Physical Activity Moderates the Relationship between Cardiovascular Disease Risk Burden and Cognition in Older Adults.

INTRODUCTION: Older individuals with a higher cardiovascular disease (CVD) burden have a higher risk for accelerated cognitive decline and dementia. Physical activity (PA) is an inexpensive and accessible preventive measure to CVD, cognitive impairment, and dementia. The current study examined (1) whether PA moderates the relationship between CVD burden and cognition and (2) whether the moderating effect of PA differs by race/ethnicity groups and by APOE-ɛ4 status. METHODS: Our cross-sectional study included participants from the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, community-based, longitudinal study on aging and dementia among individuals aged 65 years and older who reside in northern Manhattan. All participants underwent an interview and a neuropsychological assessment for global cognition, memory, language, visuospatial, and speed functioning. RESULTS: In 2,122 older individuals without dementia, having a higher CVD burden was associated with worse cognitive scores for global, language, speed, and visuospatial cognitive functions. PA mitigated the relationship between CVD burden and visuospatial function. Furthermore, PA mitigated the association of CVD burden with global cognition, language, and visuospatial functions in APOE-ɛ4 carriers but not in non-carriers. DISCUSSION/CONCLUSION: Our study suggests that PA may mitigate the negative association between CVD and cognition, especially in APOE-ɛ4 carriers. The moderating effect of PA did not differ by race/ethnicity.

A Narrative Review of Literature Examining Studies Researching the Impact of Law on Health and Economic Outcomes.

CONTEXT: Public health policy can play an important role in improving public health outcomes. Accordingly, there has been an increasing emphasis by policy makers on identifying and implementing evidence-informed public health policy interventions. PROGRAM OR POLICY: Growth and refinement of the field of research assessing the impact of legal interventions on health outcomes, known as legal epidemiology, prompted this review of studies on the relationship between laws and health or economic outcomes. IMPLEMENTATION: Authors systematically searched 8 major literature databases for all English language journal articles that assessed the effect of a law on health and economic outcomes published between January 1, 2009, and September 18, 2019. This search generated 12 570 unique articles 177 of which met inclusion criteria. The team conducting the systematic review was a multidisciplinary team that included health economists and public health policy researchers, as well as public health lawyers with expertise in legal epidemiological research methods. The authors identified and assessed the types of methods used to measure the laws' health impact. EVALUATION: In this review, the authors examine how legal epidemiological research methods have been described in the literature as well as trends among the studies. Overall, 3 major themes emerged from this study: (1) limited variability in the sources of the health data across the studies, (2) limited differences in the methodological approaches used to connect law to health outcomes, and (3) lack of transparency surrounding the source and quality of the legal data relied upon. DISCUSSION: Through highlighting public health law research methodologies, this systematic review may inform researchers, practitioners, and lawmakers on how to better examine and understand the impacts of legal interventions on health and economic outcomes. Findings may serve as a source of suggested practices in conducting legal epidemiological outcomes research and identifying conceptual and method-related gaps in the literature.

The urban-rural disparities and factors associated with the utilization of public health services among diabetes patients in China.

BACKGROUND: Basic public health services for diabetes play an essential role in controlling glycemia in patients with diabetes. This study was conducted to understand the urban-rural disparities in the utilization of basic public health services for people with diabetes and the factors influencing them. METHODS: The data were obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS) with 2976 diabetes patients. Chi-square tests were used to examine the disparities in the utilization of diabetes physical examination and health education between urban and rural areas. Logistic regression was performed to explore the factors associated with the utilization of diabetes public health services. RESULTS: Among all participants, 8.4% used diabetes physical examination in the past year, and 28.4% used diabetes health education services. A significant association with age (OR = 0.64, 95% CI:0.49-0.85; P < 0.05) was found between patients' use of health education services. Compared with diabetes patients living in an urban area, diabetes patients living in a rural area used less diabetes health education. (χ2= 92.39, P < 0.05). Patients' self-reported health status (OR = 2.04, CI:1.24-3.35; P < 0.05) and the use of glucose control (OR = 9.33, CI:6.61-13.16; P < 0.05) were significantly positively associated with the utilization of diabetes physical examination. Patients with higher education levels were more likely to use various kinds of health education services than their peers with lower education levels (OR = 1.64, CI:1.21-2.22; P < 0.05). CONCLUSION: Overall, urban-rural disparities in the utilization of public health services existed. Vulnerable with diabetes, such as those in rural areas, are less available to use diabetes public health services. Providing convenient health service infrastructure facilitates the utilization of basic public health services for diabetes in older patients with diabetes, especially in rural areas.

