Associate Professor John Hall

Background and Objectives: With rapid population ageing and an increasing rate of hypertension in China, this study aims to examine the association between dietary patterns, dietary lead and hypertension among older Chinese population. Methods and Study Design: We analysed the 2009 China Health and Nutrition Survey data (2,634 individuals with dietary and hypertension measurement data, aged =60 years). Dietary data were obtained using 24 hour-recall over three consecutive days. Dietary lead intake is based on a published systematic review of food lead concentration and dietary lead exposure in China. Factor analysis was used to identify dietary patterns. Poisson regression and multinomial logistic regression models were used to explore the association between dietary patterns and hypertension. Results: The prevalence of hypertension was 47.0% in men and 48.9% in women. Traditional dietary pattern (high intake of rice, pork and vegetables) was significantly inversely associated with known hypertension. In the fully adjusted model, compared with the lowest quartile of traditional dietary pattern, the highest quartile had a lower risk of known hypertension, with Relative Risk Ratio=0.69 (95% CI: 0.50; 0.95). However, associations between modern dietary pattern and hypertension differed by urbanization; an inverse, positive and null association was seen in low, medium and high urbanization. Additionally, dietary lead showed a significant positive association with hypertension and known hypertension. Conclusions: Policies that facilitate and promote healthy diets, and the availability of healthy foods particularly at the regional and local levels, are important for the prevention of hypertension.

© 2016 Japan Geriatrics Society Aim: China faces a ¿time-bomb¿ of the aging population. Successful aging has long been a goal in the field of gerontology. The present study aimed to evaluate successful aging among Chinese older adults. Methods: Data on a total of 7102 people in the China Health and Retirement Study aged =60 years were analyzed in the present study. Successful aging is defined by the model of Rowe and Kahn including the following five indicators: ¿no major diseases,¿ ¿no disability,¿ ¿high cognitive functioning,¿ ¿high physical functioning¿ and ¿active engagement with life.¿ Using logistic regression analysis, crude and adjusted odds ratios with 95% confidence intervals were calculated to evaluate the relationship between sociodemographic parameters and successful aging. Results: The prevalence of successful aging was 13.2% among Chinese older people. The percentage of older people with the five indicators, ¿no major diseases,¿ ¿no disability,¿ ¿high cognitive functioning,¿ ¿high physical functioning,¿ and ¿active engagement with life¿ was 41.7%, 92.1%, 54.2%, 70.2% and 46.0%, respectively. Multiple logistic regression showed people who had received education of high/vocational school or above had significantly greater odds of successful aging compared with those with less than primary school education (P < 0.05). The effect of education to college level or above on cognitive functioning was 2.51-fold higher in women than men (P = 0.006). Older people from a non-agricultural Hukou had 1.85-fold higher odds of successful aging than those from an agricultural Hukou. Older people living in the central, northeast or western regions had lower odds of successful aging relative to those living in the east coast region (0.72, 0.72 and 0.56, respectively). Conclusions: The prevalence of successful aging is low among Chinese older people, and is affected by sociodemographic factors, such as education, Hukou and regions. Geriatr Gerontol Int 2017; 17: 1183¿1190.

