Ecological momentary assessment of digital food and beverage marketing exposure and impact in young adults: A feasibility study.

Unhealthy food marketing is contributing to the obesity epidemic, but real-time insights into the mechanisms of this relationship are under-studied. Digital marketing is growing and following food and beverage (F&B) brands on social media is common, but measurement of exposure and impact of such marketing presents novel challenges. Thus, this study aimed to evaluate the feasibility of collecting data on exposure and impact of digital F&B marketing (DFM) using a smartphone-based ecological momentary assessment (EMA) methodology. We hypothesized that DFM-induced food cravings would vary based on whether (or not) participants engaged with F&B brands online. Participants were Singapore residents (n = 95, 21-40 years), recruited via telephone from an existing cohort. Participants were asked to upload screenshots of all sightings of online F&B marketing messages for seven days, and answer in-app contextual questions about sightings including whether any cravings were induced. Participants provided a total of 1310 uploads (median 9 per participant, Q1-Q3: 4-21) of F&B marketing messages, 27% of which were provided on Day 1, significantly more than on other days (P < 0.001). Followers of food/beverage brands on social media encountered 25.6 percentage points (95% CI 11.4, 39.7) more marketing messages that induced cravings than participants who were not followers. University education was also associated with more (18.1 percentage points; 95% CI 3.1, 33.1) encounters with marketing messages that induced cravings. It was practical and acceptable to participants to gather insights into digital F&B marketing exposure and impact using EMA in young adults, although a shorter study period is recommended in future studies. Followers of food and beverage brands on social media appear to be more prone to experience cravings after exposure to digital F&B marketing.

The cross-sectional and prospective associations of parental practices and environmental factors with 24-hour movement behaviours among school-aged Asian children.

BACKGROUND: Parental practices and neighbourhood environmental factors may influence children's movement behaviours. We aimed to investigate the cross-sectional and prospective associations of parental practices and neighbourhood environmental factors with accelerometer-measured 24-hour movement behaviours (24 h-MBs) among school-aged children in Singapore. METHODS: The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study collected information on dimensions of parental practices and neighbourhood environment at age 5.5 years. Confirmatory factor analyses were performed to generate latent variables and used to compute overall parental practices [involvement in PA + support for PA + control of screen viewing context] and environmental scores [facilities for active play + active mobility facilitators + barriers*-1]. Children wore an accelerometer on their non-dominant wrist for seven consecutive days at ages 5.5 and 8 years. The R-package GGIR 2.6 was used to derive moderate-to-vigorous-intensity physical activity (MVPA), light-intensity physical activity (LPA), inactivity, and total-sleep (napping+night sleep) minutes per day. Associations were determined using compositional data analysis with multivariate linear regression models, taking into account potential confounders. RESULTS: Among 425 children (48% girls, 59% Chinese), higher parental involvement in PA, parental support for PA and overall parental practices were associated with 24 h-MBs at ages 5.5 and 8 years, specifically with greater time spent in MVPA and less time being inactive relative to the remaining movement behaviours. The corresponding mean changes in the overall 24 h-MB for increasing parental practices from lowest to highest scores (- 2 to + 2 z-scores) indicated potential increases of up to 15-minutes in MVPA, 20-minutes in LPA, 5-minutes in sleep duration, and a reduction of 40-minutes in inactivity at age 5.5 years. At age 8 years, this could translate to approximately 15-minutes more of MVPA, 20-minutes more of LPA, a 20-minute reduction in sleep duration, and a 20-minute reduction in inactivity. Parental control of screen viewing contexts and neighbourhood environmental factors were not associated with 24 h-MBs. CONCLUSIONS: Parental practices but not environmental factors were associated with higher MVPA and lower inactivity among Singaporean children, even at a later age. Further research may provide insights that support development of targeted public health strategies to promote healthier movement behaviours among children. STUDY REGISTRATION: This study was registered on 4th August 2010 and is available online at ClinicalTrials.gov: NCT01174875.

Empowering patients with comorbid diabetes and hypertension through a multi-component intervention of mobile app, health coaching and shared decision-making: Protocol for an effectiveness-implementation of randomised controlled trial.

INTRODUCTION: Diabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension. METHODS: We will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months. DISCUSSION: Our trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension. TRIAL REGISTRATION: This study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies.

PURPOSE: Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. METHODS: We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. RESULTS: We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66). CONCLUSION: In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.

Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis.

PURPOSE: We aimed to conduct a systematic review and meta-analysis to assess the effects of anemia and anemia severity on patient outcomes in cardiac surgery and determine whether preoperative treatments confer postoperative benefit. SOURCE: We searched four international databases for observational and randomized studies published until 1 October 2022. Study quality was assessed via Newcastle-Ottawa scores and the Cochrane Risk-of-Bias 2 tool and certainty of evidence was rated with the Grading of Recommendations, Assessment, Development and Evaluations approach. We conducted random-effects meta-analyses for our primary outcome of mortality, for secondary outcomes including length of stay (LOS) in the hospital and intensive care unit, and for postsurgical complications. As part of a secondary analysis, we analyzed short-term preoperative anemia treatments and conducted trial sequential analysis of randomized trials to assess the efficacy of these treatment programs. PRINCIPAL FINDINGS: We included 35 studies (159,025 patients) in our primary meta-analysis. Preoperative anemia was associated with increased mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.2 to 2.9; P < 0.001, high certainty). Study-level meta-regression revealed lower hemoglobin levels and studies with lower proportions of male patients to be associated with increased risk of mortality. Preoperative anemia was also associated with an increase in LOS and postsurgical complications. Our secondary analysis (seven studies, 1,012 patients) revealed short-term preoperative anemia treatments did not significantly reduce mortality (OR, 1.1; 95% CI, 0.65 to 1.9; P = 0.69). Trial sequential analysis suggested that there was insufficient evidence to conclude if treatment programs yield any benefit or harm. CONCLUSIONS: Preoperative anemia is associated with mortality and morbidity after cardiac surgery. More research is warranted to test the efficacy of current anemia treatment programs. STUDY REGISTRATION: PROSPERO (CRD42022319431); first submitted 17 April 2023.

RéSUMé: OBJECTIF: Notre objectif était de mener une revue systématique et une méta-analyse pour évaluer les effets de l'anémie et de la gravité de l'anémie sur les devenirs des patient·es en chirurgie cardiaque et déterminer si les traitements préopératoires conféraient un bénéfice postopératoire. SOURCES: Nous avons réalisé des recherches dans quatre bases de données internationales pour en extraire des études observationnelles et randomisées publiées jusqu'au 1er octobre 2022. La qualité des études a été évaluée à l'aide des scores de Newcastle-Ottawa et de l'outil Cochrane 2 sur le risque de biais, et la certitude des données probantes a été évaluée selon l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluations). Nous avons réalisé des méta-analyses à effets aléatoires pour notre critère d'évaluation principal de mortalité, pour les critères d'évaluation secondaires, notamment la durée du séjour à l'hôpital et à l'unité de soins intensifs, et pour les complications postopératoires. Dans le cadre d'une analyse secondaire, nous avons examiné les traitements préopératoires de l'anémie à court terme et effectué une analyse séquentielle d'études randomisées afin d'évaluer l'efficacité de ces modalités de traitement. CONSTATATIONS PRINCIPALES: Nous avons inclus 35 études portant sur 159 025 patient·es dans notre méta-analyse. L'anémie préopératoire était associée à une augmentation de la mortalité (rapport de cotes [RC], 2,5; intervalle de confiance [IC] à 95 %, 2,2 à 2,9; P < 0,001, certitude élevée). La méta-régression au niveau de l'étude a révélé que des taux d'hémoglobine plus faibles et des études avec des proportions plus faibles de patients masculins étaient associées à un risque accru de mortalité. L'anémie préopératoire était également associée à une augmentation de la durée de séjour et des complications postopératoires. Notre analyse secondaire (sept études, 1012 patient·es) a révélé que les traitements préopératoires de l'anémie à court terme ne réduisaient pas significativement la mortalité (RC, 1,1; IC 95 %, 0,65 à 1,9; P = 0,69). L'analyse séquentielle des études a suggéré qu'il n'y avait pas suffisamment de données probantes pour conclure si les modalités de traitement entraînaient un bénéfice ou un préjudice. CONCLUSION: L'anémie préopératoire est associée à la mortalité et à la morbidité après une chirurgie cardiaque. D'autres recherches sont justifiées pour tester l'efficacité des programmes actuels de traitement de l'anémie. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42022319431); première soumission le 17 avril 2023.

Examining resilience in Singapore in the face of COVID-19 community restrictions.