The number of metabolic syndrome risk factors predicts alterations in gut microbiota in Chinese children from the Huantai study.

BACKGROUND: Evidence on the effect of gut microbiota on the number of metabolic syndrome (MetS) risk factors among children is scarce. We aimed to examine the alterations of gut microbiota with different numbers of MetS risk factors among children. METHODS: Data were collected from a nested case-control study at the baseline of the Huantai Childhood Cardiovascular Health Cohort Study in Zibo, China. We compared the differences in gut microbiota based on 16S rRNA gene sequencing among 72 children with different numbers of MetS risk factors matched by age and sex (i.e., none, one, and two-or-more MetS risk factors; 24 children for each group). RESULTS: The community richness (i.e., the total number of species in the community) and diversity (i.e., the richness and evenness of species in the community) of gut microbiota decreased with an increased number of MetS risk factors in children (P for trend < 0.05). Among genera with a relative abundance greater than 0.01%, the relative abundance of Lachnoclostridium (PFDR = 0.009) increased in the MetS risk groups, whereas Alistipes (PFDR < 0.001) and Lachnospiraceae_NK4A136_group (PFDR = 0.043) decreased in the MetS risk groups compared to the non-risk group. The genus Christensenellaceae_R-7_group excelled at distinguishing one and two-or-more risk groups from the non-risk group (area under the ROC curve [AUC]: 0.84 - 0.92), while the genera Family_XIII_AD3011_group (AUC: 0.73 - 0.91) and Lachnoclostridium (AUC: 0.77 - 0.80) performed moderate abilities in identifying none, one, and two-or-more MetS risk factors in children. CONCLUSIONS: Based on the nested case-control study and the 16S rRNA gene sequencing technology, we found that dysbiosis of gut microbiota, particularly for the genera Christensenellaceae_R-7_group, Family_XIII_AD3011_group, and Lachnoclostridium may contribute to the early detection and the accumulation of MetS risk factors in childhood.

Deep Learning Analysis of COVID-19 Vaccine Hesitancy and Confidence Expressed on Twitter in 6 High-Income Countries: Longitudinal Observational Study.

BACKGROUND: An ongoing monitoring of national and subnational trajectory of COVID-19 vaccine hesitancy could offer support in designing tailored policies on improving vaccine uptake. OBJECTIVE: We aim to track the temporal and spatial distribution of COVID-19 vaccine hesitancy and confidence expressed on Twitter during the entire pandemic period in major English-speaking countries. METHODS: We collected 5,257,385 English-language tweets regarding COVID-19 vaccination between January 1, 2020, and June 30, 2022, in 6 countries-the United States, the United Kingdom, Australia, New Zealand, Canada, and Ireland. Transformer-based deep learning models were developed to classify each tweet as intent to accept or reject COVID-19 vaccination and the belief that COVID-19 vaccine is effective or unsafe. Sociodemographic factors associated with COVID-19 vaccine hesitancy and confidence in the United States were analyzed using bivariate and multivariable linear regressions. RESULTS: The 6 countries experienced similar evolving trends of COVID-19 vaccine hesitancy and confidence. On average, the prevalence of intent to accept COVID-19 vaccination decreased from 71.38% of 44,944 tweets in March 2020 to 34.85% of 48,167 tweets in June 2022 with fluctuations. The prevalence of believing COVID-19 vaccines to be unsafe continuously rose by 7.49 times from March 2020 (2.84% of 44,944 tweets) to June 2022 (21.27% of 48,167 tweets). COVID-19 vaccine hesitancy and confidence varied by country, vaccine manufacturer, and states within a country. The democrat party and higher vaccine confidence were significantly associated with lower vaccine hesitancy across US states. CONCLUSIONS: COVID-19 vaccine hesitancy and confidence evolved and were influenced by the development of vaccines and viruses during the pandemic. Large-scale self-generated discourses on social media and deep learning models provide a cost-efficient approach to monitoring routine vaccine hesitancy.

