Addressing the global obesity burden: a gender-responsive approach to changing food environments is needed.

Obesity is a leading cause of death and disability globally. There is a higher proportion of women living with obesity than men, with differences in prevalence rates between women and men particularly staggering in low- and middle-income countries. The food environments that most people live in have been defined as 'obesogenic', characterised by easy access to energy dense, highly palatable foods with poor nutritional value. There is an established need to intervene to change food environments to prevent obesity. However, minimal successes are evident with no country set to meet the WHO goal of reducing obesity prevalence to 2010 numbers by 2025. In this review, we provide a narrative around the sex (biological)- and gender (sociocultural)-related considerations for the relationship between nutrition, interactions with the food environment and obesity risk. We provide an argument that there are gendered responses to food environments that place women at a higher risk of obesity particularly in relation to food industry influences, due to gendered roles and responsibilities in relation to paid and unpaid labour, and due to specific food security threats. This review concludes with hypotheses for addressing the obesity burden in a gender-responsive manner, with a call for gender equity to be a key component of the development, implementation and monitoring of obesity prevention focused policies going forward.

Retrospective cohort study of the association between socioeconomic deprivation and incidence of gestational diabetes and perinatal outcomes.

INTRODUCTION: Socioeconomic disparities have been shown to correlate with perinatal mortality and the incidence of type 2 diabetes. Few studies have explored the relationship between deprivation and the incidence of gestational diabetes (GDM). We aimed to identify the relationship between deprivation and incidence of GDM, after adjusting for age, BMI, and ethnicity. We also examined for relationships between deprivation and perinatal outcomes. METHODS: A retrospective cohort analysis of 23,490 pregnancies from a major National Health Service Trust in Northwest London was conducted. The 2019 English Indices of Multiple Deprivation was used to identify the deprivation rank and decile for each postcode. Birthweight centile was calculated from absolute birthweight after adjusting for ethnicity, maternal height, maternal weight, parity, sex and outcome (live birth/stillbirth). Logistic regression and Kendall's Tau were used to identify relationships between variables. RESULTS: After controlling for age, BMI & ethnicity, Index of Multiple Deprivation postcode decile was not associated with an increased risk of developing gestational diabetes. Each increase in decile of deprivation was associated with an increase in birthweight centile by 0.471 (p < 0.001). After adjusting for confounders, age was associated with a 7.1% increased GDM risk (OR: 1.076, p < 0.001); BMI increased risk by 5.81% (OR: 1.059, p < 0.001). There was no significant correlation between Index of Multiple Deprivation rank and perinatal outcomes. DISCUSSION: Our analysis demonstrates that socioeconomic deprivation was not associated with incidence of GDM or adverse perinatal outcomes. Factors such as genetic predisposition and lifestyle habits may likely play a larger role in the development of GDM compared to socioeconomic deprivation alone.

Attitudes and behaviours regarding e-cigarettes in people aged 15-30 years in the UK: a cross-sectional study.

