Lifestyle factors and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study

Association between changes in cardiovascular health and the risk of multimorbidity: community-based cohort studies in the UK and Finland

Background

Better cardiovascular health is associated with lower risk of various chronic diseases, but its association with multimorbidity is poorly understood. We aimed to examine whether change in cardiovascular health is associated with multimorbidity risk.

Methods

The primary analysis was conducted in the Whitehall II multiwave prospective cohort study (UK) and the validation analysis in the Finnish Public Sector cohort study (Finland). Change in cardiovascular health was assessed using the American Heart Association Life's Simple 7 (LS7) and Life's Essential 8 (LE8) at baseline and re-assessments, using objective measures in Whitehall II and self-reports and pharmacy claims in the Finnish Public Sector cohort study, respectively. Multimorbidity was defined as the presence of two or more of 12 chronic diseases during follow-up. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox's proportional hazard models with age as time scale, adjusting for sex, education, occupation, marital status, and ethnicity.

Findings

In the primary analysis among 9715 participants, mean age was 44.8 (standard deviation 6.0) years and 67.6% participants were men at baseline. During the median follow-up of 31.4 (interquartile range 26.8-32.3) years, 2751 participants developed multimorbidity. The hazard of multimorbidity decreased by 8% (HR 0.92, 95% CI 0.88-0.96) per ideal LS7 metric increment over 5 years and by 14% (HR 0.86, 95% CI 0.80-0.93) per ten points increase in LE8 score over 10 years. These findings were replicated in the validation analysis among 75,377 participants in terms of 4-year change in cardiovascular health.

Interpretation

Improvement in cardiovascular health was associated with lower multimorbidity risk in two community-based cohort studies. Interventions improving cardiovascular health of the community may contribute to multimorbidity prevention.

Funding

None.

Association of lifestyles and multimorbidity with mortality among individuals aged 60 years or older: Two prospective cohort studies

Lifestyles are associated with all-cause mortality, yet limited research has explored the association in the elderly population with multimorbidity. We aim to investigate the impact of adopting a healthy lifestyle on reducing the risk of all-cause mortality in older individuals with or without multimorbidity in both China and UK. This prospective study included 29,451 and 173,503 older adults aged 60 and over from Chinese Longitudinal Healthy Longevity Survey (CLHLS) and UK Biobank. Lifestyles and multimorbidity were categorized into three groups, respectively. Cox proportional hazards regression was used to estimate the Hazard Ratios (HRs), 95% confidence intervals (95% CIs), and dose-response for all-cause mortality in relation to lifestyles and multimorbidity, as well as the combination of both factors. During a mean follow-up period of 4.7 years in CLHLS and 12.14 years in UK Biobank, we observed 21,540 and 20,720 deaths, respectively. For participants with two or more conditions, compared to those with an unhealthy lifestyle, adopting a healthy lifestyle was associated with a 27%-41% and 22%-42% reduction in mortality risk in the CLHLS and UK Biobank, respectively; Similarly, for individuals without multimorbidity, this reduction ranged from 18% to 41%. Among participants with multimorbidity, individuals with an unhealthy lifestyle had a higher mortality risk compared to those maintaining a healthy lifestyle, with HRs of 1.15 (95% CI: 1.00, 1.32) and 1.27 (95% CI: 1.16, 1.39) for two conditions, and 1.24 (95% CI: 1.06, 1.45) and 1.73 (95% CI: 1.56, 1.91) for three or more conditions in CLHLS and UK Biobank, respectively. Adherence to a healthy lifestyle can yield comparable mortality benefits for older individuals, regardless of their multimorbidity status. Furthermore, maintaining a healthy lifestyle can alleviate the mortality risks linked to a higher number of diseases.

Healthy lifestyle change and all-cause and cancer mortality in the European Prospective Investigation into Cancer and Nutrition cohort

BACKGROUND

Healthy lifestyles are inversely associated with the risk of noncommunicable diseases, which are leading causes of death. However, few studies have used longitudinal data to assess the impact of changing lifestyle behaviours on all-cause and cancer mortality.

METHODS

Within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, lifestyle profiles of 308,497 cancer-free adults (71% female) aged 35-70 years at recruitment across nine countries were assessed with baseline and follow-up questionnaires administered on average of 7 years apart. A healthy lifestyle index (HLI), assessed at two time points, combined information on smoking status, alcohol intake, body mass index, and physical activity, and ranged from 0 to 16 units. A change score was calculated as the difference between HLI at baseline and follow-up. Associations between HLI change and all-cause and cancer mortality were modelled with Cox regression, and the impact of changing HLI on accelerating mortality rate was estimated by rate advancement periods (RAP, in years).

RESULTS

After the follow-up questionnaire, participants were followed for an average of 9.9 years, with 21,696 deaths (8407 cancer deaths) documented. Compared to participants whose HLIs remained stable (within one unit), improving HLI by more than one unit was inversely associated with all-cause and cancer mortality (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.81, 0.88; and HR: 0.87; 95% CI: 0.82, 0.92; respectively), while worsening HLI by more than one unit was associated with an increase in mortality (all-cause mortality HR: 1.26; 95% CI: 1.20, 1.33; cancer mortality HR: 1.19; 95% CI: 1.09, 1.29). Participants who worsened HLI by more than one advanced their risk of death by 1.62 (1.44, 1.96) years, while participants who improved HLI by the same amount delayed their risk of death by 1.19 (0.65, 2.32) years, compared to those with stable HLI.

CONCLUSIONS

Making healthier lifestyle changes during adulthood was inversely associated with all-cause and cancer mortality and delayed risk of death. Conversely, making unhealthier lifestyle changes was positively associated with mortality and an accelerated risk of death.

Association of the CUN-BAE body adiposity estimator and other obesity indicators with cardiometabolic multimorbidity: a cross-sectional study

Cardiometabolic multimorbidity (CM), defined as the coexistence of two or three cardiometabolic disorders, is one of the most common and deleterious multimorbidities. This study aimed to investigate the association of Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE), body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) with the prevalence of CM. The data were obtained from the 2021 health checkup database for residents of the Electronic Health Management Center in Xinzheng, Henan Province, China. 81,532 participants aged ≥ 60 years were included in this study. Logistic regression models were used to estimate the odd ratios (ORs) and 95% confidence intervals (CIs) for CUN-BAE, BMI, WC, and WHtR in CM. The area under the receiver operating characteristic curve (AUC) was used to compare the discriminatory ability of different anthropometric indicators for CM. The multivariable-adjusted ORs (95% CIs) (per 1 SD increase) of CM were 1.799 (1.710-1.893) for CUN-BAE, 1.329 (1.295-1.364) for BMI, 1.343 (1.308-1.378) for WC, and 1.314 (1.280-1.349) for WHtR, respectively. Compared with BMI, WC and WHtR, CUN-BAE had the highest AUC in both males and females (AUC: 0.642; 95% CI 0.630-0.653 for males, AUC: 0.614; 95% CI 0.630-0.653 for females). CUN-BAE may be a better measure of the adverse effect of adiposity on the prevalence of CM than BMI, WC, and WHtR.

General population normative values for the EORTC QLQ-C30 by age, sex, and health condition for the French general population

BACKGROUND

General population normative values for the widely used health-related quality of life (HRQoL) measure EORTC QLQ-C30 support the interpretation of trial results and HRQoL of patients in clinical practice. Here, we provide sex-, age- and health condition-specific normative values for the EORTC QLQ-C30 in the French general population.

METHODS

French general population data was collected in an international EORTC project. Online panels with quota samples were used to recruit sex and age groups. Number and type of comorbidities were assessed. Descriptive statistics were used to calculate general population values for each QLQ-C30 scale, separately for sex, age, and presence of one- and more chronic health conditions. A multivariate linear regression model has been developed to allow estimating the effect of sex, age, and the presence for one- and more chronic health conditions on EORTC QLQ-C30 scores. Data was weighted according to United Nation statistics adjusting for the proportion of sex and age groups.

RESULTS

In total, 1001 French respondents were included in our analyses. The weighted mean age was 47.9 years, 514 (51.3%) participants were women, and 497 (52.2%) participants reported at least one health condition. Men reported statistically significant better scores for Emotional Functioning (+9.6 points, p = 0.006) and Fatigue (-7.8 point; p = 0.04); women reported better profiles for Role Functioning (+8.7 points; p = 0.008) and Financial Difficulty (-7.8 points, p = 0.011). According to the regression model, the sex effect was statistically significant in eight scales; the effect of increasing age had a statistically significant effect on seven of the 15 EORTC QLQ-C30 scales. The sex- and age effect varied in its direction across the various scales. The presence of health conditions showed a strong negative effect on all scales.

CONCLUSION

This is the first publication of detailed French normative values for the EORTC QLQ-C30. It aims to support the interpretation of HRQoL profiles in French cancer populations. The strong impact of health conditions on QLQ-C30 scores highlights the importance of considering the impact of comorbidities in cancer patients when interpreting HRQoL data.

The regional disparities in liver disease comorbidity among elderly Chinese based on a health ecological model: the China Health and Retirement Longitudinal Study

PURPOSE

This study aimed to investigate the risk factors for liver disease comorbidity among older adults in eastern, central, and western China, and explored binary, ternary and quaternary co-morbid co-causal patterns of liver disease within a health ecological model.

METHOD

Basic information from 9,763 older adults was analyzed using data from the China Health and Retirement Longitudinal Study (CHARLS). LASSO regression was employed to identify significant predictors in eastern, central, and western China. Patterns of liver disease comorbidity were studied using association rules, and spatial distribution was analyzed using a geographic information system. Furthermore, binary, ternary, and quaternary network diagrams were constructed to illustrate the relationships between liver disease comorbidity and co-causes.

RESULTS

Among the 9,763 elderly adults studied, 536 were found to have liver disease comorbidity, with binary or ternary comorbidity being the most prevalent. Provinces with a high prevalence of liver disease comorbidity were primarily concentrated in Inner Mongolia, Sichuan, and Henan. The most common comorbidity patterns identified were "liver-heart-metabolic", "liver-kidney", "liver-lung", and "liver-stomach-arthritic". In the eastern region, important combination patterns included "liver disease-metabolic disease", "liver disease-stomach disease", and "liver disease-arthritis", with the main influencing factors being sleep duration of less than 6 h, frequent drinking, female, and daily activity capability. In the central region, common combination patterns included "liver disease-heart disease", "liver disease-metabolic disease", and "liver disease-kidney disease", with the main influencing factors being an education level of primary school or below, marriage, having medical insurance, exercise, and no disabilities. In the western region, the main comorbidity patterns were "liver disease-chronic lung disease", "liver disease-stomach disease", "liver disease-heart disease", and "liver disease-arthritis", with the main influencing factors being general or poor health satisfaction, general or poor health condition, severe pain, and no disabilities.