Association between gut microbiota and obesity combined with high carotid intima-media thickness among Chinese children.

BACKGROUND AND OBJECTIVES: Obesity and related target organ damage such as high carotid intima-media thickness (cIMT) in children is associated with cardiovascular disease (CVD) later in life. However, the asso-ciation between gut microbiota and obesity combined with high cIMT among children remains unclear. Therefore, we compared differences in composition, community diversity, and richness of gut microbiota among normal children and obesity combined with or without high cIMT to identify differential microbiota biomarkers. METHODS AND STUDY DESIGN: A total of 24 children with obesity combined with high cIMT (OB+high-cIMT), 24 with obesity but normal cIMT (OB+non-high cIMT), and 24 with normal weight and normal cIMT aged 10-11 years matched by age and sex from the "Huantai Childhood Cardiovascular Health Cohort Study" were included. All included fecal samples were tested using 16S rRNA gene sequencing. RESULTS: The community richness and diversity of gut microbiota in OB+high-cIMT children were decreased compared with OB+non-high cIMT children and normal children. At the genus level, the relative abundances of Christensenellaceae_R-7_group, UBA1819, Family_XIII_AD3011_group, and unclassi-fied_o_Bacteroidales were associated with reduced odds of OB+high-cIMT among children. Receiver operating characteristic (ROC) analysis showed that combined Christensenellaceae_R-7_group, UBA1819, Fami-ly_XIII_AD3011_group, and unclassified_o_Bacteroidales performed a high ability in identifying OB+high-cIMT. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) showed that several pathways such as biosynthesis of amino acids and aminoacyl-tRNA pathways were lower in the OB+high-cIMT group compared with the normal group. CONCLUSIONS: We found that the alteration of gut microbiota was associated with OB+high-cIMT among children, which indicates that the gut microbiota may be a marker for obesity and related cardiovascular damage among children.

Associations of Chinese diagnosis-related group systems with inpatient expenditures for older people with hip fracture.

BACKGROUND: Hip fracture is frequent in older people and represents a major public health issue worldwide. The increasing incidence of hip fracture and the associated hospitalization costs place a significant economic burden on older patients and their families. On January 1, 2018, the Chinese diagnosis-related group (C-DRG) payment system, which aims to reduce financial barriers, was implemented in Sanming City, southern China. This study aimed to evaluate the associations of C-DRG system with inpatient expenditures for older people with hip fracture. METHODS: An uncontrolled before-and-after study employed data of all the patients with hip fracture aged 60 years or older from all the public hospitals enrolled in the Sanming Basic Health Insurance Scheme from January 1, 2016 to December 31, 2018. The 'pre C-DRG sample' included patients from January 1, 2016 to December 31, 2017. The 'post C-DRG sample' included patients from January 1, 2018 to December 31, 2018. A propensity score matching analysis was used to adjust the difference in baseline characteristic parameters between the pre and post samples. Data were analyzed using generalized linear models adjusted for the demographic, clinical, and institutional factors. Robust tests were performed by accounting for time trend, the fixed effects of the year and hospitals, and clustering effect within hospitals. RESULTS: After propensity score matching, we obtained two homogeneous groups of 1123 patients each, and the characteristic variables of the two matched groups were similar. We found that C-DRG reform was associated with a 19.51% decrease in out-of-pocket (OOP) payments (p < 0.001) and a 99.93% decrease in OOP payments as a share of total inpatient expenditure (p < 0.001); whereas total inpatient expenditure was not significantly associated with the C-DRG reform. All the sensitivity analyses did not change the results significantly. CONCLUSION: The implementation of C-DRG payment system reduced both the absolute amount of OOP payments and OOP payments as a share of total inpatient expenditure for older patients with hip fracture, without affecting total inpatient expenditure. These results may provide significant insights for policymakers in reducing the financial burden on older patients with hip fracture in other countries.

Willingness and uptake of the COVID-19 testing and vaccination in urban China during the low-risk period: a cross-sectional study.