BACKGROUND: The use of e-cigarettes has been rising in the UK, with 7·7% of people aged over 16 years currently vaping daily or occasionally. Young people aged 16-24 years have the highest proportion of vapers at 11·1%. Therefore, this study investigated behaviours, attitudes, and beliefs about e-cigarettes among people aged 15-30 year in the UK. METHODS: For this cross-sectional study, we administered an online survey to a representative sample of people aged 15-30 years in the UK (based on a web panel) between Oct 1, and Nov 30, 2021. Questions related to respondent demographics; use of vaping or smoking products; motivations, attitudes, and behaviours related to vaping; and exposure to e-cigarette advertising. Ever use was described as use even "just once or twice". We used multivariable logistic regression to identify factors associated with ever e-cigarette use. FINDINGS: 1009 participants responded to the survey (mean age 23 years, 520 [51·5%] women, 470 [46.6%] men) and were included in the study. 222 (22·3%) participants vaped at least monthly, with one in ten doing it daily. Current smokers were the most likely to use e-cigarettes (453, 44·9%), followed by previous smokers (288, 28·5%) and never smokers (23, 2·3%). Of the 222 participants vaping at least monthly, 199 (89·6%) had used e-cigarettes containing nicotine. The most common reasons for vaping were having friends who used e-cigarettes (103, 46·4%) and quitting or reducing smoking (89, 40·1%). Most participants agreed that e-cigarettes are addictive (698, 75·1%), help people quitting smoking (597, 64·2%), and are bad for health (584, 62·8%). Warning labels on e-cigarettes were seen by 611 (65·7%) participants, and 489 (52·6%) had been exposed to e-cigarette advertising, especially online. Previous or current tobacco smokers were nine and 22 times more likely to use e-cigarettes than never smokers, respectively (odds ratio [OR] 8·5, 95% CI 5·2-14·0 for previous smokers and 22·3, 12·2-40·7 for current smokers). Perceiving e-cigarettes as harmful was associated with a 40% lower likelihood of vaping (OR 0·6, 0·49-0·83). INTERPRETATION: Vaping seems relatively common among people aged 15-30 years in the UK, mainly among previous and current smokers. Caution should be taken as these findings might not be generalisable to the young UK population, and cross-sectional associations might not be causal. However, perceiving e-cigarettes as harmful might reduce their use, and many users seem unaware of their potential harms, which emphasises the need for further regulation on labelling, marketing, and sales. FUNDING: National Health and Medical Council.

Exposure to e-cigarette advertising and young people's use of e-cigarettes: A four-country study.

INTRODUCTION: The World Health Organization recommends banning all forms of e-cigarette advertising, promotion, and sponsorship. The aims of the present study were to: 1) examine young people's exposure to e-cigarette advertising across a wide range of media in four diverse countries; and 2) identify any association between the number of different types of media exposures and e-cigarette use. METHODS: A cross-sectional online survey was administered to approximately 1000 people aged 15-30 years in Australia, China, India, and the United Kingdom (n=4107). The survey assessed demographic characteristics, e-cigarette and tobacco use, numbers of friends and family members who vape, and exposure to multiple forms of e-cigarette advertising (e.g. television, radio, print, and various types of social media). Descriptive analyses were conducted on those who had heard of e-cigarettes (n=3095, significance threshold p<0.001) and a logistic regression analysis was used to identify factors associated with e-cigarette ever use (significance threshold p<0.05). RESULTS: The majority (85%) of respondents who had heard of e-cigarettes reported being exposed to e-cigarette advertising on at least one type of media, and the average number of types of media to which respondents were exposed was 5 (range: 0-17). The number of media types was significantly associated with ever use of e-cigarettes (OR=1.05; 95% CI: 1.02-1.08, p=0.001). CONCLUSIONS: Despite advertising restrictions in place in all four countries, large majorities of young people reported being exposed to e-cigarette advertising. Social media and advertising on/around vape shops and other retailers appear to be key exposure locations. Urgent attention is needed to address these forms of exposure given their apparent association with e-cigarette use.

Women's representation in clinical trials of patients with chronic kidney disease.

Background: Sex and gender differences in chronic kidney disease (CKD), including epidemiology and response to treatment, remain poorly understood. This study aimed to investigate how women are represented in CKD clinical trials and whether sex- and gender-disaggregated outcomes were reported. Methods: Clinical trials on CKD were identified from ClinicalTrials.gov. Randomised, phase 3/4 trials with ≥100 participants were selected to quantify women's representation among participants by computing the participation:prevalence ratio (PPR) and investigating whether sex-disaggregated analyses had been performed. Results: In total, 192 CKD trials registered on ClinicalTrials.gov and published between 1995 and 2022 were included. Overall, women accounted for 66 875 (45%) of the 147 136 participants. Women's participation in clinical trials was lower than their representation in the underlying CKD population globally (55%). The PPR was 0.75 (95% confidence interval 0.72-0.78), with no significant variation irrespective of mean age, CKD stage, dialysis, location, type of intervention or funding agency. A total of 39 (20%) trials reported sex-disaggregated efficacy outcomes and none reported sex-disaggregated safety outcomes. Conclusion: Women's participation in CKD clinical trials was lower than their representation in the underlying CKD population. Sex-disaggregated efficacy and safety outcomes were rarely reported. Improving women's enrolment into clinical trials is crucial to enable sex- and gender-disaggregated analysis and thus identify potential differences in treatment response between women and men.