© 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism Background & aims Epidemiological data of dietary patterns and anaemia among older Chinese remains extremely scarce. We examined the association between dietary patterns and anaemia in older Chinese, and to assess whether biomarkers of serum magnesium, C-reactive protein (CRP) and serum ferritin can mediate these associations. Methods We analysed the 2009 China Health and Nutrition Survey data (2401 individuals aged =60 years for whom both dietary and biomarker data are available). Dietary data was obtained using 24¿h-recall over three consecutive days. Fasting blood samples and anthropometry measurement were also collected. Factor analysis was used to identify dietary patterns. Factor scores representing dietary patterns were used in Poisson regression models to explore the association between each dietary pattern and anaemia. Results Of the 2401 participants, 18.9% had anaemia, 1.9% had anaemia related to inflammation (AI), and 1.3% had iron-deficiency anaemia (IDA). A traditional dietary pattern (high intake of rice, pork and vegetables) was positively associated with anaemia; a modern dietary pattern (high intake of fruit and fast food) was inversely associated with anaemia. Progressively lower magnesium and BMI levels were associated with increasing traditional dietary quartiles; while a progressively higher magnesium and BMI levels were associated with increasing modern dietary quartiles (p¿<¿0.001). There were no significant differences (p¿>¿0.05) in CRP and serum ferritin across quartiles for either dietary pattern. In the fully adjusted model, the prevalence ratio (PR) of anaemia, comparing the fourth quartile to the first quartile, was 1.75 (95% CI: 1.33; 2.29) for a traditional dietary pattern, and 0.89 (95% CI: 0.68; 1.16) for a modern dietary pattern. The association between dietary patterns and anaemia is mediated by serum magnesium. Conclusion Traditional dietary pattern is associated with a higher prevalence of anaemia among older Chinese. Future studies need to examine whether correcting micronutrient deficiency (e.g. magnesium) by promoting overall healthy diet, rather than iron supplementation, is a suitable strategy for anaemia prevention in older Chinese people.

Copyright © International Psychogeriatric Association 2016. Background: Both diabetes and depression have become serious public health problems and are major contributors to the global burden of disease. People with diabetes have been shown to have higher risk of depression. The purpose of this study was to observe the differences in depression between older Chinese adults with known or unknown diabetes. Methods: Data came from the national baseline survey of China Health and Retirement Longitudinal Study (CHARLS). The Center for Epidemiologic Studies Depression Scale was used to assess depression. Participants with a history of diabetes diagnosis were considered to have known diabetes, and those with newly-diagnosed diabetes were considered to have unknown diabetes. Multiple logistic regression analysis was applied to estimate odds ratio (OR) for depression in predictor variables. Results: Overall, 39.1% of the 2,399 participants with diabetes suffered from depression. The prevalence of depression was significantly higher (p < 0.001) in people with known diabetes (43.5%) than those with unknown diabetes (35.1%). The biggest differences between the two groups were found in the middle aged, in women, in the less educated and in married people. In known diabetes, people treated with traditional Chinese medicine (TCM) coupled with oral western medicine (WM) and/or insulin had two-fold odds of depression compared to those without treatment. Conclusion: The knowledge of having diabetes, treatments and suffering from other chronic diseases were associated with the higher prevalence of depression in people with known diabetes compared to those with unknown diabetes. Prevention of depression in diabetics should receive more attention in the middle aged, women and the less education.

© 2016 Elsevier B.V. Objective This study aims to assess the association between sleep and successful aging among Chinese¿=60 years of age. Methods Data were collected from the baseline survey of the China Health and Retirement Longitudinal Study. Two self-reported questions about sleep quality and duration were examined. Successful aging was defined following Rowe and Kahn's multidimensional model. To assess the adjusted association between sleep and successful aging, multivariable logistic regression was applied. Results The average number of self-reported hours of sleep was 6.2¿±¿2.0 among older Chinese people. Successful aging was related to sleep duration, with the proportion of those adults considered to be aging successfully falling into the following sleep duration categories (<6¿h ¿ 7.8%; 6¿h ¿ 16.3%; 7¿h ¿ 19.1%; 8¿h ¿ 14.7%; and¿=9¿h ¿ 12.8%). The plots between sleep duration and successful aging were an inverse U-shape. Participants who slept less than 6¿h per day had lower odds ratios of successful aging [odds ratio (OR)¿=¿0.52, 95% confidence interval (CI) 0.40¿0.67] relative to those who slept for 7¿h per day. Compared with those who reported poor sleep less than once a week, older people who reported poor sleep five to seven days a week showed a lower ratio of successful aging (OR¿=¿0.29, 95% CI 0.21¿0.39). Conclusion Older age, shorter or longer sleep, and poor sleep were related to lower odds of, rates of successful aging. Most older Chinese adults experience insufficient sleep and poor sleep quality, which could be an important influential factor in successful aging.