CONCLUSION

The comorbidities associated with liver disease exhibit specific clustering patterns at both the overall and local levels. By analyzing the comorbidity patterns of liver diseases in different regions and establishing co-morbid co-causal patterns, this study offers a new perspective and scientific basis for the prevention and treatment of liver diseases.

The association between Chinese visceral adiposity index and cardiometabolic multimorbidity among Chinese middle-aged and older adults: a national cohort study

Objective

This study aimed to explore the association between the Chinese visceral adiposity index (CVAI) and cardiometabolic multimorbidity in middle-aged and older Chinese adults.

Methods

The data used in this study were obtained from a national cohort, the China Health and Retirement Longitudinal Study (CHARLS, 2011-2018 wave). The CVAI was measured using previously validated biomarker estimation formulas, which included sex, age, body mass index, waist circumference, triglycerides, and high-density lipoprotein cholesterol. The presence of two or more of these cardiometabolic diseases (diabetes, heart disease, and stroke) is considered as cardiometabolic multimorbidity. We used Cox proportional hazard regression models to examine the association between CVAI and cardiometabolic multimorbidity, adjusting for a set of covariates. Hazard ratios (HRs) and 95% confidence intervals (CIs) were used to show the strength of the associations. We also conducted a subgroup analysis between age and sex, as well as two sensitivity analyses. Receiver operator characteristic curves (ROC) were used to test the predictive capabilities and cutoff value of the CVAI for cardiometabolic multimorbidity.

Results

A total of 9028 participants were included in the final analysis, with a mean age of 59.3 years (standard deviation: 9.3) and women accounting for 53.7% of the sample population. In the fully-adjusted model, compared with participants in the Q1 of CVAI, the Q3 (HR = 2.203, 95% CI = 1.039 - 3.774) and Q4 of CVAI (HR = 3.547, 95% CI = 2.100 - 5.992) were associated with an increased risk of cardiometabolic multimorbidity. There was no evidence of an interaction between the CVAI quartiles and sex or age in association with cardiometabolic multimorbidity (P >0.05). The results of both sensitivity analyses suggested that the association between CVAI and cardiometabolic multimorbidity was robust. In addition, the area under ROC and ideal cutoff value for CVAI prediction of cardiometabolic multimorbidity were 0.685 (95% CI = 0.649-0.722) and 121.388.

Conclusion

The CVAI is a valid biomarker with good predictive capability for cardiometabolic multimorbidity and can be used by primary healthcare organizations in the future for early warning, prevention, and intervention with regard to cardiometabolic multimorbidity.

Nutrient intake and risk of multimorbidity: a prospective cohort study of 25,389 women

BACKGROUND

Multimorbidity is becoming an increasingly serious public health challenge in the aging population. The impact of nutrients on multimorbidity remains to be determined and was explored using data from a UK cohort study.

METHOD

Our research analysis is mainly based on the data collected by the United Kingdom Women's Cohort Study (UKWCS), which recruited 35,372 women aged 35-69 years at baseline (1995 to 1998), aiming to explore potential associations between diet and chronic diseases. Daily intakes of energy and nutrients were estimated using a validated 217-item food frequency questionnaire at recruitment. Multimorbidity was assessed using the Charlson comorbidity index (CCI) through electronic linkages to Hospital Episode Statistics up to March 2019. Cox's proportional hazards models were used to estimate associations between daily intakes of nutrients and risk of multimorbidity. Those associations were also analyzed in multinomial logistic regression as a sensitivity analysis. In addition, a stratified analysis was conducted with age 60 as the cutoff point.

RESULTS

Among the 25,389 participants, 7,799 subjects (30.7%) were confirmed with multimorbidity over a median follow-up of 22 years. Compared with the lowest quintile, the highest quintile of daily intakes of energy and protein were associated with 8% and 12% increased risk of multimorbidity respectively (HR 1.08 (95% CI 1.01, 1.16), p-linearity = 0.022 for energy; 1.12 (1.04, 1.21), p-linearity = 0.003 for protein). Higher quintiles of daily intakes of vitamin C and iron had a slightly lowered risk of multimorbidity, compared to the lowest quintile. A significantly higher risk of multimorbidity was found to be linearly associated with higher intake quintiles of vitamin B12 and vitamin D (p-linearity = 0.001 and 0.002, respectively) in Cox models, which became insignificant in multinomial logistic regression. There was some evidence of effect modification by age in intakes of iron and vitamin B1 associated with the risk of multimorbidity (p-interaction = 0.006 and 0.025, respectively).

CONCLUSIONS

Our findings highlight a link between nutrient intake and multimorbidity risk. However, there is uncertainty in our results, and more research is needed before definite conclusions can be reached.

Assessing the modifiable and non-modifiable risk factors associated with multimorbidity in reproductive aged women in India

BACKGROUND

Reproductive span is the foundation of every woman's health in later life. India is currently facing a growing burden of multiple morbidities among the women in their reproductive age group which may further increase over the coming decades. The purpose of the present study aimed to identify different modifiable and non-modifiable risk factors affecting multimorbidity among the women in reproductive age group in Indian context.

METHODS

Secondary data were obtained from the Demography and Health Survey (DHS), conducted in India during 2019-2021. A total of 671,967 women aged 15-49 years were selected for this present study. Descriptive, association studies and multinominal logistic regression analyses were performed to accomplish the objectives.

RESULTS

Currently, 6.3% of total study participant's reproductive age group women suffered from multimorbidity in India. Never consuming protein, fruits, vegetables and milk increase the chances of developing multimorbidity. Consumption of fried foods, aerated drinks and addiction towards tobacco and alcohol also has a greater influence on the prevalence of multimorbidity. The prevalence of multimorbidity is sharply increased with increasing age and Body Mass Index (BMI). Regionally, the prevalence of multimorbidity was found more among the women hailed from eastern and north-eastern India.

CONCLUSION

To reduce the risk of developing multimorbidity, targeted interventions are needed in the form of educating every woman concerning the importance of having minimum health-related knowledge, maintaining healthy lifestyle, weight management and having proper and balanced diet.

Management of cancer patients at high and very-high risk of cardiotoxicity: Main questions and answers

In recent years, important advances have been made in the field of Cardio-Oncology. The 2022 ESC Guidelines on Cardio-Oncology proposed a baseline cardiovascular risk stratification for cancer patients and preventive strategies in patients at high and very-high risk of cardiotoxicity. Cardiovascular toxic effects of anti-cancer drugs are being extensively studied; surveillance programs have been proposed, based on the baseline cardiovascular risk. On the other hand, there is little data on Cardio-Oncological management of patients at high and very-high cardiovascular risk with previous cardiovascular diseases. For example, little is known about management of cancer patients with heart failure with reduced ejection fraction (HFrEF), patients with a recent myocardial infarction or other cardiovascular diseases; when to resume anti-cancer drugs after a cardiovascular toxic event. Collaboration between Cardiologists and Oncologists and multidisciplinary team evaluations are certainly essential to decide the best therapeutic strategy for cancer patients, to treat cancer while saving the heart. Therefore, in the present review, we attempt to provide a useful guide to clinicians in treating patients with high and very-high risk of cardiotoxicity by enucleating main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.

Healthy lifestyle decreases the risk of the first incidence of non-communicable chronic disease and its progression to multimorbidity and its mediating roles of metabolic components: a prospective cohort study in China

OBJECTIVES

To identify the influence of healthy lifestyles on the incidence of the first NCD (FNCD), multiple chronic conditions (MCCs), and the progression from FNCD to MCCs.

DESIGN

cohort study.

SETTING

Zhejiang, China PARTICIPANTS: 10566 subjects (55.5 ± 13.5 years, 43.1% male) free of NCDs at baseline from the Zhejiang Metabolic Syndrome prospective cohort.

MEASUREMENTS

Healthy lifestyle score (HLS) was developed by 6 common healthy lifestyle factors as smoking, alcohol drinking, physical activity, body mass index (BMI) and waist-to-hip ratio (WHR). Healthy lifestyle data and metabolic biomarkers collected via a face-to-face questionnaire-based interview, clinical health examination and routine biochemical determination. Biochemical variables were determined using biochemical auto-analyzer. Participants were stratified into four group based on the levels of HLS as ≤2, 3, 4 and ≥5. Multiple Cox proportional hazards model was applied to examine the relationship between HLS and the risk of FNCD, MCCs and the progression from FNCD to MCCs. The population-attributable fractions (PAF) were used to assess the attributable role of HLS. Mediating effect was examined by mediation package in R.

RESULTS

After a median of 9.92 years of follow-up, 1572 participants (14.9%) developed FNCD, and 149 (1.4%) developed MCCs. In the fully adjusted model, the higher HLS group (≥5) was associated with lower risk of FNCD (HR = 0.68 and 95% CI: 0.56-0.82), MCCs (HR = 0.31 and 95%CI: 0.14-0.69); and the progression from FNCD to MCCs (HR = 0.39 and 95%CI: 0.18-0.85). Metabolic components (TC, TG, HDL-C, LDC-C, FPG, and UA) played the mediating roles with the proportion ranging from 5.02% to 22.2% for FNCD and 5.94% to 20.1% for MCCs. PAFs (95%CI) for poor adherence to the overall healthy lifestyle (HLS ≤ 3) were 17.5% (11.2%, 23.7%) for FNCD, 42.9% (23.4%, 61.0%) for MCCs, and 37.0% (15.5%, 56.3%) for the progression from FNCD to MCCs.

CONCLUSIONS

High HLS decreases the risk of FNCD, MCCs, and the progression from FNCD to MCCs. These effects are partially mediated by metabolic components. Maintaining healthy lifestyles might reduce the disease burden of common chronic diseases.

Effects of the Omaha System- and HeartScore®-Based Impaired-Risk Perception Reduction Program on the Risk Perception of Individuals Aged 50-65 Years: A One-Group Pre-Test-Post-Test Study

PURPOSE

This study evaluates the impact of interventions in the Omaha System and HeartScore®-based program to reduce impaired-risk perception.

DESIGN

and setting: This study utilized a one-group pre-test-post-test design.

SUBJECTS

The program was conducted among participants aged over 50 years from different social settings.

INTERVENTION

The program had three parts: a briefing on HeartScore® recommendations, Omaha System interventions, and referral to a doctor.

MEASURES

HeartScore® determined cardiovascular disease (CVD) risk, body mass index (BMI) was calculated from height and weight, and the International PA Questionnaire evaluated physical activity (PA) levels. Self-assessment was used to perceived CVD risk, BMI, and PA.

ANALYSIS

We used the Wilcoxon signed-rank test to compare the pre-test and post-test scores of the Omaha System, the problem rating scale (PRS) subscales and McNemar test to measure changes in CVD risk perception, BMI, and PA level.

