequate intake for the musculoskeletal health of their respective populations. In 2010, the dietary guidelines for vitamin D for Canadians and Americans aged 1­70 years increased from 5 µg/d to 15 µg/d, whereas in 2016 for citizens of the UK aged ≥4 years 10 µg/d is recommended. The vitamin D status of Canadian children following the revised dietary guidelines is unknown. Therefore, this study aimed to assess the prevalence and determinants of vitamin D deficiency and sufficiency among Canadian children. For this study, we assumed serum 25-hydroxy vitamin D (25(OH)D) concentrations <30 nmol/l as 'deficient' and ≥50 nmol/l as 'sufficient'. Data from children aged 3­18 years (n 2270) who participated in the 2012/2013 Canadian Health Measures Survey were analysed. Of all children, 5·6% were vitamin D deficient and 71% were vitamin D sufficient. Children who consumed vitamin D-fortified milk daily (77 %) were more likely to be sufficient than those who consumed it less frequently (OR 2·4; 95% CI 1·7, 3·3). The 9% of children who reported taking vitamin D-containing supplements in the previous month had higher 25(OH)D concentrations (ß 5·9 nmol/l; 95% CI 1·3, 12·1 nmol/l) relative to those who did not. Children who were older, obese, of non-white ethnicity and from low-income households were less likely to be vitamin D sufficient. To improve vitamin D status, consumption of vitamin D-rich foods should be promoted, and fortification of more food items or formal recommendations for vitamin D supplementation should be considered.

Is it nutrients, food items, diet quality or eating behaviours that are responsible for the association of children's diet with sleep?

Both diet quality and sleep duration of children have declined in the past decades. Several studies have suggested that diet and sleep are associated; however, it is not established which aspects of the diet are responsible for this association. Is it nutrients, food items, diet quality or eating behaviours? We surveyed 2261 grade 5 children on their dietary intake and eating behaviours, and their parents on their sleep duration and sleep quality. We performed factor analysis to identify and quantify the essential factors among 57 nutrients, 132 food items and 19 eating behaviours. We considered these essential factors along with a diet quality score in multivariate regression analyses to assess their independent associations with sleep. Nutrients, food items and diet quality did not exhibit independent associations with sleep, whereas two groupings of eating behaviours did. 'Unhealthy eating habits and environments' was independently associated with sleep. For each standard deviation increase in their factor score, children had 6 min less sleep and were 12% less likely to have sleep of good quality. 'Snacking between meals and after supper' was independently associated with sleep quality. For each standard deviation increase in its factor score, children were 7% less likely to have good quality sleep. This study demonstrates that eating behaviours are responsible for the associations of diet with sleep among children. Health promotion programmes aiming to improve sleep should therefore focus on discouraging eating behaviours such as eating alone or in front of the TV, and snacking between meals and after supper.

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts.

BACKGROUND: The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce. METHODS: The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline. RESULTS: A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive. CONCLUSIONS: HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.

The effect of opportunistic illness on HIV RNA viral load and CD4+ T cell count among HIV-positive adults taking antiretroviral therapy.

INTRODUCTION: HIV RNA viral load (VL) has been shown to increase during opportunistic illnesses (OIs), suggesting active HIV replication in response to infection among patients not taking antiretroviral therapy (ART). We assessed the effects of OIs on HIV RNA VL and CD4+ T cell counts among patients on ART with initially suppressed VL. METHODS: Between 2003 and 2007, we enrolled and followed 1094 HIV-1-infected adults who initiated ART and had quarterly blood draws for VL and CD4+ T cell count. In VL/CD4+ T cell measurement intervals following undetectable VL, we compared the elevation in VL to detectable levels and CD4+ T cell count changes between intervals when participants had episodes of OIs and intervals when they did not have OIs. RESULTS: VL was more likely to be detectable if participants had OIs in the prior three months compared to when they did not (OR=4.0 (95% CI=1.9-8.6)). The CD4+ T cell counts declined 24.1 cells/µL per three months in intervals where the participants had OIs compared to an increase of 21.3 cells/µL per three months in intervals where they did not have OIs (adjusted difference in the rate of CD4+ T cell count change of 61.7 cells/µL per three months (95% CI=13.7-109.7), P value=0.012). The rate of CD4+ T cell count increase was 25.6 cells/µL per three months (95% CI=11.6-39.6) higher for females compared to males (p value=<0.001), 1.4 cells/µL per three months lower per one year increase in age (p value=0.046) and 4 cells/µL per three months lower per 10 cells/µL increase in the starting CD4+ T cell count value (p value=<0.001). CONCLUSION: Episodes of opportunistic infections among patients taking ART with undetectable VL were associated with elevation of HIV RNA VL to detectable levels and decline in CD4+ T cell counts. CLINICAL TRIAL NUMBER: NCT00119093.