BACKGROUND: Regular testing and vaccination are effective measures to mitigate the ongoing COVID-19 pandemic. Evidence on the willingness and uptake of the COVID-19 testing is scarce, and the willingness and uptake of vaccination may change as the pandemic evolves. This study aims to examine willingness and uptake of COVID-19 testing and vaccination during a low-risk period of the COVID-19 pandemic in urban China. METHODS: A cross-sectional online survey was conducted among 2244 adults in urban China. Descriptive analyses were performed to compare the respondents' willingness and uptake of COVID-19 testing and vaccination. Multivariate logistic regressions were fitted to investigate factors associated with the willingness and uptake of the two measures. RESULTS: In early 2021, about half (52.45%) of the respondents had received or scheduled a COVID-19 test at least once, and a majority (95.63%) of the respondents were willing to receive testing. About two-thirds (63.28%) of the respondents had received/scheduled or were willing to receive a COVID-19 vaccine. Willingness and uptake of COVID-19 testing were not associated with socio-demographic characteristics, except for occupation. Being of older age, migrants, having higher educational attainment and secure employment were associated with a higher uptake of COVID-19 vaccination among the surveyed respondents, while willingness to vaccinate was consistent across socio-demographic characteristics among those who had not been vaccinated. CONCLUSIONS: By early 2021, Chinese adults expressed almost universal willingness of COVID-19 testing and over half of adults have been tested, while the willingness and uptake of COVID-19 vaccination were relatively low at the low-risk period of the COVID-19 pandemic. Maintaining willingness of COVID-19 vaccination is critical and necessary, especially when the pandemic evolved into a low-risk period.

Use of Selected Recommended Clinical Preventive Services - Behavioral Risk Factor Surveillance System, United States, 2018.

Clinical preventive services play an important role in preventing deaths, and Healthy People 2020 has set national goals for using clinical preventive services to improve population health (1). The Patient Protection and Affordable Care Act (ACA) requires many health plans to cover certain recommended clinical preventive services without cost-sharing when provided in-network (covered clinical preventive services).* To ascertain prevalence of the use of selected recommended clinical preventive services among persons aged ≥18 years, CDC analyzed data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a state-based annual nationwide survey conducted via landline and mobile phones in the United States, for 10 clinical preventive services covered in-network with no cost-sharing pursuant to the ACA. The weighted prevalence of colon, cervical, and breast cancer screening, pneumococcal and tetanus vaccination, and diabetes screening ranged from 66.0% to 79.2%; the prevalence of the other four clinical preventive services were <50%: 16.5% for human papillomavirus (HPV) vaccination, 26.6% for zoster (shingles) vaccination, 33.2% for influenza vaccination, and 45.8% for HIV testing. Prevalence of HIV testing had the widest variation (3.1-fold differences) across states among the 10 services included in this report. The prevalence of use of clinical preventive services varied by insurance status, income level, and rurality, findings that are consistent with previous studies (2-6). The use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status was the dominant factor strongly associated with use of clinical preventive services, followed by income-level and rurality. Understanding factors influencing use of recommended clinical preventive services can potentially help decision makers better identify policies to increase their use including strategies to increase insurance coverage.

Economic burden of comorbid chronic conditions among survivors of stroke in China: 10-year longitudinal study.

BACKGROUND: The coexistence of chronic diseases among people with stroke is common. However, little is known about the extent of incremental healthcare expenditures associated with having physically and psychologically chronic conditions among stroke survivors. METHODS: We used the nationally representative data from the China Health and Nutrition Survey, including 36,076 participants enrolled as our analytic cohort of ten years of follow-up visits (2006, 2009, 2011, 2015). Chronic conditions include hypertension, diabetes, obesity, and impaired cognitive function. Two-part models were used to estimate the effect of comorbid chronic conditions on total annual healthcare expenditure, out-of-pocket (OOP) healthcare expenditure, and incidence of catastrophic healthcare expenditure (CHE). RESULTS: Among survivors of stroke during 2006 to 2015, the prevalence rates of hypertension, diabetes, obesity and impaired cognitive function were 75.5, 9.8, 12.7 and 65.1%, significantly higher than those among adults without stroke history (27.9, 2.7, 10.0 and 41.2%). Having hypertension ($794.5, p = 0.004), diabetes ($3978.5, p < 0.001) were associated with the largest incremental total healthcare expenditures. Stroke survivors with diagnosed hypertension and diabetes had additional 5.7 (p < 0.001) and 10.4 (p < 0.001) percentage point of CHE rate, respectively. Total healthcare expenditures were $2413.0 (P < 0.001) and $5151.7 (P < 0.001) higher among patients with 2, and ≥ 3 chronic conditions, respectively, than those individuals with no chronic conditions. CONCLUSIONS: Excess expenditures associated with chronic diseases were substantial among stroke survivors. These results highlight the needs for both prevention and better management of multimorbidity among stroke survivors, which in turn may lower the financial burden of treating these concurrent comorbidities.

Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs.

OBJECTIVES: To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay. DESIGN: A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database. SETTING: Twenty-two public hospitals in Sanming, Southern China. PATIENTS: All patients admitted to ICUs from January 1, 2017, to December 31, 2018. INTERVENTION: The implementation of Chinese diagnosis-related group-based payments on January 1, 2018. MEASUREMENTS AND MAIN RESULTS: Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay. CONCLUSIONS: Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

Internet Access and Hypertension Management Among the Elderly Population: A Nationally Representative Cross-Sectional Survey in China.

BACKGROUND: Hypertension is a rapidly growing epidemic in China. Yet, it remains inadequately controlled, especially in rural areas. The internet has shown potential for better health management in different settings; however, few studies have investigated its role in hypertension management in China. OBJECTIVE: This study aims to examine the association between internet access and hypertension awareness, treatment, and control among elderly Chinese adults and to investigate whether the association between internet access and hypertension management differed between those living in urban and rural areas. METHODS: We obtained data from the nationally representative survey of the China Health and Retirement Longitudinal Study in 2011. Hypertension was defined as (1) average systolic blood pressure of ≥140 mm Hg or average diastolic blood pressure of ≥90 mm Hg or (2) currently taking antihypertensive medications. The outcome assessed included hypertension awareness, treatment, and control. The key independent variable was defined as whether one had internet access at home. We performed multivariate logistic regressions for each of the 3 outcomes. RESULTS: Among 5135 hypertensive respondents (age 62.4 [SD 9.9] years; 2351/5135, 45.78% men), 12.89% (662/5135) had internet access at home. Compared with those who had no internet access, internet access was positively associated with hypertension awareness (odds ratio [OR] 1.36, 95% CI 1.07-1.73) and treatment (OR 1.38, 95% CI 1.09-1.75), but not with control (OR 1.19, 95% CI 0.90-1.58). Internet access reduced urban-rural disparity in hypertension awareness by 9.6% (P=.02), treatment by 8.3% (P=.05), but not in control. In addition, the moderating effect of internet access on urban-rural disparities in hypertension management was larger among females. The decreased urban-rural disparities were primarily driven by that internet access improved the management level in rural areas. CONCLUSIONS: Despite the low rate of internet access among the elderly population, the internet shows its potential as a platform for achieving better hypertension management in China. Strategies for reducing the disparities in hypertension management and overall disease burden of hypertension among the elderly population might consider the internet as a platform.

A Chaotic Electromagnetic Field Optimization Algorithm Based on Fuzzy Entropy for Multilevel Thresholding Color Image Segmentation.

Multilevel thresholding segmentation of color images is an important technology in various applications which has received more attention in recent years. The process of determining the optimal threshold values in the case of traditional methods is time-consuming. In order to mitigate the above problem, meta-heuristic algorithms have been employed in this field for searching the optima during the past few years. In this paper, an effective technique of Electromagnetic Field Optimization (EFO) algorithm based on a fuzzy entropy criterion is proposed, and in addition, a novel chaotic strategy is embedded into EFO to develop a new algorithm named CEFO. To evaluate the robustness of the proposed algorithm, other competitive algorithms such as Artificial Bee Colony (ABC), Bat Algorithm (BA), Wind Driven Optimization (WDO), and Bird Swarm Algorithm (BSA) are compared using fuzzy entropy as the fitness function. Furthermore, the proposed segmentation method is also compared with the most widely used approaches of Otsu's variance and Kapur's entropy to verify its segmentation accuracy and efficiency. Experiments are conducted on ten Berkeley benchmark images and the simulation results are presented in terms of peak signal to noise ratio (PSNR), mean structural similarity (MSSIM), feature similarity (FSIM), and computational time (CPU Time) at different threshold levels of 4, 6, 8, and 10 for each test image. A series of experiments can significantly demonstrate the superior performance of the proposed technique, which can deal with multilevel thresholding color image segmentation excellently.