Introduction: To curb transmission of COVID-19, Singapore has experienced multiple, ongoing community restrictions. Gaining the ability to adapt and thrive under pressure will be key to addressing effects of these restrictions on mental health. To inform this, we examine the following research questions, (1) What typifies adversity related to living with on-off COVID-19 restrictions? (2) Who are the resilient? (3) How are negative effects of adversity attenuated? Methods: Participants were a part of the Strengthening Our Community's Resilience Against Threats from Emerging Infections (SOCRATES) cohort, invited to participate in this survey either via email or text message. Using the community survey data (N = 1,364), analyses including Wilcoxon rank sum test and logistic regression were conducted. Results: Adversities are identified as circumstances associated with a significant increase in Hospital Anxiety and Depression Scale (HADS) scores. These are typified by having financial worries; experiencing heightened emotions and frequent crying; having "out of body" experiences; having to move frequently or not being able to settle into accommodation; and regularly feeling mistreated by someone close to you. Being resilient in the face of adversity was determined by HADS scores for depression and anxiety (dichotomized at the median) and characterized by overall better social relationships such as having harmonious living situations and solution-driven coping strategies, especially the ability to harness the belief that difficult situations can lead to growth. Discussion: In accordance with the Loads-Levers-Lifts model, results indicate that initiatives that increase access to identified protection, while minimizing exposure to known adversities where possible, will promote resilience under COVID-19 restrictions.

Associations of childhood and current secondhand smoke exposure at home with current secondhand smoke exposure at work: A cross-sectional analysis of the Singapore multi-ethnic cohort.

INTRODUCTION: Relationships between secondhand smoke exposure (SHSE) in various temporal and physical settings are not fully studied despite its adverse impacts on human health, especially in multi-ethnic Asian populations. We investigated associations of childhood and current SHSE at home (SHSEhome) with current SHSE at work (SHSEwork) in Singapore and its relation to sources of daily smokers at home. METHODS: This cross-sectional study identified 925 healthy, never smoker working adults from the Singapore Multi-Ethnic Cohort (2004-2010). Firstly, the multiple logistic regression model estimated the adjusted odds ratios (AORs) of SHSEhome. Subsequently, sources of daily smokers entered through an additional model building process using the former as a base. RESULTS: Current adults (AOR=2.05; 95% CI: 1.28-3.29) and childhood SHSEhome (AOR=1.43; 95% CI: 0.93-2.19) had a positive and no association with current SHSEwork, respectively. These findings persisted when smoker identity-related variables entered the model: child (AOR=3.56; 95% CI: 1.19-10.64) for current daily smokers; father (AOR=2.30; 95% CI: 0.94-5.64) and sibling (AOR=2.97; 95% CI: 1.55-5.68) for childhood. Compared to no childhood SHSEhome, only those living with their fathers and siblings who smoked daily at home had significantly higher odds of reporting current SHSEwork (AOR=3.70; 95% CI: 1.88-7.30). CONCLUSIONS: Current SHSEhome was a risk factor for current SHSEwork, with risks elevated among those who smoke daily at home and living with their children. Childhood SHSEhome becomes a risk factor when daily household smokers include fathers and siblings. Deformalizing smoking could consider interpersonal dynamics of daily smokers at home with family members in different temporal settings, to reduce SHSEwork.

Evaluating the Effects of Rewards and Schedule Length on Response Rates to Ecological Momentary Assessment Surveys: Randomized Controlled Trials.