RESULTS

310 high-risk individuals out of 522 had impaired perception of their CVD risk. Only 201 responded to follow-up phone calls. Interventions based on HeartScore® and Omaha System improved CVD risk and PA perceptions (P < .001) but not BMI. The program significantly increased knowledge, status, and behavior scores (P < .001). After participating, 39% saw a cardiologist, and 57.2% saw a family physician within six months to reduce impaired risk perception. CVD risk perception increased to the actual level after the intervention, mostly in the group with low education level.

CONCLUSIONS

The program using the Omaha System and HeartScore® can help middle-aged individuals better understand their risk of cardiovascular disease.

Association of Dietary Protein Sources and Their Adequacy, Body Composition and Risk of Sarcopenic Obesity in South Korean Populations: A Cross-Sectional Study

Dietary protein sources and protein adequacy are crucial modulators of muscle quality and body composition. We investigated the association between dietary protein sources (and their adequacy) and body composition and the risk of sarcopenic obesity (SO) in South Korean populations. The participants (n = 1967) were classified into SO, obese, sarcopenia, and normal groups. A cross-sectional survey was conducted using the KS-15 questionnaire, short-form food frequency questionnaire, and anthropometric measurements. The percentage of body fat (male: 35.36 ± 0.51%; female: 44.14 ± 0.36%) was significantly high, while appendicular skeletal muscle (ASM; male: 36.39 ± 0.30%, female: 30.32 ± 0.19%) was low in the SO group. Beef and pork consumption was negatively associated with ASM (%) but positively associated with body fat (%) in the normal group and positively associated with ASM (kg/m2: beta = 0.002, p = 0.02) and BFM (kg: beta = 0.012, p = 0.03) in the SO group, respectively. The highest quintile (Q5: 173.6 g/day) showed a decreased risk of SO prevalence (AORs: 0.46, CI: 0.22-0.94) compared with that in the lowest quintile (Q1: 21.6 g/day) among the people with inadequacy protein intake. Daily poultry and egg intake was positively linked with body composition in the participants with SO, while red meat showed a negative effect on imbalanced body composition in participants in the normal and SO groups. Furthermore, a lower intake of poultry and eggs was strongly associated with SO prevalence in people who consumed inadequate amounts of daily dietary protein.

Walking pace and the time between the onset of noncommunicable diseases and mortality: a UK Biobank prospective cohort study

PURPOSE

To estimate time spent in various cardiovascular disease (CVD) and cancer states, according to self-reported walking pace.

METHODS

In total, 391,744 UK Biobank participants were included (median age = 57 years; 54.7% women). Data were collected 2006-2010, with follow-up collected in 2021. Usual walking pace was self-defined as slow, steady, average, or brisk. Multistate modeling determined the transition rate and mean sojourn time in and across three different states (healthy, CVD or cancer, and death) upon a time horizon of 10 years.

RESULTS

The mean sojourn time in the healthy state was longer, while that in the CVD or cancer state was shorter in individuals reporting an average or brisk walking pace (vs. slow). A 75-year-old woman reporting a brisk walking pace spent, on average, 8.4 years of the next 10 years in a healthy state; an additional 8.0 (95% CI: 7.3, 8.7) months longer than a 75-year-old woman reporting a slow walking pace. This corresponded to 4.3 (3.7, 4.9) fewer months living with CVD or cancer. Similar results were seen in men.

CONCLUSIONS

Adults reporting an average or brisk walking pace at baseline displayed a lower transition to disease development and a greater proportion of life lived without CVD or cancer.

AVAILABILITY OF DATA AND MATERIALS

Research was conducted using the UK Biobank resource under Application #33266. The UK Biobank resource can be accessed by researchers on application. Variables derived for this study have been returned to the UK Biobank for future applicants to request. No additional data are available.

Environmental inequalities and multimorbidity: Insights from the Southwest China Multi-Ethnic Cohort Study

Multimorbidity is an increasingly significant public health challenge worldwide. Although the association between environmental factors and the morbidity and mortality of individual chronic diseases is well-established, the relationship between environmental inequalities and multimorbidity, as well as the patterns of multimorbidity across different areas and ethnic groups, remains unclear. We first focus on analyzing the differences in environmental exposures and patterns of multimorbidity across diverse areas and ethnic groups. The results show that individuals of Han ethnicity residing in Chongqing and Sichuan are exposure to higher levels of air pollutants such as PM2.5, PM10, and NO2. Conversely, Tibetans in Tibet and Yi people in Yunnan face elevated concentrations of O3. Furthermore, the Dong, Miao, Buyi ethnicities in Guizhou and Bai in Yunnan have greater access to green spaces. The key multimorbidity patterns observed in Southwest China are related to metabolic abnormalities combined with digestive system diseases. However, significant differences in multimorbidity patterns exist among different regions and ethnic groups. Further utilizing the logistic regression model, the analysis demonstrates that increased exposure to environmental pollutants (PM2.5, PM10, NO2, O3) is significantly associated with higher odds ratios of multimorbidity. Conversely, a greater presence of green spaces (NDVI 250, NDVI 500, NDVI 1000) significantly reduces the risk of multimorbidity. This large-scale epidemiological study provides some evidence of a significant association between environmental inequalities and multimorbidity. By addressing these environmental inequalities and promoting healthy environments for all, we can work towards reducing the prevalence of multimorbidity and improving overall population health.

Longitudinal analysis of the Alternative Healthy Eating Index-2010 and incident non-communicable diseases over 15 years in the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health

In studies that contain repeated measures of variables, longitudinal analysis accounting for time-varying covariates is one of the options. We aimed to explore longitudinal association between diet quality (DQ) and non-communicable diseases (NCDs). Participants from the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health (ALSWH) were included, if they; responded to survey 3 (S3, 2003, aged 25-30 years) and at least one survey between survey 4 (S4, 2006) and survey 8 (S8, 2018), were free of NCDs at or before S3, and provided dietary data at S3 or S5. Outcomes were coronary heart disease (CHD), hypertension (HT), asthma, cancer (except skin cancer), diabetes mellitus (DM), depression and/or anxiety, and multimorbidity (MM). Longitudinal modelling using generalised estimation equation (GEE) approach with time-invariant (S4), time-varying (S4-S8) and lagged (S3-S7) covariates were performed. The mean (± standard deviation) of Alternative Healthy Eating Index-2010 (AHEI-2010) of participants (n = 8022) was 51·6 ± 11·0 (range: 19-91). Compared to women with the lowest DQ (AHEI-2010 quintile 1), those in quintile 5 had reduced odds of NCDs in time-invariant model (asthma: OR (95 % CI): 0·77 (0·62-0·96), time-varying model (HT: 0·71 (0·50-0·99); asthma: 0·62 (0·51-0·76); and MM: 0·75 (0·58-0·97) and lagged model (HT: 0·67 (0·49-0·91); and asthma: 0·70 (0·57-0·85). Temporal associations between diet and some NCDs were more prominent in lagged GEE analyses. Evidence of diet as NCD prevention in women aged 25-45 years is evolving, and more studies that consider different longitudinal analyses are needed.

Effectiveness of a socioecological model-guided, smart device-based, self-management-oriented lifestyle intervention in community residents: protocol for a cluster-randomized controlled trial

BACKGROUND

Healthy lifestyles are crucial for preventing chronic diseases. Nonetheless, approximately 90% of Chinese community residents regularly engage in at least one unhealthy lifestyle. Mobile smart devices-based health interventions (mHealth) that incorporate theoretical frameworks regarding behavioral change in interaction with the environment may provide an appealing and cost-effective approach for promoting sustainable adaptations of healthier lifestyles. We designed a randomized controlled trial (RCT) to evaluate the effectiveness of a socioecological model-guided, smart device-based, and self-management-oriented lifestyles (3SLIFE) intervention, to promote healthy lifestyles among Chinese community residents.

METHODS

This two-arm, parallel, cluster-RCT with a 6-month intervention and 6-month follow-up period foresees to randomize a total of 20 communities/villages from 4 townships in a 1:1 ratio to either intervention or control. Within these communities, a total of at least 256 community residents will be enrolled. The experimental group will receive a multi-level intervention based on the socioecological model supplemented with a multi-dimensional empowerment approach. The control group will receive information only. The primary outcome is the reduction of modifiable unhealthy lifestyles at six months, including smoking, excess alcohol consumption, physical inactivity, unbalanced diet, and overweight/obesity. A reduction by one unhealthy behavior measured with the Healthy Lifestyle Index Score (HLIS) will be considered favorable. Secondary outcomes include reduction of specific unhealthy lifestyles at 3 months, 9 months, and 12 months, and mental health outcomes such as depression measured with PHQ-9, social outcomes such as social support measured with the modified Multidimensional Scale of Perceived Social Support, clinical outcomes such as obesity, and biomedical outcomes such as the development of gut microbiota. Data will be analyzed with mixed effects generalized linear models with family and link function determined by outcome distribution and accounting for clustering of participants in communities.

DISCUSSION

This study will provide evidence concerning the effect of a mHealth intervention that incorporates a behavioral change theoretical framework on cultivating and maintaining healthy lifestyles in community residents. The study will provide insights into research on and application of similar mHealth intervention strategies to promote healthy lifestyles in community populations and settings.

TRIAL REGISTRATION NUMBER

ChiCTR2300070575. Date of registration: April 17, 2023. https://www.chictr.org.cn/index.aspx .

Use of computed tomography coronary calcium score for prediction of cardiovascular events in cancer patients: a retrospective cohort analysis

BACKGROUND

CT- coronary calcium score, is one of the most studied and widely available modalities in cardiovascular medicine. Coronary artery calcium score (CACS) is an established predictor of coronary artery disease. The 'standard of care' diagnostic modality to measure CACS is ECG-gated Cardiac Multi-Detector Computed Tomography. There is convincing evidence of a strong association between CACS and major cardiovascular (CV) events in asymptomatic individuals. Cancer patients (C) may have a higher risk for CV disease than non-cancer patients (NC) related not only to cancer treatments but also to shared biological factors and pathways. Thus, identifying tools for early detection of CV disease in this population is of utmost importance.

METHODS

A retrospective cohort analysis was performed with patients from Cleveland Clinic Florida and Ohio who had CACS from 2017 to 2021. Patients who had cancer diagnosis prior to CACS were matched to NC for age and sex. CV events after their index CACS events were compared between C and NC, and matched control and propensity analysis were conducted.