E-cigarette attitudes and behaviours amongst 15-30-year-olds in the UK.

BACKGROUND: The use of e-cigarettes has been rising in the UK, particularly by young people. This study investigated behaviours, attitudes and beliefs about e-cigarettes amongst 15-30-year-olds in the UK. METHODS: An online survey was administered to a sample of 1009 15-30-year-olds in the UK. RESULTS: About one in five participants currently used e-cigarettes at least monthly, with 1 in 10 using them daily. Amongst those using e-cigarettes at least monthly, 90% had used e-cigarettes containing nicotine. E-cigarettes were mainly obtained from vape shops and used at home. Having friends who used e-cigarettes and using them to help quit/reduce smoking were the most common reasons for vaping. About half of participants had been exposed to e-cigarette advertising, especially online, and warning labels on e-cigarettes. Most participants agreed that e-cigarettes are addictive (75%), help people quitting smoking (64%) and are bad for health (63%). Previous or current tobacco smokers were 9 and 22 times more likely to use e-cigarettes than never smokers, respectively. Perceiving e-cigarettes as harmful was associated with a 40% lower likelihood of use. CONCLUSION: Raising awareness on the uncertain long-term consequences of vaping and regulation of marketing and sales are crucial to protect young people in the UK.

Women's representation as authors of retracted papers in the biomedical sciences.

Women are under-represented among authors of scientific papers. Although the number of retractions has been rising over the past few decades, gender differences among authors of retracted papers remain poorly understood. Therefore, this study investigated gender differences in authorship of retracted papers in biomedical sciences available on RetractionWatch. Among 35,635 biomedical articles retracted between 1970 and 2022, including 20,849 first authors and 20,413 last authors, women accounted for 27.4% [26.8 to 28.0] of first authors and 23.5% [22.9 to 24.1] of last authors. The lowest representation of women was found for fraud (18.9% [17.1 to 20.9] for first authors and 13.5% [11.9 to 15.1] for last authors) and misconduct (19.5% [17.3 to 21.9] for first authors and 17.8% [15.7 to 20.3] for last authors). Women's representation was the highest for issues related to editors and publishers (35.1% [32.2 to 38.0] for first authors and 24.8% [22.9 to 26.8] for last authors) and errors (29.5% [28.0 to 31.0] for first authors and 22.1% [20.7 to 23.4] for last authors). Most retractions (60.9%) had men as first and last authors. Gender equality could improve research integrity in biomedical sciences.

Inequalities in smoking among pregnant women in North West London.

BACKGROUND: London has the lowest smoking prevalence among pregnant women in England. However, it was unclear whether the low overall prevalence masked inequalities. This study investigated the prevalence of smoking among pregnant women in North West London stratified by ethnicity and deprivation. METHODS: Data regarding smoking status, ethnicity and deprivation were extracted from electronic health records collected by maternity services at Imperial Healthcare NHS Trust between January 2020 and August 2022. RESULTS: A total of 25 231 women were included in this study. At the time of booking of antenatal care (mean of 12 weeks), 4% of women were current smokers, 17% were ex-smokers and 78% never smokers. There were marked differences in the smoking prevalence between ethnic groups. Women of Mixed-White and Black Caribbean ethnicity and White Irish women had the highest prevalence of smoking (12 and 9%, respectively). There was an over 4-fold increase in the prevalence of smoking between the most and the least deprived groups (5.6 versus 1.3%). CONCLUSIONS: Even in a population with an overall low prevalence of smoking in pregnancy, women experiencing deprivation and from certain ethnic backgrounds have a high smoking prevalence and hence are the most likely to benefit from smoking cessation interventions.

Gender equality related to gender differences in life expectancy across the globe gender equality and life expectancy.