BACKGROUND: Ecological momentary assessments (EMAs) are short, repeated surveys designed to collect information on experiences in real-time, real-life contexts. Embedding periodic bursts of EMAs within cohort studies enables the study of experiences on multiple timescales and could greatly enhance the accuracy of self-reported information. However, the burden on participants may be high and should be minimized to optimize EMA response rates. OBJECTIVE: We aimed to evaluate the effects of study design features on EMA response rates. METHODS: Embedded within an ongoing cohort study (Health@NUS), 3 bursts of EMAs were implemented over a 7-month period (April to October 2021). The response rate (percentage of completed EMA surveys from all sent EMA surveys; 30-42 individual EMA surveys sent/burst) for each burst was examined. Following a low response rate in burst 1, changes were made to the subsequent implementation strategy (SMS text message announcements instead of emails). In addition, 2 consecutive randomized controlled trials were conducted to evaluate the efficacy of 4 different reward structures (with fixed and bonus components) and 2 different schedule lengths (7 or 14 d) on changes to the EMA response rate. Analyses were conducted from 2021 to 2022 using ANOVA and analysis of covariance to examine group differences and mixed models to assess changes across all 3 bursts. RESULTS: Participants (N=384) were university students (n=232, 60.4% female; mean age 23, SD 1.3 y) in Singapore. Changing the reward structure did not significantly change the response rate (F3,380=1.75; P=.16). Changing the schedule length did significantly change the response rate (F1,382=6.23; P=.01); the response rate was higher for the longer schedule (14 d; mean 48.34%, SD 33.17%) than the shorter schedule (7 d; mean 38.52%, SD 33.44%). The average response rate was higher in burst 2 and burst 3 (mean 50.56, SD 33.61 and mean 48.34, SD 33.17, respectively) than in burst 1 (mean 25.78, SD 30.12), and the difference was statistically significant (F2,766=93.83; P<.001). CONCLUSIONS: Small changes to the implementation strategy (SMS text messages instead of emails) may have contributed to increasing the response rate over time. Changing the available rewards did not lead to a significant difference in the response rate, whereas changing the schedule length did lead to a significant difference in the response rate. Our study provides novel insights on how to implement EMA surveys in ongoing cohort studies. This knowledge is essential for conducting high-quality studies using EMA surveys. TRIAL REGISTRATION: ClinicalTrials.gov NCT05154227; https://clinicaltrials.gov/ct2/show/NCT05154227.

Cross-sectional and prospective associations between children's 24-h time use and their health-related quality of life: a compositional isotemporal substitution approach.

Background: Promoting active, balanced lifestyles among children may be an important approach to optimising their health-related quality of life (HRQoL). However, the relationships between children's movement behaviours and HRQoL remain unclear. Methods: We examined the associations between movement behaviours (sleep, inactivity, light and moderate-to-vigorous intensity physical activity) assessed using accelerometers at ages 8 and 10 years and self-reported HRQoL scores (overall, and physical and emotional well-being, self-esteem, relationship with family and friends, and school functioning domains) at age 10 years among 370 children in a local birth cohort using compositional isotemporal substitution techniques. Findings: Cross-sectionally, light and moderate-to-vigorous intensity physical activities were associated with better self-esteem (ß = 15.94 [2.71, 29.18]) and relationship with friends (ß = 10.28 [3.81, 16.74]) scores respectively. Prospectively, inactivity was associated with lower overall HRQoL (ß = -10.00 [-19.13, -0.87]), relationship with friends (ß = -16.41 [-31.60, -1.23]) and school functioning (ß = -15.30 [-29.16, -1.44]) scores, while sleep showed a positive trend with overall HRQoL (ß = 10.76 [-1.09, 22.61]) and school functioning (ß = 17.12 [-0.87, 35.10]) scores. Children's movement behaviours were not associated with their physical and emotional well-being, or relationship with family scores. The isotemporal substitution analyses suggest that increasing time spent in physical activity and/or sleep at the expense of inactivity may benefit children's HRQoL. Interpretation: Our findings suggest that sleep and physical activity may be associated with better HRQoL, with the inverse for inactivity. However, the relationship between children's movement behaviours and HRQoL is complex and warrants further research. Funding: Singapore National Research Foundation, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research.

Association of physical activity with dementia and cognitive decline in UK Biobank.

INTRODUCTION: There is a lack of studies on the association between specific physical activity (PA) types and dementia. We examined the association of leisure time physical activity (LTPA), occupational physical activity (OPA), and sedentary lifestyle with dementia risk and cognitive decline using the UK-Biobank study. METHODS: Baseline PA was collected using questionnaires. A total of 502,481 dementia-free participants were recruited in 2006-2010 and followed for 10 years until the end of 2020 for the ascertainment of dementia. Associations of PA with incident dementia and cognitive decline were examined. RESULTS: Higher levels of LTPA and OPA and lower levels of sedentary hours were associated with lower dementia risk. The fifth quintiles of LTPA (hazard ratio [HR] = 0.53, 95% confidence interval [CI]: 0.43-0.67) and OPA (HR = 0.68, 95% CI:0.51-0.90) had lower dementia risk, whereas the fifth quintile of sedentary lifestyle had higher dementia risk (HR = 1.23, 95% CI:1.08-1.41). DISCUSSION: Our findings suggest the promotion of an active lifestyle suggested to be preventive of dementia risk. This research has been conducted using the UK Biobank Resource under Application Number 71022.

