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Section Editors' Highlights

New Content ItemWelcome to the BMC Public Health Section Editors' Highlights page. Here, the Section Editors have chosen recent papers published in their section of the journal that are of particular importance or interest to highlight to a wider audience.

Chronic disease epidemiology

Severity of depression, anxious distress and the risk of type 2 diabetes – a population-based cohort study in Sweden

Chosen by: Jianguang Ji

The established association between depression and type 2 diabetes calls for clinical attention, especially in recent decades with an increasing prevalence of depression. It is thus necessary to explore whether the observed association is causal and to explore the underlying mechanisms by using prospective longitudinal data and by stratifying the observed association by various severity of depression (dose-response relationship). A total of 10 thousand individuals who lived in Stockholm County, Sweden have answered the postal questionnaires on depression and factors related to mental health in 1998–2000 in which depression was evaluated using the Major Depression Inventory. These individuals were followed until 2015 to identify their subsequent type 2 diabetes by using a few national registers. Deleskog and her colleagues did find that individuals with depression were at 1.48 times higher risk of type 2 diabetes after adjusting for potential confounders. It should be noted that the risk of type 2 diabetes was increased to 1.72 for individuals with severe depression, suggesting a causal association. In addition, they found that individuals with depression and concurrent moderate/severe anxious distress had 1.73 times higher risk. This study added strong evidence that depression is a strong risk factor for developing type 2 diabetes. However, further studies are highly needed to understand underlying mechanisms, as the authors acknowledged.

Energy balance-related behaviors

Evaluating differences in the clinical impact of a free online weight loss programme, a resource-intensive commercial weight loss programme and an active control condition: a parallel randomised controlled trial.

Chosen by: Janice Thompson

There is a clear and urgent need to identify effective weight loss programmes that also  reduce risks for related diseases such as cardiovascular diseases and type 2 diabetes. While there is evidence of the effectiveness for some commercial weight loss programmes, these programmes do not necessarily meet the needs of the diverse population of overweight and obese individuals, and most do not include intensive support to change both dietary and exercise behaviours. It is recognised that there is no ‘one size fits all’ programme that will be effective, and as such robust evidence is needed to compare programmes that vary in cost, intensity of delivery of both nutritional and exercise support, and approach (online or face-to-face). This paper describes the results of a parallel randomised controlled trial evaluating the efficacy of three different weight loss programmes over 12 weeks on reducing body mass and improving obesity-related health indicators.  The programmes were: 1) The Healthy Weight programme, a commercial, individually tailored 12-week intervention providing dedicated face-to-face exercise and nutritional support; 2) The National Health Service (NHS) programme, a free, online, self-managed resource that provides advice on both healthy eating and physical activity.  Participants were also given full access to gym and swimming pool facilities following a gym induction, but were not provided with access to personal training; and 3) The Gym only active control group, receiving no guidance or formal intervention. These participants were provided with a gym induction and familiarised with the basic American College of Sports Medicine (ACSM) physical activity guidelines via a handout, with no additional advice given. A total of 76 participants (66% female) were randomised, with 83% retention. After 12 weeks, overall there was a significant decrease in body mass and various obesity-related health indicators (e.g., plasma triglycerides, LDL-C, fasting blood glucose, HbA1C, and 10-year cardiovascular disease risk). Weight loss was significantly greater in the Healthy Weight (-5.17kg) and NHS groups (-4.19kg) as compared to the Gym group (-1.17kg).  There were no differences between the groups with regard to changes in obesity-related health indicators. The findings from this study suggest that the commercial Healthy Weight Programme and the free online NHS weight loss tool are superior to an active control condition with regard to short-term weight loss in people who are highly motivated to lose weight. These findings are promising, as the free NHS tool is widely accessible and may be more attractive to people who are not interested in group-based programmes. Future studies of effectiveness are needed to determine if the NHS tool with full gym access is comparable to an intensive commercial programme over the longer-term in a much larger sample.