RESULTS

Ten thousand seven hundred forty-two patients had CACS; 703 cancer patients had CACS and were eligible. Extensive CACS (> 400) were significantly higher in cancer, 94 (13.37%) vs non-cancer patients, 76 (10.83%), P = 0.011. Furthermore, after propensity matched analysis, CACS > 400 was 14.8% in C vs 9.6% in NC, P =  < 0.05. CV events were similar in both cohorts (p = NS), despite less CV risk factors in cancer patients (P =  < 0.05). For the combined moderate (101-400) & extensive (> 400) CACS, the prevalence of stroke and peripheral arterial disease, a marker of systemic atherosclerosis, was significantly higher in patients with cancer (P < 0.01).

CONCLUSIONS

Despite having fewer CV risk factors in our study, similar CACS in cancer patients are suggestive of a higher prevalence of CV disease independent of traditional risk factors. High CACS and the overall prevalence of vascular events were more frequent in patients with cancer. Higher prevalence of peripheral arterial disease and cerebrovascular accident further suggests the increased atherosclerotic burden in C.

Lifestyle and clinical factors as predictive indicators of cardiometabolic multimorbidity in Chinese adults: Baseline findings of the Beijing Health Management Cohort (BHMC) study

BACKGROUND

Cardiometabolic multimorbidity (CMM) is increasing globally as a result of lifestyle changes and the aging population. Even though previous studies have examined risk factors associated with CMM, there is a shortage of prediction models that can accurately identify high-risk individuals for early prevention.

METHODS

In the baseline survey of the Beijing Health Management Cohort, a total of 77,752 adults aged 18 years or older were recruited from 2020 to 2021. Data on lifestyle factors, clinical profiles, and diagnoses of diabetes, coronary heart disease, and stroke were collected. Logistic regression models were used to identify risk factors for CMM. Nomograms were developed to estimate an individual's probability of CMM based on the identified risk factors. The performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

In men, the top three risk factors for CMM were hypertension (OR: 3.52, 95 % CI: 2.97-4.18), eating very fast (3.43, 2.27-5.16), and dyslipidemia (2.59, 2.20-3.06). In women, hypertension showed the strongest association with CMM (3.62, 2.90-4.52), followed by night sleep duration less than 5 h per day (2.41, 1.67-3.50) and dyslipidemia (1.91, 1.58-2.32). The ORs for holding passive and depressed psychological traits were 1.49 (95%CI: 1.08-2.06) in men and 1.58 (1.03-2.43) in women. Prediction models incorporating these factors demonstrated good discrimination in the test set, with AUC 0.84 (0.83-0.86) for men and 0.90 (0.89-0.91) for women. The sex-specific nomograms were established based on selected predictors.

CONCLUSIONS

Modifiable lifestyle factors, metabolic health and psychological trait are associated with the risk of CMM. The developed prediction models and nomograms could facilitate early identification of individuals at high-risk of CMM.

Childhood and adolescence physical activity and multimorbidity later in life: A systematic review

Background

No systematic summary exists on childhood physical activity and later-life multimorbidity risks. We primarily investigated the association of physical activity in childhood and adolescence and the development of multimorbidity in adulthood. Secondarily, we examined whether physical activity level differ in children and adolescents with and without multimorbidity and whether there is a cross-sectional association between physical activity and multimorbidity.

Methods

Following Cochrane Handbook guidelines and adhering to PRISMA recommendations, we included cross-sectional, case-control and longitudinal studies that investigated the association between physical activity in children and adolescents and development of multimorbidity. Results were summarized narratively and we assessed the certainty of the evidence using the GRADE approach. The protocol was registered in PROSPERO, CRD42023407063.

Results

Of 9064 studies identified, 11 were included in 13 papers. Longitudinals studies suggested that being physically active in childhood and adolescence was associated with a lower risk of multimorbidity in adulthood. Three out of five studies reported lower physical activity level in children and adolescents with multimorbidity compared to those without, and two did not find a between-group difference. Cross-sectional evidence on the association between multimorbidity and lower physical activity was uncertain. Overall, the evidence certainty for all outcomes was considered low due to the indirectness and inconsistency in findings.

Conclusions

Childhood and adolescence physical activity appeared to be linked with a reduced risk of later-life multimorbidity but the certainty of the evidence is low. These results support the promotion of physical activity during childhood and adolescence.

Impact of healthy lifestyles on risk of hypertension in the Chinese population: finding from SHUN-CVD study

INTRODUCTION

Lifestyle factors are known to play a role in the development of hypertension. We aimed to study the relationship between lifestyle and hypertension in a Chinese population.

METHODS

This study involved 3,329 participants (1,463 men and 1,866 women) aged 18-96 years in the Shenzhen-Hong Kong United Network on Cardiovascular Disease. A healthy lifestyle score was derived from 5 factors: no smoking, no alcohol consumption, active physical activity, normal body mass index, and a healthy diet. Multiple logistic regression was used to investigate the relationship between lifestyle score and hypertension. The influence of each lifestyle component on hypertension was also assessed.

RESULTS

In the overall population, 950 (28.5%) participants had hypertension. The risk of hypertension decreased with increasing healthy lifestyle scores. Compared with participants with the lowest score (score: 0), the multivariable odds ratios (ORs) and corresponding 95% confidence intervals for participants with scores 3, 4, and 5 were 0.65 (0.41-1.01), 0.62 (0.40-0.97), and 0.37 (0.22-0.61), respectively (P for trend <0.001). After adjusting for age, sex, and diabetes, the score was associated with hypertension risk (P for trend = 0.005). Compared with a lifestyle score of 0, the adjusted OR for hypertension for participants with a score of 5 was 0.46 (0.26-0.80).

CONCLUSIONS

The risk of hypertension is inversely related to the healthy lifestyle score. This reinforces the need to address lifestyle to reduce the risk of hypertension.

Consumption of ultra-processed foods and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study

Background

It is currently unknown whether ultra-processed foods (UPFs) consumption is associated with a higher incidence of multimorbidity. We examined the relationship of total and subgroup consumption of UPFs with the risk of multimorbidity defined as the co-occurrence of at least two chronic diseases in an individual among first cancer at any site, cardiovascular disease, and type 2 diabetes.

Methods

This was a prospective cohort study including 266,666 participants (60% women) free of cancer, cardiovascular disease, and type 2 diabetes at recruitment from seven European countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Foods and drinks consumed over the previous 12 months were assessed at baseline by food-frequency questionnaires and classified according to their degree of processing using Nova classification. We used multistate modelling based on Cox regression to estimate cause-specific hazard ratios (HR) and their 95% confidence intervals (CI) for associations of total and subgroups of UPFs with the risk of multimorbidity of cancer and cardiometabolic diseases.

Findings

After a median of 11.2 years of follow-up, 4461 participants (39% women) developed multimorbidity of cancer and cardiometabolic diseases. Higher UPF consumption (per 1 standard deviation increment, ∼260 g/day without alcoholic drinks) was associated with an increased risk of multimorbidity of cancer and cardiometabolic diseases (HR: 1.09, 95% CI: 1.05, 1.12). Among UPF subgroups, associations were most notable for animal-based products (HR: 1.09, 95% CI: 1.05, 1.12), and artificially and sugar-sweetened beverages (HR: 1.09, 95% CI: 1.06, 1.12). Other subgroups such as ultra-processed breads and cereals (HR: 0.97, 95% CI: 0.94, 1.00) or plant-based alternatives (HR: 0.97, 95% CI: 0.91, 1.02) were not associated with risk.

Interpretation

Our findings suggest that higher consumption of UPFs increases the risk of cancer and cardiometabolic multimorbidity.

Funding

Austrian Academy of Sciences, Fondation de France, Cancer Research UK, World Cancer Research Fund International, and the Institut National du Cancer.

Association Between the Healthy Lifestyle Index and Risk of Multimorbidity in the Women's Health Initiative

BACKGROUND

Multimorbidity, defined as the presence of 2 or more chronic health conditions, is increasingly common among older adults. The combination of lifestyle characteristics such as diet quality, smoking status, alcohol intake, physical activity (PA), sleep duration, and body fat as assessed by body mass index (BMI) or waist circumference, and risk of multimorbidity are not well understood.

OBJECTIVES

We investigated the association between the healthy lifestyle index (HLI), generated by combining indicators of diet quality, smoking, alcohol, PA, sleep amount, and BMI, and risk of multimorbidity, a composite outcome that included cardiovascular disease (CVD), diabetes, cancer, and fracture.

METHODS

We studied 62 037 postmenopausal women aged 50-79 years at enrollment in the Women's Health Initiative, with no reported history of CVD, diabetes, cancer, or fracture at baseline. Lifestyle characteristics measured at baseline were categorized and a score (0-4) was assigned to each category. The combined HLI (0-24) was grouped into quintiles, with higher quintiles indicating a healthier lifestyle. Multivariable adjusted estimates of hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the risk of developing multimorbidity were obtained using Cox proportional hazard models.

RESULTS

Over an average follow-up period of 16.3 years, 5 656 women developed multimorbidity. There was an inverse association between the HLI levels and risk of multimorbidity (compared to the HLI_1st quintile: HR_2nd quintile = 0.81 95% CI 0.74-0.83, HR_3rd quintile = 0.77 95% CI 0.71-0.83, HR_4th quintile = 0.70 95% CI 0.64-0.76, and HR_5th quintile = 0.60 95% CI 0.54-0.66; p trend < .001). Similar associations were observed after stratification by age or BMI categories.

CONCLUSIONS

Among postmenopausal women, higher levels of the HLI were associated with a reduced risk of developing multimorbidity.

Body mass index and cancer risk among adults with and without cardiometabolic diseases: evidence from the EPIC and UK Biobank prospective cohort studies

BACKGROUND

Whether cancer risk associated with a higher body mass index (BMI), a surrogate measure of adiposity, differs among adults with and without cardiovascular diseases (CVD) and/or type 2 diabetes (T2D) is unclear. The primary aim of this study was to evaluate separate and joint associations of BMI and CVD/T2D with the risk of cancer.

METHODS

This is an individual participant data meta-analysis of two prospective cohort studies, the UK Biobank (UKB) and the European Prospective Investigation into Cancer and nutrition (EPIC), with a total of 577,343 adults, free of cancer, T2D, and CVD at recruitment. We used Cox proportional hazard regressions to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between BMI and incidence of obesity-related cancer and in turn overall cancer with a multiplicative interaction between BMI and the two cardiometabolic diseases (CMD). HRs and 95% CIs for separate and joint associations for categories of overweight/obesity and CMD status were estimated, and additive interaction was quantified through relative excess risk due to interaction (RERI).

RESULTS

In the meta-analysis of both cohorts, BMI (per ~ 5 kg/m2) was positively associated with the risk of obesity-related cancer among participants without a CMD (HR: 1.11, 95%CI: 1.07,1.16), among participants with T2D (HR: 1.11, 95% CI: 1.05,1.18), among participants with CVD (HR: 1.17, 95% CI: 1.11,1.24), and suggestively positive among those with both T2D and CVD (HR: 1.09, 95% CI: 0.94,1.25). An additive interaction between obesity (BMI ≥ 30 kg/m2) and CVD with the risk of overall cancer translated into a meta-analytical RERI of 0.28 (95% CI: 0.09-0.47).

