Cut-off values for anthropometric indices in predicting morbidity and mortality in Turkey: a cohort

Background

Anthropometric measurements are associated with cardiovascular outcomes and mortality and the association varies by community. This study aims to estimate the incidence of cardiovascular outcomes and all cause mortality and determines their association with the anthropometric measurements.

Methods

The data from Turkey Chronic Diseases and Risk Factors Survey were used for the cohort which recruited two 15 years and older adults from each family physicians' list in 2011 in Turkey using simple random sampling (n = 18,477). Family physicians collected the medical history and performed anthropometric measurements. Initially healthy participants for cardiovascular morbidity (coronary heart disease (ICD-10 codes I20.0-I25.0) and stroke (ICD-10 codes I60.0-I69.0) and all participants for all-cause and cardiovascular mortality were followed-up through electronic health records by 2017. Area under the curves (AUCs) were estimated and the adiposity risk was defined as cut-off points determined using Youden Index. The sample was stratified by age-groups (<65, ≥65). Poisson and Cox models were fitted for morbidity and mortality outcomes, respectively.

Results

Over six years of follow-up, 5.7% of 15,877 and 1.3% of 16,062 participants developed CHD and stroke respectively. In total, 664 all-cause deaths (4.0%) were observed with 155 caused by CVDs (0.9%). A body shape index (i.e. 0.658 for all-cause mortality among younger men), waist-to-height ratio (i.e. 0.743 for CHD incidence among younger women), and BMI had higher AUCs for the outcomes. Higher anthropometric measurement groups had almost always higher CHD incidence risk in all groups but lower all-cause mortality in older men. Higher body-mass index was associated with lower mortality in younger men.

Conclusions

This cohort study in Turkey showed that having higher anthropometric measurements is mostly associated with higher CHD incidence and mostly lower mortality among older men. This association deserves further studies.

Key messages

In Turkey, higher anthropometric measurements are associated with higher coronary heart disease incidence in among participants. In Turkey, higher anthropometric measurements are mostly associated with lower all-cause mortality in older age-groups.

Health-related QoL and fatality in CHD patients: findings from a national cohort study, Turkey

Background

Although strong association between self-reported health and coronary heart disease (CHD) exists, health related quality of life (HRQOL) has not been conceptualized as a predictor for fatality in CHD patients. We investigated whether HRQOL may predict the risk of death in six years in CHD patients.

Methods

There were overall, 614 of CHD cases in the national representative Chronic Diseases and Risk Factors Survey in Turkey, 2011. Baseline self-reported health data on EuroQol- 5 Dimension (EQ-5D) and a Visual Analog Scale (VAS) were used from the same survey. The cases were followed-up for all-cause and CHD specific fatality (ICD-10 diagnostic codes: I20- I25) through electronic health records by 2017. Kaplan Meier and Cox regression models were used for data analysis. Age and sex adjusted HRs [aHR 95% CIs] were estimated for having some or extreme problems in EQ5D domains and VAS.

Results

Median follow-up years (IQR) was 6.46 (6.39-6.47). The number of deaths from all causes and CHD were 103 and 26, respectively. Age and sex adjusted HRs for all causes fatality were statistically significant for some or extreme problems in usual activities [2.48 (95%CI 1.60-3.83)], in pain/comfort [2.28 (95% CI 1.44-3.62)], in self-care [2.25 (95% CI 1.46-3.46)] and in mobility [1.85 (95% CI 1.16-2.96)]. Age and sex adjusted HRs for CHD specific fatality were statistically significant for some or extreme problems in self-care [3.45 (95% CI 1.48-8.07)] and pain/comfort [3.07(95% CI 1.19-7.93)]. VAS was negatively associated with overall fatality.

Conclusions

In CHD cases, poor self reported health might be a good indicator for overall and CHD specific fatality in 6 years. Especially having some or extreme problems in selfcare and pain/comfort are closely related with overall fatality as well as CHD specific fatality.

Key messages

There are strong relationships between HRQOL and all causes fatality as well as CHD specific fatality. Poor self- reported health might be a predictor for overall and CHD specific fatality in CHD cases.

Anthropometric indicators and diabetes incidence: results from a national cohort study, Turkey

Background

Anthropometric indicators such as Body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), and Body Shape Index (ABSI) are used globally to evaluate the risk of type 2 diabetes (T2DM). Our study aimed to investigate associations between different anthropometric indicators and the risk of T2DM using data from a national cohort.

