Background Socioeconomic development is widely regarded as contributing to improved nutrition in children. We aimed to assess the association between socioeconomic indicators and child and adolescent nutritional status, and the differences in this association between urban and rural areas. Methods We extracted data from the 1995, 2000, 2005, 2010, and 2014 cycles of the Chinese National Survey on Students' Constitution and Health. We analysed these data for three nutritional outcomes-stunting, thinness, and overweight and obesity-in children and adolescents aged between 7 and 18 years, as defined by WHO standards and classifications. We included three socioeconomic indicators-gross domestic product (GDP) per capita, Engel coefficient (the proportion of household income spent on food), and urbanisation ratio-at both national and subnational levels for each survey year. We used logistic regression models to estimate the association between socioeconomic indicators and child nutritional status, and used prevalence odds ratios (ORs) to assess the urban-rural disparity for nutritional status over time. We also used generalised additive models to evaluate differences in associations between socioeconomic and nutritional status between urban and rural areas. Findings We included 1 054 602 participants ( 204 932 in 1995; 209 167 in 2000; 225 213 in 2005; 208 136 in 2010; 207 154 in 2014) with complete records on age, sex, nationality, height, and weight in the final analyses, and the final dataset contained 29 provinces ( Hong Kong, Macau, Taiwan, Chongqing, and Tibet were excluded) with complete socioeconomic indicator information and student nutritional status information. From 1995 to 2014, the mean stunting prevalence in Chinese children and adolescents decreased from 8.1% (95% CI 8.0-8.2) to 2.4% (2.4-2.5), and the mean thinness prevalence declined from 7.5% (7.4-7.6) to 4.1% (4.0-4.2). Overweight and obesity mean prevalence increased from 5.3% (5.2-5.4) to 20.5% (20.4-20.7). We observed an inverse association between socioeconomic indicators and mean stunting and thinness prevalence, and found a positive association between socioeconomic indicators and overweight and obesity prevalence. The urban-rural disparity in nutritional status gradually diminished, with the prevalence ORs approaching equivalence over time. More rapid improvement of socioeconomic indicators was associated with changed nutritional status in children and adolescents, but with differences across urban and rural settings. The association between socioeconomic status and overweight and obesity was stronger in rural than in urban areas. Improvements (reductions) in the Engel coefficient were accompanied by a greater reduction of stunting and thinness in rural than in urban areas. Interpretation Although socioeconomic development has been accompanied by continued improvements in stunting and thinness, a marked increase has occurred in overweight and obesity in Chinese children and adolescents, particularly in rural areas. There is a pressing need for policy actions to extend beyond an emphasis on economic growth alone, and to focus on promotion of healthy diets and physical activity. Copyright (C) 2019 Elsevier Ltd. All rights reserved.
Background Lifestyle interventions can delay the onset of type 2 diabetes in people with impaired glucose tolerance, but whether this leads subsequently to fewer complications or to increased longevity is uncertain. We aimed to assess the long-term effects of lifestyle interventions in people with impaired glucose tolerance on the incidence of diabetes, its complications, and mortality. Methods The original study was a cluster randomised trial, started in 1986, in which 33 clinics in Da Qing, China, were randomly assigned to either be a control clinic or provide one of three interventions (diet, exercise, or diet plus exercise) for 6 years for 577 adults with impaired glucose tolerance who usually receive their medical care from the clinics. Subsequently, participants were followed for up to 30 years to assess the effects of intervention on the incidence of diabetes, cardiovascular disease events, composite microvascular complications, cardiovascular disease death, all-cause mortality, and life expectancy. Findings Of the 577 participants, 438 were assigned to an intervention group and 138 to the control group (one refused baseline examination). After 30 years of follow-up, 540 (94%) of 576 participants were assessed for outcomes (135 in the control group, 405 in the intervention group). During the 30-year follow-up, compared with control, the combined intervention group had a median delay in diabetes onset of 3.96 years (95% CI 1.25 to 6.67; p=0.0042), fewer cardiovascular disease events (hazard ratio 0.74, 95% CI 0.59-0.92; p=0.0060), a lower incidence of microvascular complications (0.65, 0.45-0.95; p=0.025), fewer cardiovascular disease deaths (0.67, 0.48-0.94; p=0.022), fewer all-cause deaths (0.74, 0.61-0.89; p=0.0015), and an average increase in life expectancy of 1.44 years (95% CI 0.20-2.68; p=0.023). Interpretation Lifestyle intervention in people with impaired glucose tolerance delayed the onset of type 2 diabetes and reduced the incidence of cardiovascular events, microvascular complications, and cardiovascular and all-cause mortality, and increased life expectancy. These findings provide strong justification to continue to implement and expand the use of such interventions to curb the global epidemic of type 2 diabetes and its consequences. Copyright (C) 2019 Elsevier Ltd. All rights reserved.
Low HDL cholesterol dyslipidaemia affects about half of people with type 2 diabetes and represents a major independent risk factor for atherosclerotic cardiovascular disease. The "good cholesterol" label was coined decades ago on the basis of a presumed causal role of HDL cholesterol in atherosclerotic cardiovascular disease. However, this view has been challenged by the negative results of several studies of HDL cholesterol-raising drugs, creating a paradox for clinicians regarding the value of HDL cholesterol as a risk biomarker and therapeutic target, and seemingly contradicting decades of evidence substantiating an inverse relation between HDL cholesterol and cardiovascular disease risk. We seek to resolve this issue by revisiting the history of the HDL hypothesis, chronicling how this paradox is ultimately rooted in the progressive erroneous blurring of the distinction between HDL and HDL cholesterol. We describe the compositional complexity of HDL particles beyond their cholesterol cargo and focus on their role in lipid transport. We discuss the evidence regarding novel HDL functions, including effects on glucose metabolism, and speculate on the implications for type 2 diabetes. HDL cholesterol is an imperfect biomarker of a highly complex and multifunctional lipid transport system, and we should now consider how new HDL markers more causally linked to cardiovascular complications could be adapted for clinical use. In the absence of a superior alternative, HDL cholesterol generally has value as a component of primary cardiovascular disease risk prediction models, including in people with type 2 diabetes. However, to avoid prognostic overgeneralisations, it is high time that the good cholesterol label is dropped.