CONCLUSIONS

Irrespective of CMD status, higher BMI increased the risk of obesity-related cancer among European adults. The additive interaction between obesity and CVD suggests that obesity prevention would translate into a greater cancer risk reduction among population groups with CVD than among the general population.

Relationship of triglyceride-glucose index with cardiometabolic multi-morbidity in China: evidence from a national survey

BACKGROUND

Cardiometabolic multi-morbidity (CMM) is emerging as a global healthcare challenge and a pressing public health concern worldwide. Previous studies have principally focused on identifying risk factors for individual cardiometabolic diseases, but reliable predictors of CMM have not been identified. In the present study, we aimed to characterize the relationship of triglyceride-glucose (TyG) index with the incidence of CMM.

METHODS

We enrolled 7,970 participants from the China Health and Retirement Longitudinal Study (CHARLS) and placed them into groups according to quartile of TyG index. The endpoint of interest was CMM, defined as the presence of at least two of the following: stroke, heart disease, and diabetes mellitus. Cox regression models and multivariable-adjusted restricted cubic spline (RCS) curves were used to evaluate the relationship between TyG index and CMM.

RESULTS

In total, 638 (8.01%) incident cases of CMM were recorded among the participants who did not have CMM at baseline (2011) during a median follow-up of 84 months (interquartile range, 20‒87 months). The incidences of CMM for the participants in quartiles (Q) 1-4 of TyG index were 4.22%, 6.12%, 8.78%, and 12.60%, respectively. A fully adjusted Cox model showed that TyG index was closely associated with the incidence of CMM: the hazard ratio (HR) [95% confidence interval (CI)] for each 1.0-unit increment in TyG index for CMM was 1.54 (1.29-1.84); and the HRs (95% CIs) for Q3 and Q4 (Q1 as reference) of the TyG index for CMM were 1.41 (1.05-1.90) and 1.61 (1.18-2.20), respectively. The association of TyG index with the incidence of CMM was present in almost all the subgroups, and persisted in the sensitivity analyses and additional analyses. Multivariable-adjusted RCS analysis revealed a significant dose-response relationship of TyG index with the risk of CMM (overall P < 0.001; non-linear P = 0.129).

CONCLUSIONS

We found that a high TyG index is associated with a higher risk of incident CMM. This finding may have significance for clinical practice and facilitate the creation of a personalized prevention strategy that involves monitoring the TyG index.

Association of cognitive frailty and abdominal obesity with cardiometabolic multimorbidity among middle-aged and older adults: A longitudinal study

BACKGROUND

Cognitive frailty and abdominal obesity are deemed to be important targets for disease prevention. However, a possible cardiometabolic multimorbidity (CMM) link with cognitive frailty and abdominal obesity is unknown. The aim of this study was to investigate the association of cognitive frailty and abdominal obesity with CMM in the middle-aged and older people.

METHODS

The sample comprised 11,503 participants aged 45 and over from the China Health and Retirement Longitudinal Study (CHARLS) 2011. Cognitive frailty was defined as the coexisting cognitive impairment and physical frailty. Abdominal obesity was assessed using waist circumference. CMM was defined as the presence of two or more cardiometabolic diseases (CMDs), including diabetes, heart disease, and stroke. A total of 9177 participants without CMM recruited from CHARLS 2011 and were followed up in 2018.

RESULTS

Compared with 0 CMD, coexisting cognitive frailty and abdominal obesity was associated with the risk of 1 CMD (OR: 1.734, 95 % CI: 1.133-2.655), and ≥ 2 CMDs (OR: 7.218, 95%CI: 3.216-16.198). Longitudinal analysis showed that individuals with both cognitive frailty and abdominal obesity (HR: 2.162, 95%CI: 1.032-4.531) were more likely to have new onset CMM than cognitive frailty alone peers (HR: 1.667, 95 % CI: 0.721-3.853). Among the participants with first CMD, the likelihood of CMM was substantially higher in the co-existence of cognitive frailty and abdominal obesity (HR: 3.073, 95%CI: 1.254-7.527) than in the abdominal obesity alone (HR: 1.708, 95%CI: 1.201-2.427). Cognitive frailty alone was not significantly associated with CMM.

CONCLUSION

Cognitive frailty is not independently associated with the risk of CMM, but cognitive frailty and abdominal obesity together has a greater risk of CMM.

Risk factors for multimorbidity in adulthood: A systematic review

BACKGROUND

Multimorbidity, the coexistence of multiple chronic diseases in an individual, is highly prevalent and challenging for healthcare systems. However, its risk factors remain poorly understood.

OBJECTIVE

To systematically review studies reporting multimorbidity risk factors.

METHODS

A PRISMA-compliant systematic review was conducted, searching electronic databases (MEDLINE, EMBASE, Web of Science, Scopus). Inclusion criteria were studies addressing multimorbidity transitions, trajectories, continuous disease counts, and specific patterns. Non-human studies and participants under 18 were excluded. Associations between risk factors and multimorbidity onset were reported.

RESULTS

Of 20,806 identified studies, 68 were included, with participants aged 18-105 from 23 countries. Nine risk factor categories were identified, including demographic, socioeconomic, and behavioral factors. Older age, low education, obesity, hypertension, depression, low pysical function were generally positively associated with multimorbidity. Results for factors like smoking, alcohol consumption, and dietary patterns were inconsistent. Study quality was moderate, with 16.2% having low risk of bias.

CONCLUSIONS

Several risk factors seem to be consistently associated with an increased risk of accumulating chronic diseases over time. However, heterogeneity in settings, exposure and outcome, and baseline health of participants hampers robust conclusions.

Targeting endothelial cells with golden spice curcumin: A promising therapy for cardiometabolic multimorbidity

Cardiometabolic multimorbidity (CMM) is an increasingly significant global public health concern. It encompasses the coexistence of multiple cardiometabolic diseases, including hypertension, stroke, heart disease, atherosclerosis, and T2DM. A crucial component to the development of CMM is the disruption of endothelial homeostasis. Therefore, therapies targeting endothelial cells through multi-targeted and multi-pathway approaches hold promise for preventing and treatment of CMM. Curcumin, a widely used dietary supplement derived from the golden spice Carcuma longa, has demonstrated remarkable potential in treatment of CMM through its interaction with endothelial cells. Numerous studies have identified various molecular targets of curcumin (such as NF-κB/PI3K/AKT, MAPK/NF-κB/IL-1β, HO-1, NOs, VEGF, ICAM-1 and ROS). These findings highlight the efficacy of curcumin as a therapeutic agent against CMM through the regulation of endothelial function. It is worth noting that there is a close relationship between the progression of CMM and endothelial damage, characterized by oxidative stress, inflammation, abnormal NO bioavailability and cell adhesion. This paper provides a comprehensive review of curcumin, including its availability, pharmacokinetics, pharmaceutics, and therapeutic application in treatment of CMM, as well as the challenges and future prospects for its clinical translation. In summary, curcumin shows promise as a potential treatment option for CMM, particularly due to its ability to target endothelial cells. It represents a novel and natural lead compound that may offer significant therapeutic benefits in the management of CMM.

Sociodemographic characteristics and longitudinal progression of multimorbidity: A multistate modelling analysis of a large primary care records dataset in England

BACKGROUND

Multimorbidity, characterised by the coexistence of multiple chronic conditions in an individual, is a rising public health concern. While much of the existing research has focused on cross-sectional patterns of multimorbidity, there remains a need to better understand the longitudinal accumulation of diseases. This includes examining the associations between important sociodemographic characteristics and the rate of progression of chronic conditions.

METHODS AND FINDINGS

We utilised electronic primary care records from 13.48 million participants in England, drawn from the Clinical Practice Research Datalink (CPRD Aurum), spanning from 2005 to 2020 with a median follow-up of 4.71 years (IQR: 1.78, 11.28). The study focused on 5 important chronic conditions: cardiovascular disease (CVD), type 2 diabetes (T2D), chronic kidney disease (CKD), heart failure (HF), and mental health (MH) conditions. Key sociodemographic characteristics considered include ethnicity, social and material deprivation, gender, and age. We employed a flexible spline-based parametric multistate model to investigate the associations between these sociodemographic characteristics and the rate of different disease transitions throughout multimorbidity development. Our findings reveal distinct association patterns across different disease transition types. Deprivation, gender, and age generally demonstrated stronger associations with disease diagnosis compared to ethnic group differences. Notably, the impact of these factors tended to attenuate with an increase in the number of preexisting conditions, especially for deprivation, gender, and age. For example, the hazard ratio (HR) (95% CI; p-value) for the association of deprivation with T2D diagnosis (comparing the most deprived quintile to the least deprived) is 1.76 ([1.74, 1.78]; p < 0.001) for those with no preexisting conditions and decreases to 0.95 ([0.75, 1.21]; p = 0.69) with 4 preexisting conditions. Furthermore, the impact of deprivation, gender, and age was typically more pronounced when transitioning from an MH condition. For instance, the HR (95% CI; p-value) for the association of deprivation with T2D diagnosis when transitioning from MH is 2.03 ([1.95, 2.12], p < 0.001), compared to transitions from CVD 1.50 ([1.43, 1.58], p < 0.001), CKD 1.37 ([1.30, 1.44], p < 0.001), and HF 1.55 ([1.34, 1.79], p < 0.001). A primary limitation of our study is that potential diagnostic inaccuracies in primary care records, such as underdiagnosis, overdiagnosis, or ascertainment bias of chronic conditions, could influence our results.

CONCLUSIONS

Our results indicate that early phases of multimorbidity development could warrant increased attention. The potential importance of earlier detection and intervention of chronic conditions is underscored, particularly for MH conditions and higher-risk populations. These insights may have important implications for the management of multimorbidity.

Associations of heart failure to prevalence of haematologic- and solid malignancies in southern Sweden: A cross-sectional study

BACKGROUND

Heart failure (HF) and cancer are common diseases among the elderly population. Many chronic diseases, including diabetes mellitus (DM), share risk factors and increase the incidence of HF and cancer. The aim of this study was to investigate if there was an association between HF and the prevalence of haematologic- and solid malignancies.

METHODS

The study population was comprised of almost one million adults living in southern Sweden in 2015. All participants were divided into seven age groups from 20 and onwards, and 10 percentiles according to their socioeconomic status (SES). All data concerning diagnoses from each consultation in both primary- and secondary health care were collected during 18 months. The prevalence of haematologic and solid malignancies was measured separately for men and women, age groups, SES and multimorbidity levels. Multivariable logistic regression was used to determine the associations between HF and the probability of having haematologic- and solid malignancies in more complex models including stratifying variables.