© 2015 by the authors; licensee MDPI, Basel, Switzerland. Background: No studies have been conducted to explore the associations between dietary patterns and obesity among older Chinese people, by considering gender and urbanization level differences. Methods: We analyzed data from the 2009 China Health and Nutrition Survey (2745 individuals, aged e 60 years). Dietary data were obtained using 24 h-recall over three consecutive days. Height, Body Weight, and Waist Circumference were measured. Exploratory factor analysis was used to identify dietary patterns. Multinomial and Poisson regression models were used to examine the association between dietary patterns and Body Mass Index (BMI) status/central obesity. Results: The prevalence of general and central obesity was 9.5% and 53.4%. Traditional dietary pattern (high intake of rice, pork and vegetables) was inversely associated with general/central obesity; modern dietary pattern (high intake of fruit, fast food, and processed meat) was positively associated with general/central obesity. The highest quartile of traditional dietary pattern had a lower risk of general/central obesity compared with the lowest quartile, while an inverse picture was found for the modern dietary pattern. These associations were consistent by gender and urbanization levels. Conclusions: Dietary patterns are associated with general/central obesity in older Chinese. This study reinforces the importance of a healthy diet in promoting healthy ageing in China.

© 2015 Chinwong et al. Background: Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of cardiovascular disease or mortality; however, the LDL-C goal for therapy in acute coronary syndrome (ACS) patients is controversial and varies among guidelines. This study aimed to assess the effect of reaching an LDL-C goal of <70 mg/dL (<1.8 mmol/L) on first composite cardiovascular outcomes in routine clinical practice in Thailand. Methods: A retrospective cohort study was conducted using medical charts and the electronic hospital database of patients diagnosed with ACS and treated with statins at a tertiary care hospital in Thailand between 2009 and 2012. After admission, patients were followed from the date of LDL-C goal assessment until the first event of composite cardiovascular outcomes (nonfatal ACS, nonfatal stroke, or all-cause death). Cox proportional hazard models adjusted for potential confounders were used. Results: Of 405 patients, mean age was 65 years (60% males). Twenty-seven percent of the patients attained an LDL-C goal of<70 mg/dL, 38% had LDL-C between 70 and 99 mg/dL, and 35% had LDL-C =100 mg/dL. Forty-six patients experienced a composite cardiovascular outcome. Compared with patients with an LDL-C =100 mg/dL, patients achieving an LDL-C of <70 mg/dL were associated with a reduced composite cardiovascular outcome (adjusted hazard ratio [HR]=0.42; 95% confidence interval [CI]=0.18¿0.95; P-value=0.037), but patients with an LDL-C between 70 and 99 mg/dL had a lower composite cardiovascular outcome, which was not statistically significant (adjusted HR=0.73; 95% CI=0.37¿1.42; P-value=0.354). Conclusion: ACS patients who received statins and achieved an LDL-C of <70 mg/dL had significantly fewer composite cardiovascular outcomes, confirming ¿the lower the better¿ and the benefit of treating to LDL-C target in ACS patient management.