Background Few studies have used nationally representative data to describe dietary trends and the related cardiometabolic mortality burden in China. Thus, we aimed to characterise the trends in disease-related dietary factors as well as their associated disease burden among Chinese adults from 1982 to 2012. Methods For this cross-sectional population-based study, we analysed a nationally representative sample of 204802 adults aged 20 years or older, using data from the 1982, 1992, 2002, and 2010-12 China National Nutrition Surveys (CNNS). We did a comparative risk assessment, in which the effects of suboptimal intakes of 12 dietary factors, individually and collectively, on cardiometabolic mortality were estimated by calculating the population attributable fraction (PAF) to estimate the proportional reduction in cardiometabolic deaths that would occur if exposure to each dietary risk factor was reduced to an alternative optimal level. Findings The overall PAF of mortality from cardiovascular disease and type 2 diabetes that was associated with suboptimal dietary quality was 62.2% in 1982, 57.9% in 1992, 56.2% in 2002, and 51.0% in 2010-12, which accounted for 21.6% of total mortality in China in 1982, 16.6% in 1992, 17.6% in 2002, and 20.8% in 2010-12. The estimated number of cardiometabolic deaths associated with suboptimal dietary intakes was 1.07 million in 1982, 0.93 million in 1992, 1.18 million in 2002, and 1.51 million in 2010-12. Of all 12 dietary factors examined, high sodium intake 17.3%), low fruit consumption (11.5% ), and low marine omega-3 fatty acids (9.7%) were associated with the largest numbers of estimated cardiometabolic deaths in 2010-12. Interpretation We observed an improvement in several dietary factors in China in the past few decades. However, current intakes of these dietary factors remain suboptimal. Poor diet quality is estimated to be associated with a substantial proportion of deaths from heart disease, stroke, and type 2 diabetes in China. Copyright (C) 2019 Elsevier Ltd. All rights reserved.
Background Cushing's disease is a rare debilitating endocrine disorder for which few prospective interventional studies have been done. We report results of the first phase 3 trial assessing long-acting intramuscular pasireotide in patients with Cushing's disease. Methods In this phase 3 clinical trial we recruited patients aged 18 years or older with persistent, recurrent, or de-novo (non-surgical candidates) Cushing's disease who had a mean urinary free cortisol (mUFC) concentration (from three 24 h samples) of 1.5-5.0 times the upper limit of normal (ULN), a normal or greater than normal morning plasma adrenocorticotropic hormone concentration, and a pituitary source of Cushing's syndrome, from 57 sites across 19 countries. Exclusion criteria included previous pasireotide treatment, mitotane therapy within 6 months, and pituitary irradiation within 10 years. We randomly allocated patients 1: 1 (block size of four) using an interactive-response-technology system to intramuscular pasireotide 10 mg or 30 mg every 4 weeks for 12 months (in the core phase). We stratified randomisation by screening mUFC concentration (1.5 to < 2.0 x ULN and 2.0-5.0 x ULN). The dose could be uptitrated (from 10 mg to 30 mg or from 30 mg to 40 mg) at month 4 if the mUFC concentration was greater than 1.5 x ULN, and at month 7, month 9, or month 12 if the mUFC concentration was greater than 1.0 x ULN. Investigators, patients, site personnel, and those assessing outcomes were masked to dose group allocation. The primary endpoint was the proportion of patients in each group with an mUFC concentration of less than or equal to the ULN at month 7. Efficacy analyses were based on intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01374906. Findings Between Dec 28, 2011, and Dec 9, 2014, we randomly allocated 150 patients to receive pasireotide 10 mg (74 [49%] patients) or 30 mg (76 [51%] patients). The primary efficacy endpoint was met by 31 (41.9% [95% CI 30.5-53.9]) of 74 patients in the 10 mg group and 31 (40.8% [29.7-52.7]) of 76 in the 30 mg group. The most common adverse events were hyperglycaemia (36 [49%] in the 10 mg group and 36 [47%] in the 30 mg group), diarrhoea (26 [35%] and 33 [43%]), cholelithiasis (15 [20%] and 34 [45%]), diabetes mellitus (14 [19%] and 18 [24%]), and nausea (15 [20%] and 16 [21%]). Serious adverse events suspected to be study drug related were reported in eight (11%) patients in the 10 mg group and four (5%) in the 30 mg group. Two (3%) patients in the 30 mg group died during the study (pulmonary artery thrombosis and cardiorespiratory failure); neither death was judged to be related to the study drug. Interpretation Long-acting pasireotide normalised mUFC concentration in about 40% of patients with Cushing's disease at month 7 and had a similar safety profile to that of twice-daily subcutaneous pasireotide. Long-acting pasireotide is an efficacious treatment option for some patients with Cushing's disease who have persistent or recurrent disease after initial surgery or are not surgical candidates, and provides a convenient monthly administration schedule.