Methods

The data on anthropometric measures and other risk factors of diabetes were obtained from Turkey Chronic Diseases and Risk Factors Survey in 2011 (n = 18,477). Disease information for the years 2012-2017 of the cohort has been reached through electronic health records and DM was ascertained by standard ICD-10 Codes. Four logistic regression models were generated based on different groups of confounders: unmodifiable risk factors, behavioral risk factors, comorbidities and socioeconomic variables. Categorical BMI, WC, WHR, WHtR, and ABSI values were used and adjusted RRs (95% CIs) of measurements were computed for men and women separately.

Results

Median follow-up year (IQR) was 6,46 (0,06). Between 2012 and 2017, 540 people were diagnosed with new diabetes. All anthropometric measurements except ABSI were associated with T2DM risk in all models. Among the anthropometric measures, BMI showed the strongest effect on incident diabetes, both in men (BMI ≥30; RRadj: 3.06, 95% CI 1.93-4.86) and women (BMI ≥30; RRadj: 2.58; 95%CI 1.73-3.85) in model 4 (adjusting for all confounding factors). WHtR provided the second strongest association with a RRadj of 2.57 in men (95% CI 1.78-3.71) and 2.55 in women (95%CI 1.87-3.47).

Conclusions

Independent of other risk factors, individuals with high BMI, WHR, WHtR and WC are at higher risk of developing T2DM. Public health strategies aimed at prevention of weight gain and obesity will probably be the most effective way to struggle with diabetes.

Key messages

There is a strong association between anthropometric measurements and type 2 diabetes incidence. Anthropometric indicators can be used to predict the risk of type 2 diabetes in males and females by clinicians and public health practitioners.

Noncommunicable disease incidences in 2012-2017, Turkey

Background

Globally, 88% of deaths are caused by noncommunicable diseases (NCD) and they are increasing in our country as in many parts of the world. Effective control, prevention and treatment of NCD, can begin from knowing the disease incidence by age, sex and regions.

Methods

This study aimed to determine the incidence of chronic diseases (coronary heart disease, stroke, diabetes, hypertension and cancer) by record linkage of the data from the Turkey Chronic Diseases and Risk Factors Prevalence Study 2011 (TCD-RFS) with health service databases, which are Family Medicine Information System, Medulla- E-Pulse and Death Notification System. The cohort (18.477 people above age 15) from TCD-RFS is followed up to determine the incidence of coronary heart disease, hypertension, diabetes, stroke and cancer, from the electronic health record systems for the period between 2012 and 2017 (6 years). Cumulative incidences were calculated, age and sex standardized incidences were given with 95% CI.

Results

The age and sex standardized cumulative incidences are, 5939 (95% CI 5933-5945) for CHD 1378 (95%CI:1369-1388) for stroke, 2254 (95% CI 2 253 -2 255) for cancer, 4200 (95% CI 4194-4204) for diabetes and 20788 (95% CI 1369-1388) for hypertension (per 100,000). The annual incidences are approximately 990 for CHD, 229 for stroke, 375 for cancer, 700 for diabetes and 3464 for hypertension (per 100,000). CHD and cancer incidences are higher in men, while diabetes, hypertension and stroke incidences are higher in women.

Conclusions

Regardless of the difficulties in comparing incidence of NCD with other countries, we think our results show that hypertension, diabetes, stroke and CHD have higher incidence than Western European countries. We also showed that these metrics can be obtained through data linkage of National Health Records for the first time in Turkey.

Key messages

The NCDs needs to be monitored by surveillance using the current data sources for health services. This data can provide very useful information regularly to monitor and control NCDs if necessary actions are taken to adjust data management.

Educational Level Inequalities in Cardiovascular Outcomes and All-Cause Mortality in Turkey: A Cohort

Background

Recent decades witnessed an increase in the burden of non-communicable diseases including adverse cardiovascular outcomes in low- and middle income countries and the burden was not equal across socioeconomic strata. This study aimed to define educational level inequalities in cardiovascular outcomes and all-cause mortality in a six-years cohort in Turkey.

Methods

Non-communicable Diseases and Risk Factors Cohort randomly sampled two adults (>14) from each of the registered family physicians in Turkey in July 2011 (n = 18,477). The family physicians collected demographic data. Incident coronary heart disease (CHD), cardiovascular and all-cause deaths were obtained from electronic health records in the end of 2017. Ridit score transformation was applied to the educational level by gender (illiterate, primary school, secondary school, high school or higher) and then Relative Index of Inequalities by educational level were estimated using Poisson Regression for morbidity and Cox Regression for mortality.