Life expectancy (LE) depends on the wider determinants of health, many of which have gendered effects worldwide. Therefore, this study aimed to investigate whether gender equality was associated with LE for women and men and the gender gap in LE across the globe. Gender equality in 156 countries was estimated using a modified global gender gap index (mGGGI), based on the index developed by the World Economic Forum between 2010 and 2021. Linear regression was used to investigate the association between the mGGGI and its economic, political, and education subindices and the gender gap in LE and women and men's LE. Overall, the mGGGI increased from 58% in 2010 to 62% in 2021. Globally, changes in the mGGGI and its economic and political subindexes were not associated with changes in the gender gap in LE or with LE for women and men between 2010 and 2020. Improvements in gender equality in education were associated with a longer LE for women and men and widening of the gender gap in LE. In 2021, each 10% increase in the mGGGI was associated with a 4.3-month increase in women's LE and a 3.5-month increase in men's LE, and thus with an 8-month wider gender gap. However, the direction and magnitude of these associations varied between regions. Each 10% increase in the mGGGI was associated with a 6-month narrower gender gap in high-income countries, and a 13- and 16-month wider gender gap in South and Southeast Asia and Oceania, and in Sub-Saharan Africa, respectively. Globally, greater gender equality is associated with longer LE for both women and men and a widening of the gender gap in LE. The variation in this association across world regions suggests that gender equality may change as countries progress towards socioeconomic development and gender equality.

Percutaneous versus surgical revascularization of unprotected left main coronary artery: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS).

BACKGROUND: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary artery (ULMCA) culprit lesion has been under-investigated. Therefore, we compared clinical characteristics and short- and medium-term outcomes of percutaneous and surgical revascularization in ACS. METHODS AND RESULTS: Of 31886 patients enrolled in a multicenter, national, prospective registry study between October 2010 and December 2020, 246 (0.8%) had ULMCA as a culprit lesion and underwent percutaneous coronary intervention (PCI) alone (n=133, 54%) or coronary artery bypass grafting (CABG) alone (n=113, 46%). Patients undergoing PCI presented more frequently ongoing chest pain (68% versus 41%, p<0.001) and cardiogenic shock (25% versus 1%, p<0.001). Time from admission to revascularization was higher in surgical group with a median time to CABG of 4.5 days compared to 0 days to PCI (p<0.001). Angiographic success rate was 93.2% in patients who underwent PCI. Primary endpoint (all-cause death, non-fatal reinfarction and/or non-fatal stroke during hospitalization) occurred in 15.9% of patients and was more frequent in the PCI group (p<0.001). After adjustment, surgical revascularization was associated with better in-hospital prognosis (odds ratio (OR) 0.164; 95% confidence interval (CI), 0.04-0.64; p=0.009). Similar results were achieved after propensity score matching. No difference was found at one-year all-cause death. CONCLUSION: Percutaneous coronary intervention was the most common revascularization strategy in the ACS with ULMCA culprit lesion. PCI was preferred in unstable patients and presented a high angiographic success. CABG was often delayed and preferred in low-risk patients. At one-year follow-up, PCI and CABG conferred a similar prognosis. The two approaches appear complementary in this high risk cohort.

Public perceptions of responsibility for recommended food policies in seven countries.

BACKGROUND: Food policy is important to promote healthy and sustainable diets. However, who is responsible for developing and implementing food policy remains contentious. Therefore, this study aimed to investigate how the public attributes responsibility for food policy to governments, individuals and the private sector. METHODS: A total of 7559 respondents from seven countries [Australia (n = 1033), Canada (n = 1079), China (n = 1099), India (n = 1086), New Zealand (n = 1090), the UK (n = 1079) and the USA (n = 1093)] completed an online survey assessing perceived responsibility for 11 recommended food policies. RESULTS: Overall, preferred responsibility for the assessed food policies was primarily attributed to governments (62%), followed by the private sector (49%) and individuals (31%). Respondents from New Zealand expressed the highest support for government responsibility (70%) and those from the USA the lowest (50%). Respondents from the USA and India were most likely to nominate individuals as responsible (both 37%), while those from China were least likely (23%). The private sector had the highest attributed responsibility in New Zealand (55%) and the lowest in China and the USA (both 47%). Support for government responsibility declined with age and was higher among those on higher incomes, with a university degree, and who perceived themselves to consume a healthy diet or be in poor health. CONCLUSIONS: Across seven diverse countries, results indicate the public considers government should take primary responsibility for the assessed food policies, with modest contribution from the private sector and minority support for individual responsibility.