Systematic review of the impact of nutrition claims related to fat, sugar and energy content on food choices and energy intake

Chosen by: Richard Rosenkranz

Worldwide obesity prevalence has reached all-time highs in recent years, and threatens to increase the risk of premature deaths within the global population due to chronic diseases such as heart disease, cancers, stroke, and diabetes. A range of policy, systems, environmental, and educational interventions have been proposed or implemented to reduce the public health burden of obesity. One set of policy approaches pertains to the application and regulation of nutrition claims and labeling that may educate consumers by providing nutrition information to promote healthier eating behaviors. This systematic review examined the extant evidence that nutrition claims relating to fat, sugar, and energy content influences energy intake and food choices. The authors located 11 studies relevant to the research question, although the methodological quality of these studies was mostly low, with only one study having moderate methodological quality. Results showed that nutrition claims do, in fact, shape consumers' knowledge related to healthfulness of products, and also the expected and experienced tastiness of food products. Interestingly, food products with nutrition claims seem healthier, but also less tasty to consumers. Nutrition claims also can make appropriate portion sizes seem larger or lead to underestimation of energy content, which could unintentionally increase caloric intake. Evidence also revealed that nutrition claims could influence food purchases and ‘consumption guilt’ stemming from eating a food product, and to increase consumption in certain cases. So, this systematic review indicates that nutrition claims relating to fat, sugar, and energy content are likely to increase purchase intentions when food products are perceived as healthier, but they may also have the unintended consequence of leading to energy over-consumption. Further high-quality studies are needed, but caution is warranted among policymakers and intervention research regarding the potential efficacy of nutrition claims for improving dietary intake or reducing obesity within the population. 

Compliance with the 24-h movement guidelines and the relationship with anthropometry in Finnish preschoolers: the DAGIS study

Chosen by: Carol Maher

How children spend their time has fundamental impacts on their health and wellbeing. Globally, a paradigm shift is underway for physical activity guidelines to be framed within the 24 h day, in recognition that changes in one domain (e.g. physical activity) will impact time available for other domains (e.g. sleep). This study examined the associations between compliance with physical activity, screen time and sleep guidelines, and weight status in Finnish pre-school children. Results showed that around 1 in 4 children complied with all 3 guidelines. Considering the guidelines individually, children were most likely to meet the physical activity guideline (85%), followed by the sleep guideline (76%) and screen time guideline (35%).  Meeting the guidelines for physical activity and sleep was associated with better weight status, while not association was observed for screen time. Overall, these patterns are broadly consistent with patterns seen in other countries that have adopted and begun evaluating 24 h movement guidelines (Canada, Australia and Belgium). However, some differences between countries emerge, and it is impossible to determine whether these are true differences in activity patterns across countries, or rather artefacts of the various studies using different physical activity, sleep and screen time measurement approaches.


This is one of the last papers we published in the decade of the 2010s. In many ways, it characterises the current state of our field as we exit the decade. Considerable gains have been made in how we view physical activity and its interdependence with other daily activities. The new 24 h movement guidelines are being adopted in a consistent manner across numerous countries – a testament to international collaboration and extensive efforts to consolidate massive volumes of evidence. Yet, measurement of physical activity continues to lack consensus – a multitude of different measurement approaches are in use, which can lead to dramatically different estimates of physical activity. While this situation persists, it will continue to hamper our understanding of the true status of physical activity, screen time and sleep. Perhaps the 2020s will be the decade that we reach a more standardised measurement approach in order to produce comparable datasets. 


Environmental health

Assessing the micro-scale environment using Google Street View: the Virtual Systematic Tool for Evaluating Pedestrian Streetscapes (Virtual-STEPS)

Chosen by: David Stieb

There is considerable recent interest in the impact of the built environment on physical activity. This study examines the performance of a Google Street-view based tool (Virtual-STEPS) for auditing microscale features of the built environment such as condition of sidewalks, traffic-calming features (e.g. stop signs), building setbacks, bus stops, bicycle lanes, and aesthetic qualities (e.g. graffiti), which have been found to be associated with physical activity in previous studies. The authors focused on these features because they are believed to be more readily amenable to intervention than macroscale features such as connectivity, land-use mix, and population density. Virtual-STEPS was found to be reliable in terms of inter-rater agreement and comparison to field auditing, and more time-efficient by eliminating travel time, based on evaluation of 60 street segments in Montreal, Canada. The tool may provide a cost-effective means of identifying microscale features of the built environment that are readily modifiable with the objective of promoting physical activity.

Global health

Promoting population health with public-private partnerships: Where’s the evidence?