Evaluating the association of COVID-19 restrictions on discharge planning and post-discharge outcomes in the community hospital and Singapore regional health system.

Objectives: The COVID-19 is a global health issue with widespread impact around the world, and many countries initiated lockdowns as part of their preventive measures. We aim to quantify the duration of delay in discharge to community from Community Hospitals, as well as quantify adverse patient outcomes post discharge pre and during lockdown period. Design and methods: We conducted a before-after study comparing the length of stay in Community Hospitals, unscheduled readmissions or Emergency Department attendance, patients' quality of life using EQ5D-5l, number and severity of falls, in patients admitted and discharged before and during lockdown period. Results: The average length of stay in the lockdown group (27.77 days) were significantly longer than that of the pre-lockdown group (23.76 days), p = 0.003. There were similar proportions of patients with self-reported falls post discharge between both groups. Patients in the pre-lockdown group had slightly better EQ-5D-5l Index score at 0.55, compared to the lockdown study group at 0.49. Half of the patients in both groups were referred to Community Care Services on discharge. Conclusion: Our study would help in developing a future systematic preparedness guideline and contingency plans in times of disease outbreak and other similar public health emergencies.

Factors influencing myopia stabilisation in young myopic adult Singaporeans.

PURPOSE: To evaluate factors influencing stabilisation of myopia in the Singapore Cohort of Risk factors for Myopia. METHODS: We evaluated the longitudinal natural history of 424 myopic participants from 1999 to 2022. The outcome was the change in myopia from the adolescence follow-up visit (aged 12-19 years) to the adulthood follow-up visit (aged 26-33 years). Association of predictive factors, including baseline spherical error, gender, ethnicity, parental myopia, time outdoor, near work and age at adolescence, was examined with the dichotomous outcome of adult myopia progression (≤ -1.00 dioptres (D) over 10 years) using multiple logistic regression and progression in linear regression models. RESULTS: For the primary outcome, the mean rate of progression of the outcome was found to be -0.04±0.09 D per year from the adolescent to the adulthood follow-up visits. 82.3% (95% CI 78.3% to 85.8%) had myopia stabilisation, with progression of less than 1.00 D over 10 years while 61.3% (95% CI 56.5% to 66.0%) of the subjects had progression of less than 0.50 D. In logistic regression models, both male gender (p=0.035) and non-Chinese ethnicity (p=0.032) were more likely to achieve myopia stabilisation while in linear multivariate regression models, males had a significantly slower degree of myopia progression (p=0.021). CONCLUSION: 5 in 6 Singaporean young adults had myopia stabilisation. Male gender is 2 times and non-Chinese ethnicities are 2.5 times more likely to achieve myopia stabilisation. However, a proportion of myopes continue to exhibit a clinically significant degree of progression in adulthood.

Risk prediction models for type 2 diabetes using either fasting plasma glucose or HbA1c in Chinese, Malay, and Indians: Results from three multi-ethnic Singapore cohorts.

AIMS: To assess three well-established type 2 diabetes (T2D) risk prediction models based on fasting plasma glucose (FPG) in Chinese, Malays, and Indians, and to develop simplified risk models based on either FPG or HbA1c. METHODS: We used a prospective multiethnic Singapore cohort to evaluate the established models and develop simplified models. 6,217 participants without T2D at baseline were included, with an average follow-up duration of 8.3 years. The simplified risk models were validated in two independent multiethnic Singapore cohorts (N = 12,720). RESULTS: The established risk models had moderate-to-good discrimination (area under the receiver operating characteristic curves, AUCs 0.762 - 0.828) but a lack of fit (P-values < 0.05). Simplified risk models that included fewer predictors (age, BMI, systolic blood pressure, triglycerides, and HbA1c or FPG) showed good discrimination in all cohorts (AUCs ≥ 0.810), and sufficiently captured differences between the ethnic groups. While recalibration improved fit the simplified models in validation cohorts, there remained evidence of miscalibration in Chinese (p ≤ 0.012). CONCLUSIONS: Simplified risk models including HbA1c or FPG had good discrimination in predicting incidence of T2D in three major Asian ethnic groups. Risk functions with HbA1c performed as well as those with FPG.

The association of diffusion tensor MRI measures of normal appearing white matter and cognition.