RESULTS

People with HF had a higher prevalence of haematologic- and solid malignancies than the general population, but a lower prevalence of solid malignancies than the multimorbid population. The people with HF had an increased OR for haematologic malignancies, 1.69 (95% CI 1.51-1.90), and solid malignancies, OR 1.21 (95% CI 1.16-1.26), when adjusted for gender and age. In more complex multivariate models, multimorbidity explained the increased OR for haematologic- and solid malignancies in people with HF. Increasing socioeconomic deprivation was associated with a decreased risk for solid malignancies, with the lowest risk in the most socioeconomically deprived CNI-percentile.

CONCLUSIONS

HF was shown to be associated with malignancies, especially haematologic malignancies. Multimorbidity, however, was an even more important factor for both haematologic- and solid malignancies than HF in our study, but not socioeconomic deprivation. Further research on the interactions between the chronic conditions in people with HF is warranted to examine the strength of association between HF and malignancies.

Associations of Sleep Patterns With Dynamic Trajectory of Cardiovascular Multimorbidity and Mortality: A Multistate Analysis of a Large Cohort

Background The purpose of this study was to explore the association of sleep patterns with the development of first cardiovascular diseases (FCVD), progression to cardiovascular multimorbidity (CVM), and subsequently to mortality. Methods and Results This prospective study included 381 179 participants without coronary heart disease, stroke, atrial fibrillation, or heart failure at baseline, and they were followed up until March 31, 2021. We generated sleep patterns by summing the scores for 5 sleep behaviors, whereby <7 or >8 hours/d of sleep, evening chronotype, frequent insomnia, snoring, and daytime dozing were defined as high-risk groups. We used a multistate model to estimate the impacts of sleep patterns on the dynamic progression of cardiovascular diseases. Over a median follow-up of 12.1 years, 41 910 participants developed FCVD, 7302 further developed CVM, and 20 707 died. We found that adverse sleep patterns were significantly associated with the transition from health to FCVD, from FCVD to CVM, and from health to death, with hazard ratio associated with 1-factor increase in sleep scores being 1.08 (95% CI, 1.07-1.09), 1.04 (95% CI, 1.02-1.06), and 1.04 (95% CI, 1.02-1.05), respectively. When further dividing FCVD into coronary heart disease, stroke, atrial fibrillation, and heart failure, adverse sleep patterns showed a significant and persistent effect on the transition from health to each cardiovascular disease, and from heart failure or atrial fibrillation to CVM. Conclusions Our study provides evidence that adverse sleep patterns might increase the risk for the progression from health to cardiovascular diseases and further to CVM. Our findings suggest that improving sleep behaviors might be helpful for the primary and secondary prevention of cardiovascular diseases.

The Impact of Physical Activity Intensity on the Dynamic Progression of Cardiometabolic Multimorbidity: Prospective Cohort Study Using UK Biobank Data

BACKGROUND

Although many studies have reported on the associations between the amount of physical activity (PA) and the transitions of cardiometabolic multimorbidity (CMM), the evidence for PA intensity has not been fully evaluated.

OBJECTIVE

This study aimed to explore the impact of PA intensity on the dynamic progression of CMM.

METHODS

The prospective cohort of this study using data from the UK Biobank included 359,773 participants aged 37-73 years who were recruited from 22 centers between 2006 and 2010. The diagnoses of CMM, which included the copresence of type 2 diabetes (T2D), ischemic heart disease, and stroke, were obtained from first occurrence fields provided by the UK Biobank, which included data from primary care, hospital inpatient record, self-reported medical condition, and death registers. The PA intensity was assessed by the proportion of vigorous PA (VPA) to moderate to vigorous PA (MVPA). Multistate models were used to evaluate the effect of PA intensity on the dynamic progression of CMM. The first model (model A) included 5 transitions, namely free of cardiometabolic disease (CMD) to first occurrence of CMD (FCMD), free of CMD to death, FCMD to CMM, FCMD to mortality, and CMM to mortality. The other model (model B) used specific CMD, namely T2D, ischemic heart disease, and stroke, instead of FCMD and included 11 transitions in this study.

RESULTS

The mean age of the included participants (N=359,773) was 55.82 (SD 8.12) years at baseline, and 54.55% (196,271/359,773) of the participants were female. Compared with the participants with no VPA, participants with intensity levels of >0.75 to <1 for VPA to MVPA had a 13% and 27% lower risk of transition from free of CMD to FCMD (hazard ratio [HR] 0.87, 95% CI 0.83-0.91) and mortality (HR 0.73, 95% CI 0.66-0.79) in model A, respectively. The HR for the participants with no moderate PA was 0.82 (95% CI 0.73-0.92) compared with no VPA. There was a substantially protective effect of higher PA intensity on the transitions from free of CMD to T2D and from T2D to mortality, which reveals the importance of PA intensity for the transitions of T2D. More PA and greater intensity had a synergistic effect on decreasing the risk of the transitions from free of CMD to FCMD and mortality. Male participants, younger adults, adults with a higher BMI, current or previous smokers, and excessive alcohol drinkers could obtain more benefits from higher PA intensity for the lower risk of at least 1 transition from free of CMD, then to CMM, and finally to mortality.

CONCLUSIONS

This study suggests that higher PA intensity is an effective measure for preventing CMM and mortality in the early period of CMM development. Relevant interventions related to higher PA intensity should be conducted.

Association of cardiovascular health using Life's Essential 8 with noncommunicable disease multimorbidity

Cardiovascular health (CVH) is closely associated with various noncommunicable diseases (NCDs) and comorbidity; however, the influence of CVH on NCD multimorbidity was not fully elucidated. We aimed to examine the association between CVH using Life's Essential 8 (LE8) and NCD multimorbidity among adults, males, and females in the United States, conducting a cross-sectional analysis using data involving 24,445 participants from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018. LE8 was categorized into low, moderate, and high CVH groups. Multivariate logistic regressions and restricted cubic spline regressions were used to estimate the association between LE8 and NCD multimorbidity. Overall, 6162 participants had NCD multimorbidity, of which 1168 (43.5%), 4343 (25.9%), and 651 (13.4%) had low, moderate, and high CVH, separately. After multivariable adjustment, LE8 was negatively associated with NCD multimorbidity among adults (odds ratio (OR) for per 1 standard deviation (SD) increase in LE8 and 95% confidence interval (CI), 0.67 (0.64, 0.69)), and the top 3 NCDs associated with CVH were emphysema, congestive heart failure, stroke, and the dose-response relationships between LE8 and NCD multimorbidity were observed among adults (overall P < 0.001). Similar patterns were also identified among males and females. Higher CVH measured by the LE8 score was associated with lower odds of NCD multimorbidity among adults, males, and females.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Overweight and obesity in adulthood, sociodemographic factors, lifestyle, and the early burden of noncommunicable diseases among Americans: NHANES 2007-2018

OBJECTIVES

To evaluate the association between nutritional status in early adulthood and the burden of noncommunicable diseases (NCDs); To evaluate the influence of sociodemographic factors and lifestyle on the outcomes of BMI kg/m2  ≤24.9, ≥25.0, and ≥30.0; to estimate the population attributable fraction (PAF) to BMI elevated at 25 years old in the burden of NCDs in American adults.

METHODS

We used data from 15 721 American adults participating in the National Health and Nutrition Examination Survey from 2007 to 2018. The Hazard Ratio (HR), Incidence Rate Ratio (IRR), and 95% confidence intervals (CI) were estimated in the proportional risk regression models of Cox (entire population) and Poisson (restricted to non-patients), respectively. The proportionality of the risk between the burden of NCDs and BMI at 25 years old was drawn by the Kaplan-Meier curve, and the PAF was calculated. All analyses were adjusted taking into account the sample weights.

RESULTS

Health disparities (sex, age, race/ethnicity, education, poverty index, and education level), and lifestyle (physical activity, smoking, and alcohol consumption) influenced the current nutritional status. Cumulative survival in overweight and obese groups decreased considerably over time (p < .0001). Being overweight and obese in adulthood may increase the risk of early NCDs (HR: 1.68, 95% CI: 1.54-1.84 and HR: 2.87, 95% CI: 2.56-3.21, respectively). About 22.72% (95% CI: 19.99-25.36, p < .001) of the burden NCDs could have been avoided if overweight at age 25 had been prevented.

CONCLUSIONS

Monitoring weight change from young adulthood can provide a sensitive and useful clinical measure for early detection of adverse trends in NCDs risk.

Individual and joint effect of socioeconomic status and lifestyle factors on cancer in Korea

BACKGROUND

There is limited evidence on the individual and joint effect of socioeconomic status (SES) and unhealthy lifestyle on cancer. Therefore, this study aimed to examine the effects of these factors on cancer incidence and mortality.

METHODS

In this population-based cohort study, income was used as the proxy of SES. A combined unhealthy lifestyle score was obtained using data on smoking, alcohol consumption, physical activity, and body mass index. Hazard ratios were estimated using a Cox proportional hazards model.

RESULTS

The study included data on 8,353,169 participants (median follow-up period, 17 years). Although the association between low income and cancer incidence varied depending on cancer type, low income consistently increased the risk of cancer-related death with a social gradient. Unhealthy behaviors increased the risk of cancer incidence and mortality, except for thyroid and breast cancer in women and prostate cancer in men. Compared with the wealthiest and healthiest individuals, the poorest and unhealthiest men and women showed 2.1-fold (2.05-2.14) and 1.36-fold (1.31-1.41) higher risk of cancer-related death, respectively. The joint effect was most robust for lung, liver, head, and neck cancers in men and liver and cervical cancers in women; further, the effect was stronger with cancer-specific mortality than with incidence.

CONCLUSION

In conclusion, income and combined healthy lifestyle behaviors have individual and joint effects on cancer incidence and mortality. The effect varies by cancer type and sex.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Lifestyle factors related to prevalent chronic disease multimorbidity: A population-based cross-sectional study

BACKGROUND

Multimorbidity is associated with poor quality of life, polypharmacy, health care costs and mortality, with those affected potentially benefitting from a healthy lifestyle. We assessed a comprehensive set of lifestyle factors in relation to multimorbidity with major chronic diseases.

METHODS

This cross-sectional study utilised baseline data for adults from the prospective Lifelines Cohort in the north of the Netherlands (N = 79,345). We defined multimorbidity as the co-existence of two or more chronic diseases (i.e. cardiovascular disease, cancer, respiratory disease, type 2 diabetes) and evaluated factors in six lifestyle domains (nutrition, physical (in)activity, substance abuse, sleep, stress, relationships) among groups by the number of chronic diseases (≥2, 1, 0). Multinomial logistic regression models were created, adjusted for appropriate confounders, and odds ratios (OR) with 95% confidence intervals (95%CI) were reported.