Results

There were 17,847 participants in CHD and 18,461 in the mortality cohort. During six-years 1,026 cases were diagnosed with CHD, 185 cardiovascular and 769 all-cause deaths occurred respectively. The inequalities were not significant for all outcomes however Relative Index of Inequalities were close to be significant for CHD incidence among men and all-cause mortality among women (0.721 (0.507 to 1.025) and 1.721 (0.969 to 3.057), respectively).

Conclusions

This is the first-ever cohort in Turkey with the aim to define educational level inequalities in cardiovascular outcomes and all-cause mortality. The inequalities may not have been observed due to the low number of outcomes.

Key messages

In Turkey, there were no educational level inequalities in our cohort. The possible inverse inequalities among men and inequalities among women may arise with a longer follow up.

Factors associated with patient activation in a Turkish population with diabetes and/or hypertension

Background

Patient activation (PA), which is known to improve health outcomes, describes the knowledge, skills and confidence a person has in managing their own health care. We investigated the extent of PA and associated factors in adults with diabetes (DM) and/or hypertension (HT). This study is the first in Turkey evaluating PA, using the Patient Activation Measure (PAM) scale. The results of the study provide practitioners with information on the characteristics of patients who need support to increase their activation.

Methods

We conducted this cross-sectional study in 14 Family Health Centers in Istanbul. The participants were DM and/or HT patients. A questionnaire including the PAM, questions on patient characteristics, life style behaviors, healthcare utilization and health status was applied to 431 patients. Based on PAM score, patients were classified into two activation levels: level 1-2 (poor activation) and level 3-4 (good activation). χ2, t-test and logistic regression (LR) analysis were used. LR analysis was performed for all participants and for women and men separately.

Results

Of 431 patients (mean age: 63.6), 65% were women; 45% had a poor activation level (PAL). Based on LR analysis; low socioeconomic status (SES) (OR = 1.6; 95% CI:1.01-2.5), being illiterate (OR = 3.9, 95% CI: 1.5-10.7), being primary school graduate (OR = 2.1, 95% CI:1.1-4.2), lack of adult vaccination (OR = 1.9, 95% CI:1.1-3.1), higher BMI (OR = 1.1, 95% CI: 1.09-1.13) and worse self-reported health (OR = 1.2, 95% CI: 1.1-1.3) were factors associated with low PAL. The latter was associated with low PAL for both sexes; high BMI was an associated factor only among women, while low SES and lack of vaccination were factors only in men.

Conclusions

Almost half of the patients had low activation level in our sample. Associated factors may serve as the basis for the development of interventions needed to enhance activation for patients with DM/HT.

Key messages

Low patient activation is associated with low level of education, low SES, high BMI, lack of vaccination and worse self-reported health. The factors associated with patient activation vary by gender. A qualitative study with patients having different levels of activation would be useful to understand the underlying motivations.

Pre-participation screening of the athletes in Turkey: approach of primary care physicians

Background

The pre-participation screening is crucial as the risk of sudden death for competitive athletes is higher than that of non-athletes. In Turkey, screening could be performed at the primary health care setting both by family medicine specialists (FMSs) and by general practitioners (GPs). Although there is a guideline, there is no legal regulation for the process. The aim of this study is to evaluate the approach of primary care physicians in pre-participation screening.

Methods

An online questionnaire based on the Turkish Medical Association (TMA) guideline, and the 14-item Screening Guideline of the American Heart Association (AHA) was delivered to primary care physicians. Knowledge, experience and approach of the physicians were assessed. Self-confidence, application of AHA criteria, accurate referral ratios and further test requests were taken as outcome measures. Descriptive and inferential analyzes were performed and p < 0.05 was considered significant.

Results

Of 214 participants, 39.3% were women, the average age was 44.9 years, the average work experience was 7.9 years. 89.7% of the participants were aware of their authorization, 90.2% had previously given this report, but only 6.5% feels confident. Only 13.1% knows the presence of TMA guideline, and only 23.8% states being educated on the subject at any part of their career. More than 60% of the participants consider further testing necessary in addition to medical history and physical examination. Blood and urine test requests were significantly more for GPs compared to FMSs (p = 0.026, p = 0.011). Accurate referral decision ratio was only 59.3% with no difference between FMSs and GPs (p = 0.216). Work experience had no effect on any of the outcomes.