Objective: Median and peak height of fractional anisotropy (FA) and mean diffusivity (MD) are diffusion tensor imaging (DTI) markers used to quantify white matter microstructure changes. We examine the association of DTI histogram-derived measures in global normal appearing white matter (NAWM) and cognitive decline in patients with normal cognition and cognitive impairment no dementia from a memory clinic in Singapore. Methods: A total of 252 patients (mean age: 71.1 ± 7.6 years, 53.2% women) were included. All patients underwent clinical assessments, a brain MRI scan at baseline, and neuropsychological assessments annually for 2 years. DTI scans were processed to obtain MD and FA histogram-derived measures. The National Institute of Neurological Disorders and Stroke and the Canadian Stroke Network harmonization neuropsychological battery were used to assess cognitive function. Linear regression models with generalised estimating equation (GEE) and logistic regression models were used to examine the association between DTI histogram measures and cognitive decline. Results: When compared to baseline, MD and FA measures at Year 2 were associated with an accelerated worsening in global cognition (all p for interaction <0.001; Year 0 vs 2, MD median: -0.29 (95%CI: -0.49, -0.09) vs -0.45 (95%CI: -0.65,-0.25); MD peak height: 0.22 (95%CI: 0.07, 0.37) vs 0.37 (95%CI: 0.21, 0.53); FA median: 0.11 (95%CI: -0.05, 0.26) vs 0.22 (95%CI: 0.07, 0.37); FA peak height: -0.14 (95%CI: -0.28, 0.00) vs -0.24 (95%CI: -0.38, -0.10);). Similar findings were observed for executive function and visuomotor speed while only MD measures predicted worsening in memory domain. Interpretation: This study shows that DTI histogram measures are associated with accelerated cognitive decline suggesting the utility of DTI as a pre-clinical marker in predicting the worsening of cognition in clinical trials.

Association Between Domain-Specific Physical Activity and Cardiometabolic Factors in a Multiethnic Asian Population: A Longitudinal Study.

AIMS: To examine the association between domain-specific physical activity (PA) and cardiometabolic factors with longitudinal data, which is limited in current literature. METHODS: Participants who attended the Singapore Multi-Ethnic Cohort and follow-up surveys were included in this study (N = 3950, mean age: 44.7 y, female: 57.9%). Self-reported moderate- to vigorous-intensity PA (MVPA) for each domain (leisure-time, transportation, occupation, and household) was categorized into 4 levels: no, low, middle, and high MVPA. The longitudinal associations of domain-specific MVPA with cardiometabolic factors including systolic and diastolic blood pressures, low-density and high-density lipoprotein cholesterols, triglycerides, and body mass index were examined using Generalized Estimating Equations, accounting for confounding factors and repeated measurements. RESULTS: There were 5.2% participants who had no MVPA. For each domain, this rate ranged from 22.6% (household) to 83.3% (occupation). Leisure-time and occupation MVPAs had positive and linear associations with high-density lipoprotein cholesterols, corresponding to 0.030 (95% confidence interval, 0.015 to 0.045) mmol/L (leisure-time) and 0.063 (95% confidence interval, 0.043 to 0.083) mmol/L (occupation), when compared high with no respective MVPA. Occupation and household MVPAs were associated with low-density lipoprotein cholesterol. Transportation and occupation exhibited a positive and linear relationship with diastolic blood pressure. None of the domains were associated with body mass index, systolic blood pressures, or triglycerides. CONCLUSIONS: This study showed that each domain had differential association with individual cardiometabolic risk factors. As occupation, transportation, or household PA had unfavorable associations with low-density lipoprotein cholesterol or diastolic blood pressure, the overall beneficial impact of higher PA levels may not necessarily hold in the context of domain-specific PA and cardiovascular health. Further investigation is needed to corroborate our findings.

Association between nutrition and cognition in a multi-ethnic cohort from Singapore.