RESULTS

3,712 participants had multimorbidity (4.7%, age 53.5 ± 12.5 years), and this group tended to have less healthy lifestyles. Compared to those without chronic diseases, those with multimorbidity reported physical inactivity more often (OR, 1.15; 95%CI, 1.06-1.25; not significant for one condition), chronic stress (OR, 2.14; 95%CI, 1.92-2.38) and inadequate sleep (OR, 1.70; 95%CI, 1.41-2.06); as expected, they more often watched television (OR, 1.70; 95%CI, 1.42-2.04) and currently smoked (OR, 1.91; 95%CI, 1.73-2.11), but they also had lower alcohol intakes (OR, 0.66; 95%CI, 0.59-0.74).

CONCLUSIONS

Chronic stress and poor sleep, in addition to physical inactivity and smoking, are lifestyle factors of great concern in patients with multimorbidity.

Protocol: Can coronary artery calcium score identified on thoracic planning CT scans be used and actioned to identify cancer survivors at high risk of cardiac events: A feasibility study in cancer survivors undergoing radiotherapy in Australia

INTRODUCTION

A coronary artery calcium (CAC) CT scan can identify calcified plaque and predict risk of future cardiac events. Cancer survivors undergoing thoracic radiotherapy routinely undergo a planning CT scan, which presents a unique opportunity to use already obtained medical imaging to identify those at the highest risk of cardiac events. While radiation therapy is an important modality for many cancer treatments, radiation dose to the heart in thoracic radiotherapy leads to cardiotoxicity and may accelerate pre-existing atherosclerosis. The primary aims of this study are to investigate the feasibility of using CAC scores calculated on thoracic radiotherapy planning CT scans to identify a subset of cancer survivors at an increased risk of future cardiac events, and to establish and evaluate a referral pathway for assessment and management in a cardio-oncology clinic. An optional substudy aims to investigate using abdominal aortic calcification (AAC) as a practical, low-radiation alternative to CAC to evaluate and monitor vascular health.

METHODS AND ANALYSIS

This is an observational, prospective study in a minimum of 100 cancer survivors commencing radiotherapy. Participants will have CAC scored from thoracic radiotherapy planning CT scans. Those identified as high risk (CAC score>0) will be referred to a cardio-oncology clinic. Feasibility, determined by adherence to the recommended pathway, and impact on quality of life and anxiety measured via questionnaire, will be assessed. Participants in Western Australia will be invited to participate in a 12-month observational pilot substudy, investigating lifestyle behaviours and the use of a dual-energy X-ray absorptiometry machine to measure musculoskeletal health and AAC.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from St Vincent's Hospital, Sydney (Project number 2021/ETH11847), GenesisCare and Edith Cowan University (2022-03326-DALLAVIA). Study results will be reported in peer-reviewed academic journals, at scientific conferences, and at clinical forums, irrespective of the results observed.

TRIAL REGISTRATION NUMBER

ACTRN12621001343897.

Multi-morbidity and its association with common cancer diagnoses: a UK Biobank prospective study

BACKGROUND

Whilst multi-morbidity is known to be a concern in people with cancer, very little is known about the risk of cancer in multi-morbid patients. This study aims to investigate the risk of being diagnosed with lung, colorectal, breast and prostate cancer associated with multi-morbidity.

METHODS

We investigated the association between multi-morbidity and subsequent risk of cancer diagnosis in UK Biobank. Cox models were used to estimate the relative risks of each cancer of interest in multi-morbid participants, using the Cambridge Multimorbidity Score. The extent to which reverse causation, residual confounding and ascertainment bias may have impacted on the findings was robustly investigated.

RESULTS

Of the 436,990 participants included in the study who were cancer-free at baseline, 21.6% (99,965) were multi-morbid (≥ 2 diseases). Over a median follow-up time of 10.9 [IQR 10.0-11.7] years, 9,019 prostate, 7,994 breast, 5,241 colorectal, and 3,591 lung cancers were diagnosed. After exclusion of the first year of follow-up, there was no clear association between multi-morbidity and risk of colorectal, prostate or breast cancer diagnosis. Those with ≥ 4 diseases at recruitment had double the risk of a subsequent lung cancer diagnosis compared to those with no diseases (HR 2.00 [95% CI 1.70-2.35] p for trend < 0.001). These findings were robust to sensitivity analyses aimed at reducing the impact of reverse causation, residual confounding from known cancer risk factors and ascertainment bias.

CONCLUSIONS

Individuals with multi-morbidity are at an increased risk of lung cancer diagnosis. While this association did not appear to be due to common sources of bias in observational studies, further research is needed to understand what underlies this association.

Effect on life expectancy of temporal sequence in a multimorbidity cluster of psychosis, diabetes, and congestive heart failure among 1·7 million individuals in Wales with 20-year follow-up: a retrospective cohort study using linked data

BACKGROUND

To inform targeted public health strategies, it is crucial to understand how coexisting diseases develop over time and their associated impacts on patient outcomes and health-care resources. This study aimed to examine how psychosis, diabetes, and congestive heart failure, in a cluster of physical-mental health multimorbidity, develop and coexist over time, and to assess the associated effects of different temporal sequences of these diseases on life expectancy in Wales.

METHODS

In this retrospective cohort study, we used population-scale, individual-level, anonymised, linked, demographic, administrative, and electronic health record data from the Wales Multimorbidity e-Cohort. We included data on all individuals aged 25 years and older who were living in Wales on Jan 1, 2000 (the start of follow-up), with follow-up continuing until Dec 31, 2019, first break in Welsh residency, or death. Multistate models were applied to these data to model trajectories of disease in multimorbidity and their associated effect on all-cause mortality, accounting for competing risks. Life expectancy was calculated as the restricted mean survival time (bound by the maximum follow-up of 20 years) for each of the transitions from the health states to death. Cox regression models were used to estimate baseline hazards for transitions between health states, adjusted for sex, age, and area-level deprivation (Welsh Index of Multiple Deprivation [WIMD] quintile).

FINDINGS

Our analyses included data for 1 675 585 individuals (811 393 [48·4%] men and 864 192 [51·6%] women) with a median age of 51·0 years (IQR 37·0-65·0) at cohort entry. The order of disease acquisition in cases of multimorbidity had an important and complex association with patient life expectancy. Individuals who developed diabetes, psychosis, and congestive heart failure, in that order (DPC), had reduced life expectancy compared with people who developed the same three conditions in a different order: for a 50-year-old man in the third quintile of the WIMD (on which we based our main analyses to allow comparability), DPC was associated with a loss in life expectancy of 13·23 years (SD 0·80) compared with the general otherwise healthy or otherwise diseased population. Congestive heart failure as a single condition was associated with mean a loss in life expectancy of 12·38 years (0·00), and with a loss of 12·95 years (0·06) when preceded by psychosis and 13·45 years (0·13) when followed by psychosis. Findings were robust in people of older ages, more deprived populations, and women, except that the trajectory of psychosis, congestive heart failure, and diabetes was associated with higher mortality in women than men. Within 5 years of an initial diagnosis of diabetes, the risk of developing psychosis or congestive heart failure, or both, was increased.

INTERPRETATION

The order in which individuals develop psychosis, diabetes, and congestive heart failure as combinations of conditions can substantially affect life expectancy. Multistate models offer a flexible framework to assess temporal sequences of diseases and allow identification of periods of increased risk of developing subsequent conditions and death.

FUNDING

Health Data Research UK.

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Association of smoking status and nicotine dependence with multi-morbidity in China: A nationally representative crosssectional study

INTRODUCTION

Multi-morbidity is a public health priority as it is associated with an increased risk of mortality and a substantial healthcare burden. Smoking is considered a predisposing factor for multi-morbidity, but evidence for an association between multi-morbidity and nicotine dependence is insufficient. This study aimed to explore the association between smoking status, nicotine dependence, and multi-morbidity in China.

METHODS

We recruited 11031 Chinese citizens from 31 provinces in 2021 using a multistage stratified cluster sampling strategy to ensure the study population represented national population characteristics. The association between smoking status and multi-morbidity was analyzed using binary logistic regression and multinomial logit regression models. We then analyzed the associations between four kinds of smoking status (age at smoking initiation, cigarette consumption per day, smoking when ill in bed, and inability to control smoking in public places), nicotine dependence, and multi-morbidity among participants who were current smokers.

RESULTS

Compared with non-smokers, the odds of multi-morbidity were higher among ex-smokers (adjusted odd ratio, AOR=1.40, 95% CI: 1.07-1.85). The risk of multi-morbidity was greater in participants who were underweight/overweight/obese (AOR=1.90; 95% CI: 1.60-2.26) compared with those who were normal weight. and also greater for drinkers (AOR=1.34; 95% CI: 1.09-1.63) than non-drinkers. Compared with children who began smoking at the age of <15 years, participants aged >18 years had a lower likelihood of multi-morbidity (AOR=0.52; 95% CI: 0.32-0.83). People who consumed ≥31 cigarettes per day (AOR=3.77; 95% CI: 1.47-9.68) and those who smoked when ill in bed (AOR=1.70; 95% CI: 1.10-2.64) were more likely to have multi-morbidity.

CONCLUSIONS

Our findings show that smoking behavior, including initiation age, frequency of daily smoking, and still smoking during illness or in public, is a critical risk factor for multi-morbidity, especially when combined with alcohol consumption, physical inactivity, and abnormal weight (underweight, overweight, or obese). This highlights the crucial effect of smoking cessation in the prevention and control of multi-morbidity, especially in patients with three or more diseases. Implementing smoking and lifestyle interventions to promote health would both benefit adults and prevent the next generation from initiating habits that increase the risk of multi-morbidity.

Patient motivation and preferences in changing co-occurring health risk behaviors in general hospital patients

OBJECTIVES

More than 60% of general hospital patients report ≥ 2 health risk behaviors (HRBs), i.e. tobacco smoking, at-risk alcohol use, unhealthy diet, and/or insufficient physical activity. This study investigates a) the association between numbers of HRBs and motivation to change, b) patient preferences for receiving feedback on HRBs, and c) patients' expected gain in quality of life if behavior change made.

METHODS

In 2020/2021, 256 18-64-year-old general hospital patients (72.1% of eligibles) reported on their motivation to change each of their HRBs. Associations between HRB number and motivation were assessed using multivariate linear regressions. Participants ranked HRBs concerning their interest in receiving feedback and concerning their expected gain in quality of life if behavior change occurred.

RESULTS

Higher HRB number was negatively related to motivation among at-risk alcohol users (p = 0.034); 24.6% expected gain in their quality of life from behavior change. Participants overall appeared more favorable to feedback about vegetable/fruit intake and physical activity.

