Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

The maternal health behaviours of non-Irish nationals during pregnancy and the effect of time living in Ireland

OBJECTIVES

Maternal health behaviours (MHBs) can influence pregnancy outcomes. Despite efforts internationally to encourage positive MHBs, women often fail to comply with pregnancy guidelines. International studies show differences in MHBs between nationalities and an effect of time spent in the host country. There is limited Irish data in this area, with no previous research relating to the effect of time in Ireland.

STUDY DESIGN

This study is a cross-sectional analysis of the Growing Up in Ireland infant cohort, a nationally representative longitudinal study.

METHODS

Examination of the MHBs of non-Irish nationals during pregnancy and the effect of time in Ireland on the said behaviours.

RESULTS

An association was found between time spent in Ireland and increased alcohol consumption prevalence. Those living in Ireland for ≤5 years were 60.8% less likely to consume alcohol during pregnancy (0.000) and 29.3% less likely to take folic acid before conception (0.021). Those who smoked during pregnancy were 98.6% more likely to consume alcohol (0.000) and those who consumed alcohol were 95.2% more likely to smoke during pregnancy (0.000).

CONCLUSIONS

The results demonstrate differences in MHBs and the influence of time living in Ireland. These findings are of relevance for policy and intervention planning to optimise pregnancy outcomes among non-nationals.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

Background

Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional “waitlist and triage” model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction.

Methods/design

A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial.

Discussion

This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12615001016527. Approved 15/9/2015.

Late effects in patients with Fanconi anemia following allogeneic hematopoietic stem cell transplantation from alternative donors

Hematopoietic stem cell transplantation (HSCT) is curative for hematological manifestations of Fanconi anemia (FA). We performed a retrospective analysis of 22 patients with FA and aplastic anemia, myelodysplastic syndrome or acute myelogenous leukemia who underwent a HSCT at Memorial Sloan Kettering Cancer Center and survived at least 1 year post HSCT. Patients underwent either a TBI- (N=18) or busulfan- (N=4) based cytoreduction followed by T-cell-depleted transplants from alternative donors. Twenty patients were alive at time of the study with a 5- and 10-year overall survival of 100 and 84% and no evidence of chronic GvHD. Among the 18 patients receiving a TBI-based regimen, 11 (61%) had persistent hemochromatosis, 4 (22%) developed hypothyroidism, 7 (39%) had insulin resistance and 5 (27%) developed hypertriglyceridemia after transplant. Eleven of 16 evaluable patients (68%), receiving TBI, developed gonadal dysfunction. Two patients who received a TBI-based regimen died of squamous cell carcinoma. One patient developed hemochromatosis, hypothyroidism and gonadal dysfunction after busulfan-based cytoreduction. TBI appears to be a risk factor for malignant and endocrine late effects in the FA host. Multidisciplinary follow-up of patients with FA (including cancer screening) is essential for early detection and management of late complications, and improving long-term outcomes.

Added Value of Stroke Protocol MRI Following Negative Initial CT in the Acute Stroke Setting

The aim of the study was to determine the added value of stroke protocol MRI following negative initial CT brain in the acute stroke setting. A retrospective study was performed over a 6 month period in a tertiary referral stroke centre. Patients were selected from the stroke and radiology databases. Inclusion criteria: clinical stroke syndrome, negative initial CT with subsequent MRI study with diffusion weighted sequences. Ninety two patients were reviewed and 73 (M:F of 39:34, mean age 62.1 ± 14.0 years) met the inclusion criteria. Twenty MRI studies (27.4%) were positive for acute/subacute ischaemia in the setting of a normal initial CT. The average time interval between initial CT and MRI brain imaging was 4.7 ± 2.6 days. Whilst CT continues to be the first line imaging investigation for acute stroke, MRI has substantial added value following negative initial CT in the diagnosis of stroke.

