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Introduction: Rheumatic heart disease (RHD) is underdiagnosed globally resulting in missed treatment opportunities and adverse clinical outcomes. We describe the protocol for a study which aims to co-design, implement and conduct an evaluation of a task-sharing approach to echocardiographic active case finding for early detection and management of RHD in high-risk settings in Australia and Timor-Leste., Methods and Analysis: Echocardiograms will be obtained by trained local staff using hand-held echocardiographic devices employing the 'Single Parasternal Long Axis view with a Sweep of the Heart' (SPLASH) technique and interpreted by experts remote from the site of acquisition. Approximately 1500 children and pregnant women will be screened across high-risk communities in Australia and Timor-Leste over an 18-month period. The study will use a type II effectiveness-implementation hybrid design. A tailored package of implementation strategies will be co-designed with communities and health services and mapped onto a Theory of Change framework. The clinical effectiveness will be assessed as the change in the proportion of the target population that are prescribed secondary prophylaxis for RHD by the end of the study compared with baseline. The implementation will be assessed as the adoption, penetration, sustainability, fidelity and cost of the programme with a mixed-methods theory-based and economic evaluation. Data will include numbers of normal, abnormal and uninterpretable SPLASH echocardiograms obtained, numbers of participants progressing through the cascade of care, interviews with staff and programme costs., Ethics and Dissemination: Ethical approval has been obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, Darwin (HREC-2022-4479), the Western Australian Aboriginal Health Ethics Committee (HREC-1237) and the Instituto Nasional Saude Publika Timor-Leste Ethics and Technical Committee (03-UEPD/INSP-TL/V/2023). Informed consent is required to be enrolled. Study findings will be disseminated in the communities involved and submitted for publication., Trial Registration Number: NCT06002243., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aims: Diabetic nephropathy, vision loss and diabetic retinopathy (DR) are frequent comorbidities among individuals with type 2 diabetes (T2D). The Retinopathy in People Currently On Renal Dialysis (RiPCORD) study sought to examine the epidemiology and risk of vision impairment (VI) and DR among a cohort of Indigenous and non-Indigenous Australians with T2D currently receiving haemodialysis for end-stage renal failure (ESRF)., Methods: A total of 106 Indigenous and 109 non-Indigenous Australians were recruited in RiPCORD across five haemodialysis centres in urban and remote settings. Clinical assessments, questionnaires and medical record data determined the rates of ocular complications and risk factor profiles., Results: Prevalence rates include unilateral VI, 23.5 %; bilateral VI, 11.7 %; unilateral blindness, 14.2 %; and bilateral blindness, 3.7 %, with no significant differences between sub-cohorts (p=0.30). DR prevalence rates were 78.0 % among non-Indigenous Australians and 93.1 % among Indigenous Australians (p=<0.001). Non-Indigenous ethnicity (OR: 0.28) and pre-dialysis diastolic blood pressure (OR: 0.84 per 10-mmHg) were protective, while peripheral vascular disease (OR: 2.79) increased DR risk., Conclusions: Ocular complications among individuals with T2D and ESRF are disproportionately high, especially for Indigenous Australians, and beyond what can be accounted for by risk factor variation. Findings suggest a need to improve screening and preventative efforts within this high-risk population group., Competing Interests: Declaration of competing interest The authors have no conflict of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: This paper argues for the enhancement of scoping review methods to incorporate Indigenous ways of knowing, being, and doing for more effective understandings of evidence of importance to Indigenous populations., Methods: Scoping review methodology typically aims to understand existing evidence and support translation of evidence into practice. Levac and colleagues (2010) scoping review methodology stages: 1) Identify the research question; 2) Identify relevant studies; 3) Study selection; 4) Charting the data; 5) Collating, summarising, and reporting results; and 6) Consultation were considered from the perspective of Indigenous knowledges and adapted accordingly., Results: An enhanced method better aligns with Indigenous methodologies which are based on relationality, collaboration, partnership, reciprocity, and benefit. Consultation was redefined in this enhancement as partnership and integrated throughout scoping review stages, which are underpinned by key methodological principles., Conclusions: Enhancement of scoping review stages with Indigenous ways of knowing, being, and doing has the potential to strengthen the utility of scoping review methods to better meet the needs of and ensure relevance for Indigenous populations., Implications for Public Health: These enhancements can increase the potential for knowledge translation and implementation of culturally relevant evidence-based approaches into practice for Indigenous populations and for other populations who experience health inequities., Competing Interests: Conflicts of interest The authors have no competing interests to declare., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: To investigate epigenomic indices of diabetic kidney disease (DKD) susceptibility among high-risk populations with type 2 diabetes mellitus., Methods: KDIGO (Kidney Disease: Improving Global Outcomes) clinical guidelines were used to classify people living with or without DKD. Differential gene methylation of DKD was then assessed in a discovery Aboriginal Diabetes Study cohort (PROPHECY, 89 people) and an external independent study from Thailand (THEPTARIN, 128 people). Corresponding mRNA levels were also measured and linked to levels of albuminuria and eGFR., Results: Increased DKD risk was associated with reduced methylation and elevated gene expression in the PROPHECY discovery cohort of Aboriginal Australians and these findings were externally validated in the THEPTARIN diabetes registry of Thai people living with type 2 diabetes mellitus., Conclusions: Novel epigenomic scores can improve diagnostic performance over clinical modelling using albuminuria and GFR alone and can distinguish DKD susceptibility., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing., Methods: This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing., Results: Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified., Conclusion: Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Dawson, Warrior, Pearson, Boyd, Dwyer, Morey, Brodie, Towers, Waters, Avila, Hammond, Lake, Lampard, Wanganeen, Bennell, Bromley, Shearing, Rigney, Czygan, Clinch, Pitson, Brown and Howard.)