© 2015 Rifat et al. Background: Bangladesh is one of the 27 high burden countries for multidrug resistant tuberculosis listed by the World Health Organization. Delay in multidrug resistant tuberculosis treatment may allow progression of the disease and affect the attempts to curb transmission of drug resistant tuberculosis. The main objective of this study was to investigate the health system delay in multidrug resistant tuberculosis treatment in Bangladesh and to explore the factors related to the delay. Methods: Information related to the delay was collected as part of a previously conducted case-control study. The current study restricts analysis to patients with multidrug resistant tuberculosis who were diagnosed using rapid diagnostic methods (Xpert MTB/RIF or the line probe assay). Information was collected by face-to-face interviews and through record reviews from all three Government hospitals providing multidrug resistant tuberculosis services, from September 2012 to April 2013. Multivariable regression analysis was performed using Bootstrap variance estimators. Definitions were as follows: Provider delay: time between visiting a provider for first consultation on MDR-TB related symptom to visiting a designated diagnostic centre for testing; Diagnostic delay: time from date of diagnostic sample provided to date of result; Treatment initiation delay: time between the date of diagnosis and date of treatment initiation; Health system delay: time between visiting a provider to start of treatment. Health system delay was derived by adding provider delay, diagnostic delay and treatment initiation delay. Results: The 207 multidrug resistant tuberculosis patients experienced a health system delay of median 7.1 weeks. The health system delay consists of provider delay (median 4 weeks), diagnostic delay (median 5 days) and treatment initiation delay (median 10 days). Health system delay (Coefficient: 37.7; 95 %; CI 15.0-60.4; p 0.003) was associated with the visit to private practitioners for first consultation. Conclusions: Diagnosis time for multidrug resistant tuberculosis was fast using the rapid tests. However, some degree of delay was present in treatment initiation, after diagnosis. The most effective way to reduce health system delay would be through strategies such as engaging private practitioners in multidrug resistant tuberculosis control.

© Chinwong et al. 2015. Background: Acute coronary syndrome (ACS) patients are at very high cardiovascular risk and tend to have recurrent cardiovascular events. The clinical indicators for subsequent cardiovascular events are limited and need further investigation. This study aimed to explore clinical indicators that were associated with recurrent cardiovascular events following index hospitalization. Methods: The data of patients hospitalized with ACS at a tertiary care hospital in northern Thailand between January 2009 and December 2012 were retrospectively reviewed from medical charts and the electronic hospital database. The patients were classified into three groups based on the frequency of recurrent cardiovascular events (nonfatal ACS, nonfatal stroke, or all-cause death) they suffered: no recurrent events (0), single recurrent event (1), and multiple recurrent events (=2). Ordinal logistic regression was performed to explore the clinical indicators for recurrent cardiovascular events. Results: A total of 405 patients were included; 60 % were male; the average age was 64.9 ± 11.5 years; 40 % underwent coronary revascularization during admission. Overall, 359 (88.6 %) had no recurrent events, 36 (8.9 %) had a single recurrent event, and 10 (2.5 %) had multiple recurrent events. The significant clinical indicators associated with recurrent cardiovascular events were achieving an LDL-C goal of < 70 mg/dL (Adjusted OR = 0.43; 95 % CI = 0.27-0.69, p-value < 0.001), undergoing revascularization during admission (Adjusted OR = 0.44; 95 % CI = 0.24-0.81, p-value = 0.009), being male (Adjusted OR = 1.85; 95 % CI = 1.29-2.66, p-value = 0.001), and decrease estimated glomerular filtration rate (Adjusted OR = 2.46; 95 % CI = 2.21-2.75, p-value < 0.001). Conclusion: The routine clinical practice indicators assessed in ACS patients that were associated with recurrent cardiovascular events were that achieving the LDL-C goal and revascularization are protective factors, while being male and having decreased estimated glomerular filtration rate are risk factors for recurrent cardiovascular events. These clinical indicators should be used for routinely monitoring patients to prevent recurrent cardiovascular events in ACS patients.