EVALUATION OF DMSO TRANSPORT IN HUMAN ARTICULAR CARTILAGE: VEHICLE SOLUTIONS AND EFFECTS ON CELL FUNCTION

Osteochondral allografting techniques are limited by the availability of suitable donor tissue; there is an urgent need for effective cryopreservation. A fundamental requirement is the need to establish initial conditions of exposure to cryoprotectant that the chondrocytes will tolerate and that load the tissue with an adequate concentration of cryoprotectant. Three vehicle solutions to transport DMSO into the tissue were studied. Knee joints were obtained from deceased donors with appropriate consent. Whole condyles were treated with 20% w/w DMSO in each of three vehicle solutions and chondrocyte function and tissue CPA content measured. The results showed that exposure to 20% DMSO in each vehicle solution for 2 hours at 0 degrees C was tolerated without loss of GAG synthetic activity. It was observed that penetration of DMSO increased little after 1 hour of CPA exposure at 0 degrees C but the final tissue concentration of CPA was markedly lower than that in the medium.

Quantifying the contribution of ambient and indoor-generated fine particles to indoor air in residential environments

Indoor fine particles (FPs) are a combination of ambient particles that have infiltrated indoors, and particles that have been generated indoors from activities such as cooking. The objective of this paper was to estimate the infiltration factor (Finf ) and the ambient/non-ambient components of indoor FPs. To do this, continuous measurements were collected indoors and outdoors for seven consecutive days in 50 non-smoking homes in Halifax, Nova Scotia in both summer and winter using DustTrak (TSI Inc) photometers. Additionally, indoor and outdoor gravimetric measurements were made for each 24-h period in each home, using Harvard impactors (HI). A computerized algorithm was developed to remove (censor) peaks due to indoor sources. The censored indoor/outdoor ratio was then used to estimate daily Finfs and to determine the ambient and non-ambient components of total indoor concentrations. Finf estimates in Halifax (daily summer median = 0.80; daily winter median = 0.55) were higher than have been reported in other parts of Canada. In both winter and summer, the majority of FP was of ambient origin (daily winter median = 59%; daily summer median = 84%). Predictors of the non-ambient component included various cooking variables, combustion sources, relative humidity, and factors influencing ventilation. This work highlights the fact that regional factors can influence the contribution of ambient particles to indoor residential concentrations.

PRACTICAL IMPLICATIONS

Ambient and non-ambient particles have different risk management approaches, composition, and likely toxicity. Therefore, a better understanding of their contribution to the indoor environment is important to manage the health risks associated with fine particles (FPs) effectively. As well, a better understanding of the factors Finf can help improve exposure assessment and contribute to reduced exposure misclassification in epidemiologic studies.

A foodborne outbreak of Salmonella Bareilly in the United Kingdom, 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

Increase in invasive group A streptococcal infections in England, Wales and Northern Ireland, 2008-9

Increases in invasive and non-invasive group A streptococcal diseases are currently being seen in the United Kingdom. National enhanced surveillance is being launched to examine the clinical presentations, risk factors, outcome and clustering patterns of cases to further inform public health management strategies.

Strategic use of a new dental magnet system to retain partial and complete overdentures

Dental management of older adults is becoming increasingly complex. For many, denture wearing difficulties will become a norm, and implant retained prostheses may be beyond their financial resources or unacceptable for other reasons. Patients with limited or no denture wearing experience may not tolerate conventional dentures for functional or psychosocial reasons. Incorporation of Dental Magnets into dentures may be useful for patients with limited ability to tolerate or control removable dentures. This paper reports on the use of the Magfit (Aichi Steel, Nagoya, Japan) system in three patients with differing clinical problems.

Effect of high levels of intense sweetener intake in insulin dependent diabetics on the ratio of dietary sugar to fat: a case–control study

OBJECTIVE

To examine the influence of intense sweetener consumption on nutrient intakes in insulin dependent diabetics compared to controls.

DESIGN

Case-control food consumption survey.

SETTING

Dietary data were collected from individuals in Ireland between 1998 and 1999.

SUBJECTS

Diabetics were recruited through diabetic outpatient departments of St. James's Hospital Dublin. Controls were friends of the patients or staff/students of Trinity College and University College Dublin. Of the 171 diabetics contacted, 122 agreed to participate (70% response rate) and 119 completed the study.

INTERVENTIONS

In all, 3-day food diaries were used to collect the food consumption data.