Chosen by: Tim Mackey

The governance model of public private partnerships (PPPs) has been touted as an innovative approach for shared governance decision making and ways to involved multiple stakeholders in global health initiatives.  Some of the largest global health organizations are PPPs, such as the Global Fund and GAVI, which have both been evaluated in separate research for the effectiveness of their funding models, sustainability, and strategy focused on performance-based financing. However, critics have also argued that these organizations can introduce conflicts of interest, particularly when public health and private sector interests cannot be reconciled in these structures.  In this study by Parker and colleagues, authors conduct a systematic review evaluating the evidence of effectiveness of PPPs in the context of health promotion activities.  Based on the 36 studies retrieved (which covered 25 PPPs), most were for PPPs located in the UK, USA, and Australia, a majority addressed non-communicable diseases (NCDs), more than half involved a partnership with a private partners with potential for competition between financial interests and health promotion activity undertaken, and less than half (17, 47.2%) were deemed as high quality.  Importantly, this study shows that while PPPs are often touted as innovative and “hybrid” mechanisms to improve funding and delivery of health services and solutions, there remains an overall lack of published evidence supporting their effectiveness, particularly in the context of NCDs and health promotion.  However, as authors noted, there were limitations to the study sample, particularly given that non-public program evaluation or monitoring and evaluation reports may have not been published in the peer-review.  Hence, generating more purposeful, standardized, and robust evidence will be needed to ensure that this governance approach is the right fit to tackle some of our biggest global health challenges.

Health policies, systems and management in high-income countries

Impact of an excise tax on the consumption of sugar-sweetened beverages in young people living in poorer neighbourhoods of Catalonia, Spain: a difference in differences study

Chosen by: Summer Hawkins

The World Health Organization considers taxes on sugary beverages an effective, but underutilized policy tool. Royo-Bordonada and colleagues exploited the natural experiment created by an excise tax on sugar-sweetened beverages introduced in Barcelona. A unique aspect of the tax is that it was fully passed through to the price of beverages and paid by consumers. The two ‘tiers’ of taxes were based on sugar content and expected to raise the price of sugar-sweetened beverages between 10 and 20%. Royo-Bordonada and colleagues examined the impact of the excise tax on beverage consumption among 12- to 40-year-olds from low-income neighborhoods in Barcelona (intervention) compared to Madrid (control). This before-after study found that the consumption of taxed beverages by regular consumers fell by 39% in Barcelona compared to Madrid, where consumption remained stable over this one-year period. More than two-thirds of respondents reported they reduced consumption due to the price increase, followed by heightened awareness of their health effects. This study provides further evidence for the value of taxes as a policy intervention to reduce sugar-sweetened beverage consumption and the potential to address obesity.


Health policies, systems and management in low and middle-income countries

Expanding choice and access in contraception: an assessment of intrauterine contraception policies in low and middle-income countries

Chosen by: Ariadne Kapetanaki

This paper by Ali, Folz and Farron contributes to understanding the barriers and enablers of contraception use in low and middle-income countries. This is a very important topic since it can have health as well as social implications for women around the world. That fact that millions of women in low and middle-income countries are not able to use a modern contraceptive method is of great concern and so this paper looks specifically at intrauterine contraception policies that enable choice and access in contraception.
This paper reports on the status of policies on intrauterine devices (IUDs) in 69 low and middle-income countries and it shows the range and importance of policies, systems and training needed to ensure that women have access to contraception and at the same time can make an informed and safe choice about the type of contraception they would like to use.
While the results show that many countries have policies in place to support women who want to use IUDs, according to the authors, there are still several areas for improvement.


Infectious disease epidemiology

Evaluation of the influenza sentinel surveillance system in the Democratic Republic of Congo, 2012–2015

Chosen by: Giovanni Rezza

Surveillance systems for seasonal and pandemic influenza are essential in order to monitor annual trends and to identify circulating viruses, drifts, and emerging zoonotic strains. This study reports the evaluation of the “influenza sentinel surveillance system” (ISSS) of the Democratic Republic of Congo (DRC).

The ISSS is based on different sites reporting cases of influenza-like illness (ILI) occurring in outpatients and severe acute respiratory illness (SARI) in hospitalized patients. The data provide interesting information on influenza dynamics in the tropics, showing seasonal increases in the number of cases between December and May, due to the co-circulation of influenza virus type A/H3N2, A/H1N1, and B.

The performance of the surveillance system, based on the Centers for Disease Control and Prevention guidelines results to be satisfactory, proving  reliable and timely data on influenza circulation in DRC. This is encouraging, in the light of the importance of preparedness plans for influenza pandemic in medium/low income countries.  

Mental health

Child marriage and psychological well-being in Niger and Ethiopia

Chosen by: Noriko Cable

Many countries protect their children from entering adulthood prematurely and unprepared, yet some countries impose that children be married even before the age of 18, depriving them of having a crucial transition developmental phase for them to build psychosocial and material resources.  The effects of marrying young has been examined in the Western countries, but limited within the context of African countries. John, Edmeades and Murithi here have looked at adult married women as well as the head of their households in Niger (N=2,764) and Ethiopia (N=4,149) to examine the association between age of marriage and psychological well-being, indicated by the Psychological General Well-Being Index. Qualitative data were also collected from Ethiopian women.