Conclusions

As the legal regulations and awareness of the guideline are insufficient, pre-participation screening is not standardized, and this increases tendency for further testing or referral.

Key messages

The pre-participation screening of athletes in Turkey is not standardized among primary care physicians. Further testing request ratio is high and accurate referral ratio is low.

Synthesis, radiolabeling and In Vivo tissue distribution of an anti-oestrogen glucuronide compound, (99m)Tc-TOR-G

Toremifene (TOR) has been used as an anti-oestrogen drug for the treatment and prevention of human breast cancer. The aim of this study was the addition of the hydrophilic groups diethylenetriamine pentaacetic acid (DTPA) and glucuronic acid to the starting substance TOR and to label it with technetium-99m ((99m)Tc) radionuclide and to investigate radiopharmaceutical potential of the new compound. The synthesis reactions are completed in four steps, including enzymatic reaction, with the following substeps; preparation of microsomal fraction from Hutu 80 cell line and subsequent purification of UDP-glucuronyl transferase (UDPGT), estimation of protein quantity in microsomal samples and glucuronidation reaction. The results indicate that (99m)Tc-TOR-G may be proposed as a new anti-oestrogen glucuronide imaging agent for ovarian tumours.

Magnetic density of states at low energy in geometrically frustrated systems

Using muon-spin-relaxation measurements we show that the pyrochlore compound Gd(2)Ti(2)O(7), in its magnetically ordered phase below approximately 1 K, displays persistent spin dynamics down to temperatures as low as 20 mK. The characteristics of the induced muon relaxation can be accounted for by a scattering process involving two magnetic excitations, with a density of states characterized by an upturn at low energy and a small gap depending linearly on the temperature. We propose that such a density of states is a generic feature of geometrically frustrated magnetic materials.

Effects of Desialylation on Chemoattractant Induced Chemotaxis

The amount of sialic acid on the surface of the neutrophil influences its ability to interact with other cells. Neutrophil activation with various stimuli mobilizes intracellular sialidase to the plasma membrane where it cleaves sialic acid from cell surfaces. Since enhanced neutrophil adherence, spreading, deformability and motility each are associated with surface desialylation and critical to neutrophil diapedesis, we studied the role of sialic acid on neutrophil chemotaxis with interleukin-8 (IL-8), leukotriene B4 (LTB4), fMet-Leu-Phe (fMLP) and complement 5a in vitro. Migration of NANase-treated neutrophil across 3 μ pore size polycarbonate membranes was decreased in response to IL-8 and LTB4 but not to fMLP and complement 5a. These findings suggest that sialic acid content of receptors have a key role on chemoattractant-receptor binding and may be a novel strategy for limiting the inflammatory response.

Exposure to febrile temperature modifies endothelial cell response to tumor necrosis factor-alpha

Fever is an important regulator of inflammation that modifies expression and bioactivity of cytokines, including tumor necrosis factor (TNF)-alpha. Pulmonary vascular endothelium is an important target of TNF-alpha during the systemic inflammatory response. In this study, we analyzed the effect of a febrile range temperature (39.5 degrees C) on TNF-alpha-stimulated changes in endothelial barrier function, capacity for neutrophil binding and transendothelial migration (TEM), and cytokine secretion in human pulmonary artery endothelial cells (EC). Permeability for [(14)C]BSA tracer was increased by treatment with TNF-alpha, and this effect was augmented by incubating EC at 39.5 degrees C. Treating EC with 2. 5 U/ml TNF-alpha stimulated an increase in subsequent neutrophil adherence and TEM. Incubating EC at 39.5 degrees C caused a 30% increase in TEM but did not modify the enhancement of neutrophil adherence or TEM by TNF-alpha treatment. Analysis of cytokine expression in EC cultures exposed to TNF-alpha at either 37 degrees or 39.5 degrees C revealed three patterns of temperature and TNF-alpha responsiveness. Granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin (IL)-8 were not detectable in untreated EC but were increased after TNF-alpha exposure, and this increase was enhanced at 39.5 degrees C. IL-6 expression was also increased with TNF-alpha exposure, but IL-6 expression was lower in 39.5 degrees C EC cultures. Transforming growth factor-beta(1) was constitutively expressed, and its expression was not influenced either by TNF-alpha or exposure to 39.5 degrees C. These data demonstrate that clinically relevant shifts in body temperature might cause important changes in the effects of proinflammatory cytokines on the endothelium.