© 2015 Xu et al. Background/Objectives: Few studies have applied the Chinese Diet Balance Index (DBI) in evaluating dietary quality for Chinese people. The present cross-sectional study assessed dietary quality based on DBI for older people, and the associated factors, in four socioeconomically distinct regions in China. Methods: The China Health and Nutrition Survey (CHNS) involves 2745 older Chinese people, aged 60 or over, from four regions (Northeast, East Coast, Central and West) in 2009. Dietary data were obtained by interviews using 24 hour-recall over three consecutive days. Four indicators: Total Score (TS), Lower Bound Score (LBS), Higher Bound Score (HBS) and Diet Quality Distance (DQD) from DBI were calculated for assessing dietary quality in different aspects. Results: 68.9% of older people had different levels of excessive cereals intake. More than 50% of older people had moderate or severe surplus of oil (64.9%) and salt (58.6%). Intake of vegetables and fruit, milk and soybeans, water, and dietary variety were insufficient, especially for milk and soybeans. 80.8%of people had moderate or severe unbalanced diet consumption. The largest differences of DQD scores have been found for people with different education levels and urbanicity levels. People with higher education levels have lower DQD scores (p<0.001), and people living in medium and low urbanicity areas had 2.8 and 8.9 higher DQD scores than their high urbanicity counterparts (p<0.001). Also, significant differences of DQD scores have been found according to gender, marital status, work status and regions (p<0.001). Conclusion: DBI can reveal problems of dietary quality for older Chinese people. Rectifying unbalanced diet intake may lead to prevention of non-communicable diseases (NCDs). Dieticians and health care professionals need to increase dissemination and uptake of nutrition education, with interventions targeted at regions of lower socioeconomic status.

Copyright © 2014 The Authors. Little is known about the macronutrient intake status of older Chinese people. The present study evaluated the macronutrient intake status of older Chinese people (aged =A 60 years), investigated whether they had intake levels that met the Dietary Reference Intakes (DRI), and explored the associations between macronutrient intakes and age groups, sex, education levels, work status, BMI groups, urbanicity levels and four socio-economic regions of China (Northeast, East Coast, Central and Western). Dietary intake data of 2746 older Chinese with complete dietary intake data in the Longitudinal China Health and Nutrition Survey (2009 wave) carried out across four diverse regions were analysed. Dietary intake data were obtained by interviews using 24A h recalls over three consecutive days. The MUFA:SFA ratios were calculated based on the Chinese Food Composition Table. Less than one-third of the older Chinese people included in the present study had intake levels meeting the adequate intake for carbohydrate-energy and fat-energy; less than one-fifth had intake levels meeting the recommended nutrient intake for protein-energy; and more than half of the older people had fat-energy intakes higher than the DRI. There were strong associations between the proportions of energy from the three macronutrients and education levels, urbanicity levels and the four socio-economic regions of China, with older people living in the East Coast region having different patterns of macronutrient-energy intakes when compared with those living in the other three regions. Macronutrient intakes across different urbanicity levels in the four regions revealed considerable geographical variations in dietary patterns, which will affect the risk factors for non-communicable diseases. Clinical interventions and public health policies should recognise these regional differences in dietary patterns.

© 2015, BMJ. All rights reserved. Objectives: To identify common factors associated with post-neonatal, infant, child and under-5 mortality in Nigeria. Design, setting and participants: A cross-sectional data of three Nigeria Demographic and Health Surveys (NDHS) for the years 2003, 2008 and 2013 were used. A multistage, stratified, cluster random sampling method was used to gather information on 63 844 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey was examined using cox regression models. Main outcome measures: Postneonatal mortality (death between 1 and 11 months), infant mortality (death between birth and 11 months), child mortality (death between 12 and 59 months) and under-5 mortality (death between birth and 59 months). Results: Multivariable analyses indicated that children born to mothers with no formal education was significantly associated with mortality across all four age ranges (adjusted HR=1.30, 95% CI 1.01 to 1.66 for postneonatal; HR=1.38, 95% CI 1.11 to 1.84 for infant; HR=2.13, 95% CI 1.56 to 2.89 for child; HR=1.19, 95% CI 1.02 to 1.41 for under-5). Other significant factors included living in rural areas (HR=1.48, 95% CI 1.16 to 1.89 for postneonatal; HR=1.23, 95% CI 1.03 to 1.47 for infant; HR=1.52, 95% CI 1.16 to 1.99 for child; HR=1.29, 95% CI 1.11 to 1.50 for under-5), and poor households (HR=2.47, 95% CI 1.76 to 3.47 for postneonatal; HR=1.40, 95% CI 1.10 to 1.78 for infant; HR=1.72, 95% CI 1.19 to 2.49 for child; HR=1.43, 95% CI 1.17 to 1.76 for under-5). Conclusions: This study found that no formal education, poor households and living in rural areas increased the risk of postneonatal, infant, child and under-5 mortality among Nigerian children. Community-based interventions for reducing under-5 deaths are needed and should target children born to mothers of low socioeconomic status.