Public perceptions of responsibility for alcohol control actions by actor type in seven countries.

Many governments are failing to systematically introduce evidence-based alcohol control policies, and debate continues around issues of market freedom and personal responsibility. The aim of this international study was to assess the extent to which the public considers a range of alcohol control policies to be the responsibility of three different categories of actors: government, the private sector, and individuals. Around 1000 respondents from seven countries (Australia, Canada, China, India, New Zealand, the UK, and the US; n = 7559) completed an online survey assessing demographic characteristics, alcohol consumption status, and perceived responsibility for four alcohol harm-reduction actions relating to alcohol availability, advertising, and public education campaigns. Across the total sample and all assessed actions, governments were selected as an appropriate actor in 66 % of instances, the private sector in 39 %, and individuals in 28 %. Respondents from New Zealand were most likely to consider the actions to be government responsibility and respondents from the US the least. In relatively few instances (8 %), respondents considered the actions unworthy of attention by any actor. Across all seven countries, governments were considered to be the most appropriate actors to undertake actions relating to restricting alcohol availability, regulating alcohol advertising, and disseminating campaigns to educate the public about alcohol-related harm. The results indicate that the public may be receptive to greater intervention in these areas.

Hemostasis of a bleeding inverted colonic diverticulum.

The authors report a case of a 62-year-old male presenting to the emergency department with hematochezia. Urgent colonoscopy revealed numerous diverticula in the sigmoid colon, two of them inverted. Oozing bleeding from a visible vessel was identified on the top of the most distal inverted diverticulum. An over-the-scope clip was released after suction into the transparent cap and successful hemostasis was achieved.

Trends in sugar content of non-alcoholic beverages in Australia between 2015 and 2019 during the operation of a voluntary industry pledge to reduce sugar content.

OBJECTIVES: To investigate changes in mean sugar content of non-alcoholic beverages (overall and sugar-sweetened beverages (SSB)) available for purchase in Australia and to compare signatories v. non-signatories of the Australian Beverages Council voluntary pledge from 2018. DESIGN: Retrospective observational study. SETTING: Australia. PARTICIPANTS: About 1500 non-alcoholic beverages per year included in the FoodSwitch Monitoring Datasets for 2015-2019. RESULTS: Overall, mean sugar content fell by 1·3 g/100 ml (17·1 %) from 7·5 g/100 ml in 2015 to 6·2 g/100 ml in 2019. SSB have accounted for about 56 % of all beverages available for purchase since 2015. Between 2015 and 2019, the sugar content of SSB dropped by about 10 % (0·8 g/100 ml). Soft drinks and milk-based drinks were the categories with the largest decrease in sugar content. The greater reduction in sugar observed for beverages overall than SSB suggests at least some of the overall decrease in sugar content is due to the appearance of new products with low or no sugar rather than reformulation. Over the same period, beverages with added non-nutritive sweeteners increased from 41 % to 44 %. The decrease in sugar content for all beverages and SSB was, in general, larger for non-signatories than signatories of the voluntary industry pledge. CONCLUSIONS: Between 2015 and 2019, the small reduction in sugar content of non-alcoholic beverages in Australia resulted from the combined effects of introducing low- or no-sugar products and reformulation of some categories of SSB. Further policy and regulatory measures are required to reap the most benefit that sugar reduction among non-alcoholic beverages can bring to population health.

Blood pressure and risk of venous thromboembolism: a cohort analysis of 5.5 million UK adults and Mendelian randomization studies.