BACKGROUND: Nutrition, a modifiable risk factor, presents a low-cost prevention strategy to reduce the burden of cognitive impairment and dementia. However, studies examining the effects of dietary patterns on cognition are lacking in multi-ethnic Asian populations. We investigate the association between diet quality, measured with the Alternative Healthy Eating Index (AHEI)-2010, and cognitive impairment in middle-aged and older adults of different ethnicities (Chinese, Malay, Indian) in Singapore. METHODS: This cross-sectional study (n = 3138; mean age: 50.4 ± 9.8, 58.4% women) was based on data from the Singapore Multi-Ethnic Cohort. Dietary intake collected with a validated semi-quantitative Food Frequency Questionnaire was converted into AHEI-2010 scores. Cognition, assessed with the Mini-Mental State Examination (MMSE), was analysed as a continuous or binary outcome (cognitively impaired or not, using cut-offs of ≥ 24, 26 or 28 for no education, primary school education and secondary school education and above). Multivariable linear and logistic regression models were used to examine associations between AHEI-2010 and cognition, adjusting for covariates. RESULTS: A total of 988 (31.5%) participants had cognitive impairment. Higher AHEI-2010 scores were significantly associated with higher MMSE scores [ß = 0.44; 95% confidence interval (CI) 0.22-0.67 highest vs. lowest quartile; p-trend < 0.001] and lower odds of cognitive impairment [OR 0.69; 95% CI 0.54-0.88; p-trend = 0.01] after adjusting for all the covariates. No significant associations were observed for individual dietary components of the AHEI-2010 with MMSE or cognitive impairment. CONCLUSION: Healthier dietary patterns were associated with better cognitive function in middle-aged and older Singaporeans. These findings could inform better support to promote healthier dietary patterns in Asian populations.

Qualitative study exploring heterogeneity in caregiving experiences post-stroke in Singapore.

OBJECTIVE: Stroke, a common illness in older adults, accounts for up to 4% of direct medical costs in developed nations. Informal caregiving contributing a significant proportion of economic burden post-stroke warrants a deeper understanding of the caregiving context to sustain caregiving arrangement. While literature exists describing differences in motivation and preferences of caregivers, limited literature explores differences in caregiving experiences of different types of caregivers (ie, spouse, adult-child, sibling or others). Addressing this gap, our study aimed to explore the caregiving experience of stroke survivors and their family caregivers across different caregiver identities in an Asian setting. DESIGN: Qualitative descriptive study. SETTING: Community setting. PARTICIPANTS: We conducted semi-structured interviews with 26 stroke survivors and 35 caregivers purposively sampled from an outpatient rehabilitation setting, an outpatient clinic and a support organisation. Data were analysed using thematic analysis. OUTCOME MEASURES: Themes including caregiving experience of stroke survivors and their family caregivers across different caregiver identities. RESULTS: Following five themes were reported: caregiver reserve, coping strategies, caregiver burden, competing commitments and role of foreign domestic worker (FDW) in family caregiving. Spouse caregivers were less willing to ask for help, commonly adopted faith-based, and spacing or recharging types of coping, reported emotional strain and shared limited accounts of FDWs. Adult-child caregivers were more willing to ask for help, engaged in alternative care arrangements involving FDWs, commonly adopted action-focussed coping and reported multidimensional caregiver burden. CONCLUSION: Our findings illustrated the heterogeneity in factors affecting caregiving experience across spouse and adult-child caregivers. Practical implications include conducting a needs assessment for caregiver-stroke survivor dyads and providing tailored support, training and information to help caregivers cope better.

Cardiorespiratory fitness, body mass index, cardiovascular disease, and mortality in young men: A cohort study.

Objective: We examined the association between cardiorespiratory fitness (CRF), body mass index (BMI), incidence of major acute cardiovascular events (MACE), and all-cause mortality (ACM). Methods: We conducted a retrospective cohort study involving 212,631 healthy young men aged 16 to 25 years who had undergone medical examination and fitness testing (2.4 km run) from 1995 to 2015. Information on the outcomes of major acute cardiovascular events (MACE) and all-cause mortality (ACM) were obtained from the national registry data. Results: During 2,043,278 person-years of follow-up, 371 first MACE and 243 ACM events were recorded. Compared against the first run-time quintile, adjusted hazard ratios (HR) for MACE in the second to fifth quintiles were 1.26 (95% CI 0.84-1.91), 1.60 (95% CI 1.09-2.35), 1.60 (95% CI 1.10-2.33), and 1.58 (95% CI 1.09-2.30). Compared against the "acceptable risk" BMI category, the adjusted HRs for MACE in the "underweight," "increased risk," and "high-risk" categories were 0.97 (95% CI 0.69-1.37), 1.71 (95% CI 1.33-2.21), and 3.51 (95% CI 2.61-4.72), respectively. The adjusted HRs for ACM were increased in participants from the fifth run-time quintile in the "underweight" and "high-risk" BMI categories. The combined associations of CRF and BMI with MACE showed elevated hazard in the "BMI≥23-fit" category, which was more pronounced in the "BMI≥23-unfit" category. The hazards for ACM were elevated across the "BMI<23-unfit," "BMI≥23-fit," and "BMI≥23-unfit" categories. Conclusion: Lower CRF and elevated BMI were associated with increased hazards of MACE and ACM. A higher CRF did not fully compensate for elevated BMI in the combined models. CRF and BMI remain important targets for public health intervention in young men.