MAIN OUTCOME MEASURES

Fat--sugar seesaw, intense sweetness.

RESULTS

Patients had significantly higher % energy from starch, lower % energy from sugars and a high intake of fibre compared to controls. In both groups, there was an inverse relationship between % energy from fat and % en from sugar, with the diabetics at the lower level of sugar intake. A score of intense sweetness intakes was computed and across tertiles of this score, there were no significant effects on macronutrient intakes.

CONCLUSION

The fat-sugar seesaw present in the diabetic group was at a lower level compared to the control group. A high intake of intense sweeteners does not have a detrimental effect on macronutrient and micronutrient intakes.

Rationale and methods of the EFCOSUM project

OBJECTIVE

To describe the rationale and methods for a European project (EFCOSUM) to develop a method for a European food consumption survey that delivers internationally comparable data on a set of policy-relevant nutritional indicators.

RATIONALE AND METHODS

Currently Member States are collecting data and information for use at national level. At an international level, such data are often of limited comparability and of varying quality. To promote the development and exchange of adequate, reliable and comparable indicators of public health, and the structures needed to exchange the relevant data, a programme of Community action on health monitoring was set up for the EU. The objective of the action programme is to contribute to the establishment of a Community Health Monitoring System. Data will be made available to all Member States via a telematic network, which is currently being developed for the Health Monitoring Programme. With regard to nutrition, there is a need for a limited set of policy-relevant dietary indicators that are comparable among EU Member States. In the field of nutrition, however, there is a regrettable lack of internationally comparable data. The project 'European Food Consumption Survey Method' (EFCOSUM) therefore aimed to define a (minimum) set of dietary components which are relevant determinants of health and to define a method for the monitoring of food consumption in nationally representative samples of all age-sex categories in Europe in a comparable way. The project was carried out by 14 Member States as well as nine other European countries. Activities of the project included plenary sessions, desk research, and working group activities, building on existing experience from such projects as DAFNE, EPIC, FLAIR Eurofoods-Enfant project, COST Action 99 and others. The proposed method may be used alone, or as a calibration method to accompany existing ongoing studies.

A European food consumption survey method--conclusions and recommendations

OBJECTIVE

To discuss the general outcome and conclusions of a European project (EFCOSUM); to develop a method for a European food consumption survey that delivers internationally comparable data on a set of policy relevant nutritional indicators.

DESIGN AND METHODS

The EFCOSUM project was carried out within the framework of the European Health Monitoring Programme by 14 Member States as well as nine other European countries. Activities of the project included plenary sessions, desk research and working group activities, building on existing experience from such projects as DAFNE, EPIC, FLAIR Eurofoods-Enfant project, COST Action 99 and others. All participating states took part in one or more working group activities, which were discussed, adapted and finally approved in plenary sessions.

RESULTS AND CONCLUSIONS

For a limited number of countries available food consumption data can be made comparable at the food intake level, but not at the nutrient level. To achieve comparability at the food intake level, a considerable amount of work still has to be done. A minimum list of dietary indicators considered to be the most relevant to be collected for the Health information exchange and monitoring system was identified. As the most suitable method to get internationally comparable new data on population means and distributions of actual intake the 24 h recall was selected, to be conducted at least twice. This also allows for the estimation of usual intake by a modelling technique that separates intra- and inter-individual intake. For a number of micronutrients the use of biomarkers is recommended. Aspects of food classification and food composition were discussed thoroughly, as well as statistical and data collection aspects. For the implementation of a pan-European survey the establishment of a European co-ordinating centre is recommended. The standardization of field work work procedures and other aspects of operationalization have been discussed in detail. It is concluded that there is broad European consensus on the most suitable method for a pan-European dietary survey for the purposes of the EU Health Monitoring Programme. It is further concluded that such a pan-European survey is feasible, if the funds are made available.