CONCLUSIONS

Unhealthier lifestyle may be accompanied by decreased motivation to change in at-risk alcohol users. In case of co-occurring HRBs, asking patients for expected gain in quality of life may help guiding intervention target.

PRACTICE IMPLICATIONS

Relying on patient selection only, may often leave substance-use unaddressed.

Risk assessment of dietary factors in global pattern of ischemic heart disease mortality and disability-adjusted life years over 30 years

Objectives

The aim of this study was to investigate differences in the burden of ischemic heart disease (IHD)-related mortality and disability-adjusted life years (DALYs) caused by dietary factors, as well as the influencing factors with age, period, and cohort effects, in regions with different social-demographic status from 1990 to 2019.

Methods

We extracted data on IHD mortality, DALYs, and age-standardized rates (ASRs) related to dietary risks from 1990 to 2019 as IHD burden measures. Hierarchical age-period-cohort analysis was used to analyze age- and time-related trends and the interaction between different dietary factors on the risk of IHD mortality and DALYs.

Results

Globally, there were 9.2 million IHD deaths and 182 million DALYs in 2019. Both the ASRs of death and DALYs declined from 1990 to 2019 (percentage change: -30.8% and -28.6%, respectively), particularly in high and high-middle socio-demographic index (SDI) areas. Low-whole-grain, low-legume, and high-sodium diets were the three main dietary factors that increased the risk of IHD burden. Advanced age [RR (95%CI): 1.33 (1.27, 1.39)] and being male [1.11 (1.06, 1.16)] were independent risk factors for IHD mortality worldwide and in all SDI regions. After controlling for age effects, IHD risk showed a negative period effect overall. Poor diets were positively associated with increased risk of death but were not yet statistically significant. Interactions between dietary factors and advanced age were observed in all regions after adjusting for related variables. In people aged 55 and above, low intake of whole grains was associated with an increased risk of IHD death [1.28 (1.20, 1.36)]. DALY risks showed a similar but more obvious trend.

Conclusion

IHD burden remains high, with significant regional variations. The high IHD burden could be attributed to advanced age, sex (male), and dietary risk factors. Dietary habits in different SDI regions may have varying effects on the global burden of IHD. In areas with lower SDI, it is recommended to pay more attention to dietary problems, particularly in the elderly, and to consider how to improve dietary patterns in order to reduce modifiable risk factors.

Multimorbidity and adverse longitudinal outcomes among patients attending chronic outpatient medical care in Bahir Dar, Northwest Ethiopia

Background

Multimorbidity is becoming more prevalent in low-and middle-income countries (LMICs). However, the evidence base on the burden and its longitudinal outcomes are limited. This study aimed to determine the longitudinal outcomes of patients with multimorbidity among a sample of individuals attending chronic outpatient non communicable diseases (NCDs) care in Bahir Dar, northwest Ethiopia.

Methods

A facility-based longitudinal study was conducted among 1,123 participants aged 40+ attending care for single NCD (n = 491) or multimorbidity (n = 633). Data were collected both at baseline and after 1 year through standardized interviews and record reviews. Data were analyzed using Stata V.16. Descriptive statistics and longitudinal panel data analyzes were run to describe independent variables and identify factors predicting outcomes. Statistical significance was considered at p-value <0.05.

Results

The magnitude of multimorbidity has increased from 54.8% at baseline to 56.8% at 1 year. Four percent (n = 44) of patients were diagnosed with one or more NCDs and those having multimorbidity at baseline were more likely than those without multimorbidity to develop new NCDs. In addition, 106 (9.4%) and 22 (2%) individuals, respectively were hospitalized and died during the follow up period. In this study, about one-third of the participants had higher quality of life (QoL), and those having higher high activation status were more likely to be in the higher versus the combined moderate and lower QoL [AOR1 = 2.35, 95%CI: (1.93, 2.87)] and in the combined higher and moderate versus lower level of QoL [AOR2 = 1.53, 95%CI: (1.25, 1.88)].

Conclusion

Developing new NCDs is a frequent occurrence and the prevalence of multimorbidity is high. Living with multimorbidity was associated with poor progress, hospitalization and mortality. Patients having a higher activation level were more likely than those with low activation to have better QoL. If health systems are to meet the needs of the people with chronic conditions and multimorbidity, it is essential to understand diseases trajectories and of impact of multimorbidity on QoL, and determinants and individual capacities, and to increase their activation levels for better health improve outcomes through education and activation.

Association between the Finnish Diabetes Risk Score and cancer in middle-aged and older adults: Involvement of inflammation

BACKGROUND

Diabetes is associated with increased risk of common cancers. However, evidence of cancer risk in individuals with different diabetes risk is still scarce, and the underlying mechanism remains unknown. Therefore, we aimed to evaluate the relationship between the Finnish Diabetes Risk Score (FINDRISC) and risks of cancer incidence and mortality in a prospective study, and to explore whether low-grade inflammation partially mediated the association.

METHODS

A total of 330,384 participants aged 37 to 73 at baseline from the UK Biobank database was included in this study. The Cox proportional hazards model was used to examine the relationship of the FINDRISC and low-grade inflammation with risks of cancer incidence and mortality. Then, we estimated the contribution of higher FINDRISC to risks of overall and site-specific cancers. In addition, the role of low-grade inflammation in the association between FINDRISC and cancer risks was investigated through mediation analysis.

RESULTS

The increased FINDRISC was dose-dependently associated with higher incidence and mortality risks of overall cancer and an overwhelming majority of site-specific cancers. The higher FINDRISC was a strong contributor to incidence of eighteen site-specific cancers and mortality of fourteen site-specific cancers, with a population-attributable risk of 8.1 %-39.1 %, 14.2 %-39.7 %, respectively. Additionally, low-grade inflammation mainly mediated the association between the FINDRISC and risks of incidence and mortality of overall cancer, colorectal cancer, etc. CONCLUSIONS: Our findings highlighted the higher FINDRISC as critical risk factors of cancer incidence and mortality, partially mediated by low-grade inflammation. Individuals with increased risk of diabetes are also needed to be concerned about cancer prevention.

Cardiometabolic multimorbidity, lifestyle behaviours, and cognitive function: a multicohort study

BACKGROUND

Little is known about the effect of lifestyle factors on cognitive decline related to cardiometabolic multimorbidity. We aimed to examine the association between cardiometabolic multimorbidity and cognitive decline, and the role of lifestyle factors in this association.

METHODS

We did a pooled multi-cohort study using pooled data from four cohort studies (the Health and Retirement Study; the English Longitudinal Study of Ageing; the Survey of Health, Ageing and Retirement in Europe; and the China Health and Retirement Longitudinal Study) across 14 countries. Eligible participants were age 50 years and older, and those who were missing information on exposure and outcomes, or who had been diagnosed with dementia or Parkinson's disease, were excluded. Cardiometabolic multimorbidity was defined as the co-occurrence of two or three cardiometabolic diseases, including diabetes, heart disease, and stroke. The primary outcome of cognitive function was measured in three domains, on the basis of the mean and SD of the corresponding tests: memory, numeracy, and orientation, in all participants with available data. A global cognitive score was created by summing the individual scores.

FINDINGS

The final sample consisted of 160 147 individuals across all four studies (73 846 [46·1%] men and 86 301 [53·9%] women) and participants had a mean age of 67·49 years  (SD 10·43). An increasing number of cardiometabolic diseases was dose-dependently associated with the decline in cognitive function score (one disease, β=-0·15 [95% CI -0·17 to -0·13]; two diseases, β=-0·37 [-0·40 to -0·34]; three diseases, β=-0·57 [-0·64 to -0·50]), with comorbid diabetes and stroke (β=-0·23 [-0·29 to -0·17]) contributing most strongly to cardiometabolic disease-associated cognitive decline. Cognitive decline associated with cardiometabolic disease was accelerated with physical inactivity (one cardiometablic disease, p=0·020; two cardiometablic diseases, p=0·42; and three cardiometablic diseases, p=0·24), excessive alcohol use (one cardiometablic disease, p=0·016; two cardiometablic diseases, p=0·65; and three cardiometablic diseases, p=0·50), and the higher number of unhealthy lifestyle factors (one cardiometablic disease, p=0·79; two cardiometablic diseases, p=0·0050; and three cardiometablic diseases, p=0·888).

INTERPRETATION

These findings indicated a targeted approach for simultaneously developing preventative interventions on lifestyles and integrated treatment for cardiometabolic comorbidities to delay cognitive decline in older people.

FUNDING

Major Project of the National Social Science Fund of China, National Natural Science Foundation of China, China Medical Board, and Young Elite Scientists Sponsorship Program by CAST.

Dietary micronutrient adequacy and risk of multimorbidity in community-dwelling older adults

BACKGROUND

Multimorbidity refers to the coexistence of multiple chronic health conditions. The effect of nutritional adequacy on multimorbidity is mostly unknown.

OBJECTIVE

The aim of this study was to assess the prospective association between dietary micronutrient adequacy and multimorbidity among community-dwelling older adults.

METHODS

This cohort study included 1461 adults aged ≥65 years from the Seniors-ENRICA II cohort. Habitual diet was assessed at baseline (2015 to 2017) with a validated computerized diet history. Intake of 10 micronutrients (calcium, magnesium, potassium, vitamins A, C, D, E, zinc, iodine, and folate) was expressed as a percentage relative to dietary reference intakes, with higher scores indicating greater adequacy. Dietary micronutrient adequacy was computed as the average of all the nutrient scores. Information on medical diagnosis was obtained from the electronic health records up to December 2021. Conditions were grouped into a comprehensive list of 60 categories and occurrence of multimorbidity was defined as having ≥6 chronic conditions. Analyses were conducted using Cox proportional hazard models adjusted for relevant confounders.

RESULTS

The mean age was 71.0 (SD: 4.2) years and 57.8% of participants were males. During a median follow-up of 4.79 years, we documented 561 incident cases of multimorbidity. Participants in the highest (85.8-97.7%) versus the lowest tertile (40.1-78.7%) of dietary micronutrient adequacy had a lower risk of multimorbidity [fully adjusted hazard ratio (95% confidence interval): 0.75 (0.59-0.95); p trend: 0.02]. A 1-SD increment in minerals adequacy and in vitamins adequacy were associated with lower risk of multimorbidity, although estimates were attenuated after additional adjustment for the opposite subindex [minerals subindex: 0.86 (0.74-1.00); vitamins subindex: 0.89 (0.76-1.04)]. No differences were observed by strata of sociodemographic and lifestyle factors.

CONCLUSION

A higher micronutrient index score was associated with lower risk of multimorbidity. Improving the dietary micronutrient adequacy could prevent multimorbidity among older adults.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov NCT03541135.