In both countries, women were married earlier than 12 years of age, which was significantly negatively associated with their psychological well-being, reducing their psychological well-being by -7.41 points in Niger and -5.09 points in Ethiopia. Domestic violence also added to their poor psychological well-being, especially the aspects of self-control in both countries.  Qualitative results in Ethiopia revealed unrealistic demands placed upon women as a child bride and their powerlessness over marital arrangement and more importantly how they lacked opportunities to gain education and employment.

Children entering their adolescence are the most vulnerable mentally and physically, not ready for adulthood or responsibilities, especially marriage and family formation. This study adds that early marriage is detrimental to women’s psychological well-being, even though the custom of child marriage is socially accepted in these countries.

Occupational health

Effects of occupational exposure to dust on chest radiograph, pulmonary function, blood pressure and electrocardiogram among coal miners in an eastern province, China

Chosen by: Youcheng Liu

Although coal workers pneumoconiosis is an old occupational disease, it is a big occupational health issue in China given coal mining remains a big industrial sector. While it is a cross-sectional measurement in nature using 2 years of surveillance data, this study has a large sample size (23,658 participants in total); the risk factors identified are therefore more meaningful. Additionally, the study has not only focused on pulmonary health, but also measured cardiovascular health of the participants. The authors find that abnormal lung and cardiovascular functions are most related to age and duration of coal dust exposure. Smoking as a risk factor contributed to the abnormalities. The type of work tasks and mining sizes also contributed to some of the abnormalities. The percentage of coal miners’ pneumoconiosis, 0.34%, for all miners in this study, is much higher than that of US data for underground miners (0.04%) averaged across all age groups) from 2013 to 20171. Although no actual exposure to dust was measured for the study participants, the risk factors identified highlight the need to improve preventive measures in China coal miners, i.e., to reduce dust exposures. In addition, general health promotion to reduce smoking, drinking and overweight in coal miners are also important preventive measures. Future studies should aim to follow up workers with periodic measurements of pulmonary function and cardiovascular health along with dust exposure levels so that the relative risk related to exposure dose can be quantified.


References:


CDC. CWHSP: Percentage of examined underground miners with coal workers' pneumoconiosis (ILO category 1/0+) by tenure in mining, 1970-2017. Available at: https://wwwn.cdc.gov/eworld/Grouping/Coal_Workers_Pneumoconiosis/93. Accessed on Oct 20, 2019.

Psychosocial working conditions across working life may predict late-life physical function: a follow-up cohort study

Chosen by: Isabelle Niedhammer

In a context of increasing life expectancy and raising retirement age, this paper is offering us a highly topical subject. Exploring the associations between psychosocial work exposures, using a working life course approach, and late-life physical function appears indeed particularly pertinent and largely unexplored. The authors showed that exposure and particularly increasing exposure to high strain during working life were associated with limitation in late-life physical function. Although this study was not free from some biases (including residual confounding bias), it suggests that the psychosocial work environment and its exposures to work stress across working life may have an impact on health later in life. As these exposures are modifiable, this study, which is one of the first on this topic, opens the way to other research studies and potential interesting perspectives to improve the health among elderly people.

Social determinants of health

Holding the keys to health? A scoping study of the population health impacts of automated vehicles

Chosen by: David Rehkopf

This scoping review is a systematic survey of the literature on the potential impacts of Autonomous Vehicles (AV) on human health. The study encompasses a range of potential pathways that are rarely considered for social determinants of health, but a range that is necessary for understanding the ways in which AV use will have net positive or negative influences on health. For example, there are important potential pathways related to accessibility, environmental impacts, affordable housing, stress and land use. What is particularly noteworthy about this study is the explicit linking of a new technological development to the ways it may impacts social determinants of health and consequently health equity. It is forward looking in using the literature to help understand what might be done now to improve health as regulatory decisions are being made. The empirical evidence is far from clear, but the article lays out a path for evaluation, and one can imagine some useful approaches as individual U.S. states take different approaches to regulation. The article is also clear to suggest different ways in which AV use may be regulated. The technology is likely not fundamentally good or bad for health on its own, it is instead the specifics of development and regulation that are likely to determine the health impacts. Finally, more broadly, the study is an exemplar demonstrating the ways economic and technological decisions that are evolving rapidly can at any moment be more or less directed to changing myriad social determinants of health. The work demonstrates how public health researchers can play an important role in advising on the regulation and development of new technologies, using evidence on social determinants of health in order to improve health and health equity.