Utility of routine viral load, CD4 cell count, and clinical monitoring among adults with HIV receiving antiretroviral therapy in Uganda: randomised trial.

OBJECTIVE: To evaluate the use of routine laboratory monitoring in terms of clinical outcomes among patients receiving antiretroviral therapy (ART) in Uganda. DESIGN: Randomised clinical trial SETTING: A home based ART programme in rural Uganda. PARTICIPANTS: All participants were people with HIV who were members of the AIDS Support Organisation. Participants had CD4 cell counts <250 cells × 10(6)/L or World Health Organization stage 3 or 4 disease. INTERVENTIONS: Participants were randomised to one of three different monitoring arms: a viral load arm (clinical monitoring, quarterly CD4 counts, and viral load measurements), CD4 arm (clinical monitoring and CD4 counts), or clinical arm (clinical monitoring alone). MAIN OUTCOME MEASURES: Serious morbidity (newly diagnosed AIDS defining illness) and mortality. RESULTS: 1094 participants started ART; median CD4 count at baseline was 129 cells × 10(6)/L. Median follow-up was three years. In total, 126 participants died (12%), 148 (14%) experienced new AIDS defining illnesses, and 61(6%) experienced virological failure, defined as two consecutive viral loads >500 copies/mL occurring more than three months after the start of ART. After adjustment for age, sex, baseline CD4 count, viral load, and body mass index, the rate of new AIDS defining events or death was higher in the clinical arm than the viral load arm (adjusted hazard ratio 1.83, P = 0.002) or the CD4 arm (1.49, P = 0.032). There was no significant difference between the CD4 arm and the viral load arm (1.23, P = 0.31). CONCLUSION: In patients receiving ART for HIV infection in Uganda, routine laboratory monitoring is associated with improved health and survival compared with clinical monitoring alone. Trial registration Clinical Trials NCT00119093.

Father absence, body mass index, and pubertal timing in girls: differential effects by family income and ethnicity.

PURPOSE: Numerous studies show associations between father absence and girls' early puberty. However, most research has been retrospective, focused on menarche, and failed to consider body mass index (BMI), ethnicity, and income in the analyses. This study resolves these scientific gaps. METHODS: This was a prospective study of 444 girls aged 6-8 years and their caregivers (96% mothers). Data were collected annually in clinic, including weight, height, and Tanner stage for breast and pubic hair. Caregivers reported on father absence and demographics. This report focuses on the assessment of father absence at baseline and 2 years of follow-up for pubertal outcomes. Cox proportional hazards regression models were used to test whether father absence at baseline predicted pubertal onset by follow-up visit 2. BMI was assumed to be in the causal pathway. Differences by ethnicity and income were examined. RESULTS: Income and ethnicity moderated associations between father absence and pubertal onset when adjusting for BMI. Father absence predicted earlier onset of breast development only in higher-income families and onset of pubic hair development only in higher-income African Americans families. BMI was not related to father absence and therefore was not in the causal pathway. CONCLUSION: Among girls from higher-income families, father absence was linked to earlier puberty. This was particularly true for African Americans in terms of pubic hair development. These effects are not explained by body weight. Future research is needed to identify social and biophysiological mechanisms through which father absence, ethnicity, and income affect the pubertal onset.