© 2015 Chinwong et al. Background: Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of coronary artery disease. Current guidelines recommend an LDL-C target of <70 mg/dL (< 1.8 mmol/L) for acute coronary syndrome (ACS) patients, and the first-line treatment to lower lipids is statin therapy. Despite current guidelines and the efficacious k'pid-lowering agents available, about half of patients at very high risk, including ACS patients, fail to achieve their LDL-C goal. This study assessed LDL-C goal attainment according to use of high and low potency statins in routine practice in Thailand. Methods: A retrospective cohort study was performed by retrieving data from medical records and the electronic hospital database for a tertiary care hospital in Thailand between 2009 and 2011. Included were ACS patients treated with statins at baseline and with follow-up of LDL-C levels. Patients were divided into high or low potency statin users, and the proportion reaching the LDL-C goal of <70 mg/dL was determined. A Cox proportional hazard model was applied to determine the relationship between statin potency and LDL-C goal attainment. Propensity score adjustment was used to control for confounding by indication. Results: Of 396 ACS patients (60% males, mean age 64.3+11.6 years), 229 (58%) were treated with high potency statins and 167 (42%) with low potency statins. A quarter reached their target LDL-C goal (25% for patients on high potency statins and 23% on low potency statins). High potency statins were not associated with increased LDL-C goal attainment (adjusted hazards ratio 1.22, 95% confidence interval 0.79-1.88; P=0.363). Conclusion: There was no significant effect of high potency statins on LDL-C goal attainment. Moreover, this study showed low LDL-C goal attainment for patients on either low or high potency statins. The reasons for the low LDL-C goal attainment rate warrants further investigation.

Background: Nigeria continues to have one of the highest rates of neonatal deaths in Africa. This study aimed to identify risk factors associated with neonatal death in Nigeria using the 2008 Nigeria Demographic and Health Survey (NDHS). Methods. Neonatal deaths of all singleton live-born infants between 2003 and 2008 were extracted from the 2008 NDHS. The 2008 NDHS was a multi-stage cluster sample survey of 36,298 households. Of these households, survival information of 27,147 singleton live-borns was obtained, including 996 cases of neonatal mortality. The risk of death was adjusted for confounders relating to individual, household, and community level factors using Cox regression. Results: Multivariable analyses indicated that a higher birth order of newborns with a short birth interval = 2 years (hazard ratio [HR] = 2.19, confidence interval [CI]: 1.68-2.84) and newborns with a higher birth order with a longer birth interval > 2 years (HR = 1.36, CI: 1.05-1.78) were significantly associated with neonatal mortality. Other significant factors that affected neonatal deaths included neonates born to mothers younger than 20 years (HR = 4.07, CI: 2.83-5.86), neonates born to mothers residing in rural areas compared with urban residents (HR = 1.26, CI: 1.03-1.55), male neonates (HR = 1.30, CI: 1.12-1.53), mothers who perceived their neonate's body size to be smaller than the average size (HR = 2.10, CI: 1.77-2.50), and mothers who delivered their neonates by caesarean section (HR = 2.80, CI: 1.84-4.25). Conclusions: Our study suggests that the Nigerian government needs to invest more in the healthcare system to ensure quality care for women and newborns. Community-based intervention is also required and should focus on child spacing, childbearing at a younger age, and poverty eradication programs, particularly in rural areas, to reduce avoidable neonatal deaths in Nigeria. © 2014 Ezeh et al.; licensee BioMed Central Ltd.