Trends in health resource disparities in primary health care institutions in Liaoning Province in Northeast China.

BACKGROUND: The allocation of health resources in primary health care institutions (PHCI) is crucial to health reform. China has recently implemented many reform measures emphasizing the provision of primary health care services, with equity as one of the major goals. The aim of this study was to analyze the quantity, quality, and distribution of health resources in Liaoning Province from 2005 to 2017. METHODS: Data were drawn from the annual financial report from 2005 to 2017 and information from the Liaoning Province Department of Statistics. Numbers of beds and physicians were used as indicators of health resources. Capital assets per bed, value of medical equipment per bed, operational space per bed, and number of physicians with different educational levels were used as indicators of quality of health resources. Concentration indices (CI) and Gini coefficients were calculated. RESULTS: There was a steady rise in health resources in PHCI. From 2005 to 2017, the quality of health resources improved. The CI of beds showed an overall downward trend, indicating an improvement in the disparity among PHCI. There was a similar trend in the CI of fixed assets per bed. The Gini coefficients of physicians overall and physicians with different educational levels were almost always < 0.3, showing preferred equity status. There was a decreasing trend in the Gini coefficients of PHCI physicians with bachelor's degrees or higher and physicians with associate's degrees. The proportion of health resource of PHCI in health system increased from 2005 to 2009, before decreasing from 2009 to 2017 and the percentage of physicians overall and physicians with bachelor's degrees or higher in PHCI declined after 2011. CONCLUSIONS: There was an improvement in the quantity and quality of health resources in PHCI from 2005 to 2017. The distribution of health resource allocation in PHCI also improved. The findings revealed that the measures for the improvement of PHCI physicians' educational level has been successful and the measures taken by the government in health reform to strengthen the primary health care system have not been successful.

Efficiency performance of China's health care delivery system.

Improving efficiency performance of the health care delivery system has been on the agenda for the health system reform that China initiated in 2009. This study examines the changes in efficiency performance and determinants of efficiency after the reform to provide evidence to assess the progress of the reform from the perspective of efficiency. Descriptive analysis, Data Envelopment Analysis, the Malmquist Index, and multilevel regressions are used with data from multiple sources, including the World Bank, the China Health Statistical Yearbook, and routine reports. The results indicate that over the last decade, health outcomes compared with health investment were relatively higher in China than in most other countries worldwide, and the trend was stable. The overall efficiency and total factor productivity increased after the reform, indicating that the reform was likely to have had a positive impact on the efficiency performance of the health care delivery system. However, the health care delivery structure showed low system efficiency, mainly attributed to the weakened primary health care system. Strengthening the primary health care system is central to enhancing the future performance of China's health care delivery system.

Trajectory of multimorbidity before dementia: A 24-year follow-up study.

INTRODUCTION: Although the multimorbidity-dementia association has been widely addressed, little is known on the long-term trajectory of multimorbidity (TOM) in preclinical dementia. METHODS: Based on the Health and Retirement Study, burden of multimorbidity was quantified with the total number of eight long-term conditions (LTC). Patterns of TOM before dementia diagnosis were investigated with mixed-effects models. RESULTS: In 1752 dementia cases and 5256 matched controls, cases showed higher and faster increasing predicted number of LTC than controls, with a significant case-control difference from 20 years prior to dementia diagnosis. Larger increases in number of LTC during preclinical phase of dementia were found in White participants, females, those whose age at dementia onset was younger, and those who were less educated. DISCUSSION: Our findings emphasize the faster accumulation of multimorbidity in prodromal dementia than in natural aging, as well as effect modifications by age and sex. Highlights: TOM increased faster in prodromal dementia than in natural ageing.Patterns of TOM by dementia status diverged at 20 years before dementia diagnosis.Patterns of TOM were modified by age and sex.