AIMS: Evidence for the effect of elevated blood pressure (BP) on the risk of venous thromboembolism (VTE) has been conflicting. We sought to assess the association between systolic BP and the risk of VTE. METHODS AND RESULTS: Three complementary studies comprising an observational cohort analysis, a one-sample and two-sample Mendelian randomization were conducted using data from 5 588 280 patients registered in the Clinical Practice Research Datalink (CPRD) dataset and 432 173 UK Biobank participants with valid genetic data. Summary statistics of International Network on Venous Thrombosis genome-wide association meta-analysis was used for two-sample Mendelian randomization. The primary outcome was the first occurrence of VTE event, identified from hospital discharge reports, death registers, and/or primary care records. In the CPRD cohort, 104 017(1.9%) patients had a first diagnosis of VTE during the 9.6-year follow-up. Each 20 mmHg increase in systolic BP was associated with a 7% lower risk of VTE [hazard ratio: 0.93, 95% confidence interval (CI): (0.92-0.94)]. Statistically significant interactions were found for sex and body mass index, but not for age and subtype of VTE (pulmonary embolism and deep venous thrombosis). Mendelian randomization studies provided strong evidence for the association between systolic BP and VTE, both in the one-sample [odds ratio (OR): 0.69, (95% CI: 0.57-0.83)] and two-sample analyses [OR: 0.80, 95% CI: (0.70-0.92)]. CONCLUSION: We found an increased risk of VTE with lower BP, and this association was independently confirmed in two Mendelian randomization analyses. The benefits of BP reduction are likely to outweigh the harms in most patient groups, but in people with predisposing factors for VTE, further BP reduction should be made cautiously.

Incorporating environmental and sustainability considerations into health technology assessment and clinical and public health guidelines: a scoping review.

Healthcare systems account for a substantial proportion of global carbon emissions and contribute to wider environmental degradation. This scoping review aimed to summarize the evidence currently available on incorporation of environmental and sustainability considerations into health technology assessments (HTAs) and guidelines to support the National In stitute for Health and Care Excellence and analogous bodies in other jurisdictions developing theirown methods and processes. Overall, 7,653 articles were identified, of which 24 were included in this review and split into three key areas - HTA (10 studies), healthcare guidelines (4 studies), and food and dietary guidelines (10 studies). Methodological reviews discussed the pros and cons of different approaches to integrate environmental considerations into HTAs, including adjustments to conventional cost-utility analysis (CUA), cost-benefit analysis, and multicriteria decision analysis. The case studies illustrated the challenges of putting this into practice, such as lack of disaggregated data to evaluate the impact of single technologies and difficulty in conducting thorough life cycle assessments that consider the full environmental effects. Evidence was scant on the incorporation of environmental impacts in clinical practice and public health guidelines. Food and dietary guidelines used adapted CUA based on life cycle assessments, simulation modeling, and qualitative judgments made by expert panels. There is uncertainty on how HTA and guideline committees will handle trade-offs between health and environment, especially when balancing environmental harms that fall largely on society with health benefits for individuals. Further research is warranted to enable integration of environmental considerations into HTA and clinical and public health guidelines.

Dementia clinical trials over the past decade: are women fairly represented?

Background: Lack of progress in finding disease-modifying treatments for dementia may be due to heterogeneity in treatment effects among subgroups, such as by sex. Therefore, we investigated the characteristics of dementia trials completed in the last decade, with a focus on women's representation and sex-disaggregated outcomes. Methods: Clinical trials on dementia completed since 2010 were identified from ClinicalTrials.gov. Randomised, phase III/IV trials with ≥100 participants were selected to quantify women's representation among participants, by computing the participation to prevalence ratio (PPR) and investigate whether sex-disaggregated analyses had been performed. Results: A total of 1351 trials were identified between January 2010 and August 2021 (429 520 participants), of which 118 were eligible for analysis of women's representation and sex-stratified analysis. Only 113 reported the sex of participants and were included in the analysis of women's representation. Of the 110 469 participants in these 113 trials, 58% were women, lower than their estimated representation in the global dementia population of 64%. The mean PPR was 0.90 (95% CI 0.86 to 0.94). Women's participation tended to be higher when the first or last authors of the trial report were women. Eight out of the 118 trials reported sex-disaggregated outcomes, and three of those found significant sex differences in efficacy outcomes. None of the trials reported screening failures or adverse events stratified by sex. Conclusions: Overall, women and men were equally represented in dementia trials carried out over the past decade, but women's representation was lower than in the underlying dementia population. Sex-disaggregated efficacy and safety outcomes were rarely reported.