Bacillus spore inactivation methods affect detection assays

Detection of biological weapons is a primary concern in force protection, treaty verification, and safeguarding civilian populations against domestic terrorism. One great concern is the detection of Bacillus anthracis, the causative agent of anthrax. Assays for detection in the laboratory often employ inactivated preparations of spores or nonpathogenic simulants. This study uses several common biodetection platforms to detect B. anthracis spores that have been inactivated by two methods and compares those data to detection of spores that have not been inactivated. The data demonstrate that inactivation methods can affect the sensitivity of nucleic acid- and antibody-based assays for the detection of B. anthracis spores. These effects should be taken into consideration when comparing laboratory results to data collected and assayed during field deployment.

Prevalence of physical activity during leisure time in the European Union

PURPOSE

To estimate the prevalence of physical activity during leisure time in adults from the 15 member states of the European Union and the relationship with sociodemographic variables.

METHODS

A representative sample, with approximately 1000 adults, aged 15 and upward, was selected from each member state to complete a questionnaire on attitudes to physical activity, body weight, and health by a face-to-face interview, summing a total of 15,239 subjects. The amount of leisure-time physical activity was quantified by assigning metabolic equivalents (METs) to each activity. Multiple linear regression models with MET-h.wk(-1) as the dependent variable were fitted.

RESULTS

Northern European countries showed higher levels of physical activity than southern ones. The highest prevalence (91.9%) was found in Finland, and the lowest (40.7%) in Portugal. A higher percentage of men practiced any leisure-time physical activity and also showed higher mean of MET-h.wk(-1). In both genders, the multivariate models showed a significant trend to higher leisure time activity in participants with higher educational levels and in nonsmokers. Also, an inverse association between body mass index and leisure-time physical activity was found.

CONCLUSION

The prevalence of any physical activity during leisure time in the adult European population was similar to the U.S. estimates. Nevertheless, the amount of activity is low, and a wide disparity between countries exists. To our knowledge, this is the first study determining the prevalence and amount of leisure-time physical activity, which is the first step to define strategies to persuade populations to increase their physical activity.

Sources of information on healthy eating in a Mediterranean country and the level of trust in them: a national sample in a pan-European survey

OBJECTIVE

To know the sources of information and the level of trust in these sources in a population to facilitate the promotion of healthy dietary habits.

PATIENTS AND METHODS

A national survey was carried out according to an established protocol on a representative sample of 1009 Spanish subjects over 15 years of age selected by a random multietapic procedure. This study belongs to the Spanish partnership in a pan-European Survey about sources of information on healthy eating and their level of trust. The analysis was focussed on the evaluation of the 5 most frequently chosen sources.

RESULTS

There was a trend towards a greater use and trust in "Health professionals" than other sources. Thus, about 26% of the respondents mentioning "health professionals" as the source of information on healthy eating. However, "TV/radio" (25.7%) was almost so often selected as "Health professionals". About 17.4% of subjects declared that they obtained no information at all on healthy eating. Subjects with university level of studies exhibited a greater mention of "Health professionals", while individuals belonging to higher socio-economic levels preferred "TV/radio". The degree of trust was higher for messages obtained from "Health professionals" (89.9%) and the "Department of Health" (78.7%) and lower for information obtained from "newspaper" (34.2%) and "advertising" (17.6%).

CONCLUSION

Nutrition and health educators must promote dietary guidelines through the appropriate channels for communicating messages to different targets groups.

Sodium channels and neurological disease: insights from Scn8a mutations in the mouse

The human genome contains 10 voltage-gated sodium channel genes, 7 of which are expressed in neurons of the CNS and PNS. The availability of human genome sequences and high-throughput mutation screening methods make it likely that many human disease mutations will be identified in these genes in the near future. Mutations of Scn8a in the mouse demonstrate the broad spectrum of neurological disease that can result from different alleles of the same sodium channel gene. Null mutations of Scn8a produce motor neuron failure, loss of neuromuscular transmission, and lethal paralysis. Less severe mutations result in ataxia, tremor, muscle weakness, and dystonia. The effects of Scn8a mutations on channel properties have been studied in the Xenopus oocyte expression system and in neurons isolated from the mutant mice. The Scn8a mutations provide insight into the mode of inheritance, effect on neuronal sodium currents, and role of modifier genes in sodium channel disease, highlighting the ways in which mouse models of human mutations can be used in the future to understand the pathophysiology of human disease.