Higher ratio of plasma omega-6/omega-3 fatty acids is associated with greater risk of all-cause, cancer, and cardiovascular mortality: a population-based cohort study in UK Biobank.

Background: Circulating omega-3 and omega-6 polyunsaturated fatty acids (PUFAs) have been associated with various chronic diseases and mortality, but results are conflicting. Few studies examined the role of omega-6/omega-3 ratio in mortality. Methods: We investigated plasma omega-3 and omega-6 PUFAs and their ratio in relation to all-cause and cause-specific mortality in a large prospective cohort, the UK Biobank. Of 85,425 participants who had complete information on circulating PUFAs, 6,461 died during follow-up, including 2,794 from cancer and 1,668 from cardiovascular disease (CVD). Associations were estimated by multivariable Cox proportional hazards regression with adjustment for relevant risk factors. Results: Risk for all three mortality outcomes increased as the ratio of omega-6/omega-3 PUFAs increased (all Ptrend < 0.05). Comparing the highest to the lowest quintiles, individuals had 26% (95% CI, 15-38%) higher total mortality, 14% (95% CI, 0-31%) higher cancer mortality, and 31% (95% CI, 10-55%) higher CVD mortality. Moreover, omega-3 and omega-6 PUFAs in plasma were all inversely associated with all-cause, cancer, and CVD mortality, with omega-3 showing stronger effects. Conclusions: Using a population-based cohort in UK Biobank, our study revealed a strong association between the ratio of circulating omega-6/omega-3 PUFAs and the risk of all-cause, cancer, and CVD mortality.

Associations of plasma omega-6 and omega-3 fatty acids with overall and 19 site-specific cancers: a population-based cohort study in UK Biobank.

Background: Previous epidemiological studies of the associations between polyunsaturated fatty acids (PUFAs) and cancer incidence have been inconsistent. We investigated the associations of plasma omega-3 and omega-6 PUFAs with the incidence of overall and 19 site-specific cancers in a large prospective cohort. Methods: 253,138 eligible UK Biobank participants were included in our study. With a mean follow-up of 12.9 years, 29,838 participants were diagnosed with cancer. The plasma levels of omega-3 and omega-6 PUFAs were expressed as percentages of total fatty acids (omega-3% and omega-6%). Results: In our main models, both omega-6% and omega-3% were inversely associated with overall cancer incidence (HR per SD = 0.98, 95% CI = 0.96-0.99; HR per SD = 0.99, 95% CI = 0.97-1.00; respectively). Of the 19 site-specific cancers available, 14 were associated with omega-6% and five with omega-3%, all indicating inverse associations, with the exception that prostate cancer was positively associated with omega-3% (HR per SD = 1.03, 95% CI = 1.01 - 1.05). Conclusions: Our population-based cohort study in UK Biobank indicates small inverse associations of plasma omega-6 and omega-3 PUFAs with the incidence of overall and most site-specific cancers, although there are notable exceptions, such as prostate cancer.

Factors associated with psychological insulin resistance among patients with type 2 diabetes in China.

Objective: The aim of this study was to understand the psychological insulin resistance status among Chinese patients with type 2 diabetes and investigate its associated factors in these patients. Methods: A multi-stage stratified random sampling was performed to randomly select patients with type 2 diabetes from the eastern, central, and western regions in Shandong Province, China, and 660 valid questionnaires were collected. Psychological insulin resistance was assessed by the scale of My Opinion on Insulin (MOI). Factors associated with psychological insulin resistance were examined in a binary logistic model. Results: Four-fifths of the patients with type 2 diabetes (82.1%) had psychological insulin resistance. Being female (OR = 1.770, 95% CI: 1.063-2.950, p < 0.05), having a monthly income of greater than 4,000 Renminbi (approximately $1,540) (OR = 0.444, 95% CI: 0.216-0.915, p < 0.05), living with type 2 diabetes for 11 years or more (OR = 0.387, 95% CI: 0.238-0.630, p < 0.05), self-rated poor health (OR = 1.706, 95% CI: 1.092-2.664, p < 0.05), and moderate discrimination against type 2 diabetes (OR = 1.924, 95% CI: 1.166-3.175, p < 0.05) were associated with psychological insulin resistance. Conclusions: The prevalence of psychological insulin resistance among Chinese patients with type 2 diabetes is relatively high. Approaches are needed to address the issue of psychological insulin resistance of type 2 diabetes.