Association of Interleukin-6 and Interleukin-8 with Cognitive Decline in an Asian Memory Clinic Population.

BACKGROUND: Neuroinflammation has been postulated to play an important role in cognitive impairment, cognitive decline, and dementia. Inflammatory biomarkers such as interleukin-6 (IL-6) and IL-8 are found to be associated with the neuro-inflammatory process and worse cognitive function. However, it is unknown whether these interleukins are associated with long-term cognitive function. OBJECTIVE: To investigate the association of baseline IL-6 and IL-8 with cognitive function at baseline as well as its association with cognitive decline over five-year follow-up. METHODS: 387 patients were recruited from an ongoing memory clinic-based study who underwent comprehensive physical, medical, neuropsychological and blood assessments together with brain MRI. IL-6 and IL-8 were measured using LUMINEX assays. The National Institute of Neurological Disorders and Stroke-Canadian Stroke Network neuropsychological battery was used to assess cognitive decline across multiple domains. RESULTS: Among the 387 (mean age = 72.9 years and 53.7% males) participants, 322 had at least two follow-up assessments and were included in the longitudinal analysis. Negative linear trend associations were found between tertiles of IL-8 with baseline global cognition (p-trend< 0.001), attention (p-trend = 0.005), executive function (p-trend< 0.001), and visuospatial function (p-trend = 0.002) domains. No association was found between baseline IL-8 and cognitive decline. IL-6 was not associated with both baseline and follow-up cognition. CONCLUSION: IL-8 was associated with worse cognition especially in attention, executive function, and visuospatial function, suggesting the role of neuroinflammation in cognitive impairment. Hence, blood inflammatory biomarkers may be useful indicators in identifying patients at risk of cognitive impairment and warrant consideration for inclusion in treatment trials.

Digital Intergenerational Program to Reduce Loneliness and Social Isolation Among Older Adults: Realist Review.

BACKGROUND: There is a compelling need for an innovative and creative approach to promote social connectedness among older adults to optimize their well-being and quality of life. One possible solution may be through a digital intergenerational program. OBJECTIVE: This realist review aimed to identify existing digital intergenerational programs that were used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes. METHODS: We performed a realist review with an extensive search of published and gray literature. For scholarly literature, we searched PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. A grey literature search was performed using the Google search engine, and the search was completed in May 2021. We included programs that evaluated digital intergenerational programs for older adults, which described outcomes of loneliness or social isolation. We included quantitative, mixed methods, and qualitative studies, as well as relevant theoretical papers, policy documents, and implementation documents. The studies were appraised based on their relevance and rigor. We synthesized the available evidence from the literature into Strategy-Context-Mechanism-Outcome (S-C-M-O) configurations to better understand what, when, and how programs work. RESULTS: A total of 31 documents reporting 27 digital intergenerational programs were reviewed. Our final results identified 4 S-C-M-O configurations. For S-C-M-O configuration 1, we found that for community-dwelling older adults, provision of access to and training in digital technology may increase older adults' self-efficacy in digital devices and therefore increase the use of digital communication with family. In S-C-M-O configuration 2, digital psychosocial support and educational interventions from nurses were found to be useful in reducing loneliness among community-dwelling older adults. In S-C-M-O configuration 3, a video call with a student or family was found to reduce loneliness among older adults residing in long-term residential care facilities. Finally, for S-C-M-O configuration 4, we found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely. However, as almost half (11/27, 41%) of the included programs only reported quantitative results, this review focused on screening the discussion section of publications to identify author opinions or any qualitative information to elucidate the mechanisms of how programs work. CONCLUSIONS: This review identified the key strategy, context, and mechanism influencing the success of programs that promote intergenerational interaction through digital means. This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). The S-C-M-O configurations should be considered when designing and implementing digital intergenerational programs for older adults.