Perception of body image as indicator of weight status in the European union

OBJECTIVE

To identify the factors associated with an adequate perception of body image in relation to body weight.

MATERIAL AND METHODS

An observational, cross-sectional study was conducted in a representative sample of the European Union (7,155 men and 8,077 women). Body Mass Index (BMI) was grouped into four categories, perceived body image was assessed using the nine silhouettes drawing scheme. A multivariable logistic regression model for each sex was used to adjust for potentially confounding variables.

RESULTS

Underweight men and women classified themselves better than other groups (92.9% of correct answers among men and 79.3% among women). Overall, women classified themselves better than men (57.6% vs. 32.7%).

DISCUSSION

Perceived body image as a method of assessment for body weight has different validity depending on sociodemographic or attitudinal categories. Perceived body image as an estimate of the nutritional status has a limited individualized application. Thus, perhaps it could be applied as a proxy measure of adiposity among slim males and among slim and overweight females, but not among the other groups.

Puzzling elevation of blood lead levels among consumers of freshwater sportfish

The authors evaluated lead exposure of Canadians (Montreal) who fished the nearby St. Lawrence River. From screening interviews conducted with 1,118 fishers on-site during the winter and fall of 1996, the authors selected 60 Montrealers who consumed at least one sportfish meal per week and 72 who consumed less than one sportfish meal per week. Fishers at the higher level of sportfish consumption had elevated blood lead concentrations, compared with fishers who ate little sportfish (geometric mean = 57.4 microg/l vs. 48.2 microg/l, respectively; p < .05). This result was surprising inasmuch as fish is not considered a significant source of lead. In addition to sportfish consumption, age, sex, occupation, smoking, and waterfowl consumption also showed independent associations with blood lead levels. Among frequent (i.e., > or = 1 meal/wk) consumers of sportfish, ingestion of waterfowl was associated with higher blood lead levels (geometric mean = 69.4 microg/l vs. 51.8 microg/l, respectively; p < .05); this association was not present for infrequent consumers. In multivariate analysis, the association of higher blood lead levels with sportfish consumption could be accounted for in large part by waterfowl consumption among frequent consumers of sportfish.

Dissociative identity disorder and the nurse-patient relationship in the acute care setting: an action research study

This paper presents the results of an action research study into the acute care experience of Dissociative Identity Disorder. The study, which was grounded in principles of critical social science, utilized focus group interviews and narrative construction. Nurses and patients are under-represented in all clinical evaluation and their voices need to be heard if services are to be truly collaborative. Findings of the study extend intrapsychic theories of trauma to emphasize the interpersonal relationship between nurse and person who can work together to facilitate recovery from trauma, make connections both intra and interpersonally and build resilience.

Underestimation of body mass index through perceived body image as compared to self-reported body mass index in the European Union

An observational, cross-sectional study was conducted in a representative sample of the European Union (7155 men and 8077 women) to calculate the underestimation of body weight as assessed by body image among the overweight and obese population and identify the associated factors to this behavior. Participants were older than 15 years and they were living in the 15 European Union countries. Body mass index (BMI) was grouped into 4 categories using the cutpoints established by the WHO, while perceived body image (PBI) was assessed using a nine-silhouettes drawing. The degree of underestimation between PBI as compared to BMI was identified in overweight and obesity categories of BMI. A multivariable logistic regression model for each gender was used to adjust for potentially confounding variables. Men classified themselves worse than women, being more likely to underestimate their body weight (65.2% of men underestimated their weight vs 32.2% women), regardless of other socioeconomic and attitudinal variables. The greatest degree of underestimation was observed in Mediterranean individuals (68.7% of men and 37.9% of women underestimated their weight). The subjects in the 'maintenance' stage of physical activity tended more often to wrongly select their actual image (71.8% for men and 38.7% for women).

Barriers and benefits of a healthy diet in spain: comparison with other European member states

OBJECTIVE

Our purpose was to identify the main barriers and benefits perceived by the European citizens in regard to following a healthy diet and to assess the differences in expected benefits and difficulties between Spain and the remaining countries of the European Union.