Higher ratio of plasma omega-6/omega-3 fatty acids is associated with greater risk of all-cause, cancer, and cardiovascular mortality: A population-based cohort study in UK Biobank.

Background: Circulating omega-3 and omega-6 polyunsaturated fatty acids (PUFAs) have been associated with various chronic diseases and mortality, but results are conflicting. Few studies examined the role of omega-6/omega-3 ratio in mortality. Methods: We investigated plasma omega-3 and omega-6 PUFAs and their ratio in relation to all-cause and cause-specific mortality in a large prospective cohort, the UK Biobank. Of 85,425 participants who had complete information on circulating PUFAs, 6461 died during follow-up, including 2794 from cancer and 1668 from cardiovascular disease (CVD). Associations were estimated by multivariable Cox proportional hazards regression with adjustment for relevant risk factors. Results: Risk for all three mortality outcomes increased as the ratio of omega-6/omega-3 PUFAs increased (all Ptrend <0.05). Comparing the highest to the lowest quintiles, individuals had 26% (95% CI, 15-38%) higher total mortality, 14% (95% CI, 0-31%) higher cancer mortality, and 31% (95% CI, 10-55%) higher CVD mortality. Moreover, omega-3 and omega-6 PUFAs in plasma were all inversely associated with all-cause, cancer, and CVD mortality, with omega-3 showing stronger effects. Conclusions: Using a population-based cohort in UK Biobank, our study revealed a strong association between the ratio of circulating omega-6/omega-3 PUFAs and the risk of all-cause, cancer, and CVD mortality. Funding: Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institute of Health under the award number R35GM143060 (KY). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Fatty acids play an essential role in health. Studies have shown that diets high in omega-3 fatty acids found in foods like fish, fish oil, flaxseed and walnuts may be beneficial. Yet some studies have raised concern that too many omega-6 fatty acids in Western diets rich in vegetable oils may be harmful. Some scientists have proposed that the balance of omega-3 and omega-6 in diets is vital to health. They hypothesize that a higher omega-6 to omega-3 fatty acids ratio is detrimental. But, proving that a higher ratio of omega-6 to omega-3 fatty acids is harmful has been difficult. Many studies have found conflicting results. Scientists have struggled to accurately measure fatty acid intake as tracking an individual's dietary intake is challenging and self-reported dietary intake may be incorrect. Additionally, scientists must follow individuals for many years to determine if a high ratio of omega-6 to omega-3 is linked with cancer, heart disease, or death. But, measuring circulating fatty acids in an individual's blood may offer an easier and more reliable approach to studying the health impacts of these vital nutrients. Zhang et al. show that people with higher ratios of omega-6 to omega-3 fatty acids in their blood are at greater risk of dying from cancer, heart disease, or any cause than those with lower ratios. The experiments measured omega-6 and omega-3 fatty acid levels in more than 85,000 participants in the UK Biobank who scientists followed for an average of about 13 years. Participants with the highest ratios of omega-6 to omega-3 fatty acids were 26% more likely to die of any cause, 14% more likely to die of cancer, and 31% more likely to die of heart disease than individuals with the lowest ratios. Individually, high levels of omega-6 fatty acids and high levels of omega-3 fatty acids were both associated with a lower risk of dying. But the protective effects of omega-3 were greater. For example, individuals with the highest levels of omega-6 fatty acids were 23% less likely to die of any cause. By comparison, those with the highest levels of omega-3s were 31% less likely to die. The stronger protection offered by high levels of omega-3s likely explains why having a high ratio of omega-6s to omega-3s was linked to harm. Both are protective. But the protection provided by omega-3s is more robust. The experiments support dietary interventions to raise omega-3 fatty acid levels and maintain a low omega-6 to omega-3 fatty acid ratio to prevent early deaths from cancer, heart disease or other causes. More research is needed to understand the impact of dietary fatty acid intake on other diseases and how genetics may influence the health impact of fatty acids.