DESIGN

A cross-sectional study in which quota-controlled, nationally representative samples of approximately 1000 adults from each country completed a questionnaire.

SETTING

The survey was carried out between October 1995 and February 1996 in the 15 member states of the European Union.

SUBJECTS

Participants (aged 15 y and older) were selected and interviewed in their homes about their attitudes towards healthy diets. They were asked to select two options from a list of 22 potential barriers to achieve a healthy diet and the benefits derived from a healthy diet. The associations of the perceived benefits of barriers with the sociodemographic variables within Spain and the rest of the European Union were compared with the Pearson chi-squared test and the chi-squared linear trend test. Two multivariate logistic regression models were also fitted to assess the characteristics independently related to the selection of 'Resistance to change' among the main barriers and to the selection of 'Prevent disease/stay healthy' as the main perceived benefits.

RESULTS

The barrier most frequently mentioned in Spain was 'Irregular work hours' (29.7%) in contrast with the rest of the European Union where 'Giving up foods that I like' was the barrier most often chosen (26.2%). In the multivariate logistic regression model studying resistance to change, Spaniards were less resistant to change than the rest of the European Union. The benefit more frequently mentioned across Europe was 'Prevent disease/stay healthy'. In the multivariate logistic regression model women, older individuals, and people with a higher educational level were more likely to choose this benefit.

CONCLUSIONS

It is apparent that there are many barriers to achieve healthy eating, mostly lack of time. For this reason a higher availability of food in line with the nutrition guidelines could be helpful. The population could have a better knowledge of the benefits derived from a healthy diet.

Sociodemographic determinants of perceived influences on food choice in a nationally representative sample of Irish adults

OBJECTIVE

To identify the most important motivations for food choice from the point of view of the consumer in the Irish population, and to characterize those subjects who do and do not regard nutrition as a significant consideration in food choice.

DESIGN

As part of a pan-European Union (EU) survey on consumer attitudes to food, nutrition and health, a quota-controlled, nationally representative sample of Irish adults (n = 1009) aged 15 years upwards, completed an interview-assisted, close-ended questionnaire. Subjects selected three factors, from a list of 15, which they believed had the greatest influence on their food choice.

SETTING

The interviews for the survey were conducted in subjects' homes.

RESULTS

'Quality/freshness of food' was the most frequently selected food choice factor (51%) followed by 'taste' (43%) and 'trying to eat a healthy diet' (36%). Female gender, increasing age and higher levels of education were found to be independent sociodemographic factors affecting the selection of 'trying to eat a healthy diet' as an important factor in food choice.

CONCLUSIONS

Although included in the top five most frequently selected factors affecting food choice, nutrition/healthy eating does not appear to have top priority for the majority of Irish adults. There are differences between the various sociodemographic groups within the population; males and younger subjects appear to require specific nutrition promotion messages.

Definitions of healthy eating in Spain as compared to other European Member States

STUDY OBJECTIVE

To assess what healthy eating means for the European population and whether this concept differs between Spain and other European Countries.

DESIGN

A Pan-European survey was developed between October 1995 and February 1996 by the Institute of European Food Studies (Dublin). Each subject was asked to describe in his or her own words what he/she understood by 'healthy eating'. Comparisons were made among four groups of European countries (Northern, Central, Spain, and other Mediterranean countries).

SETTING

The survey included participants from the 15 member states of the European Union, selecting quota-controlled samples to make them nationally representative.

SUBJECTS

The questionnaire was completed by 14,331 persons, approximately 1000 from each country.

RESULTS

The responses were grouped into 89 broad categories of similar answers concerning nutritional value and afterwards these responses were collapsed to simplify the presentation. The definition of healthy eating such as 'more fiber' and 'less fat' was more prevalent in other States, members of the European Union than in Mediterranean Countries, although the definition of 'balanced diet' was more frequently mentioned in Spain than in the rest of the European Union.

CONCLUSIONS

Our results show that the concept of 'balance and variety' is more prevalent in Spaniards than in other traditional Mediterranean countries. Differences in the definitions of healthy eating among European countries could be explained, at least partially by differences in consumption patterns and in the nutrition education.