Background: For Aboriginal and Torres Strait Islander women, the premature burden of cardiovascular disease is affecting their capacity to fulfil roles in society, and promote the health and wellbeing of future generations. In Australia, there is limited understanding of the difference in primary preventive cardiovascular care experienced by women, despite knowledge of sex and gender differentials in health profile and receipt of guideline-based acute care. This paper sought to explore the health profile and receipt of assessment and management of cardiovascular risk for Aboriginal and Torres Strait Islander women accessing preventive primary health care, and investigate gender differentials., Method: Records of 1200 current clients, 50% women, aged 18-74years from three Aboriginal Health Services in central and South Australia for the period 7/2018-6/2020 were reviewed., Results: Twelve percent had documented cardiovascular disease. Compared with men, women with no recorded cardiovascular disease had a greater likelihood of being overweight or obese, a waist circumference indicative of risk, diabetes, and depression. Women were less likely to report being physically active., Conclusions: The research concluded that gaps exist in the provision and recording of guideline-recommended primary preventive care regardless of sex. These are stark, given the evident burden.

Recent crises have underscored the importance that housing has in sustaining good health and, equally, its potential to harm health. Considering this and building on Howden-Chapman's early glossary of housing and health and the WHO Housing and Health Guidelines, this paper introduces a range of housing and health-related terms, reflecting almost 20 years of development in the field. It defines key concepts currently used in research, policy and practice to describe housing in relation to health and health inequalities. Definitions are organised by three overarching aspects of housing: affordability (including housing affordability stress (HAS) and fuel poverty), suitability (including condition, accessibility and sustainable housing) and security (including precarious housing and homelessness). Each of these inter-related aspects of housing can be either protective of, or detrimental to, health. This glossary broadens our understanding of the relationship between housing and health to further promote interdisciplinarity and strengthen the nexus between these fields., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

In promoting positive cardiovascular health for Aboriginal and Torres Strait Islander peoples, there is a need to ensure provision of high-quality risk assessment and management in primary healthcare settings. There is some evidence of gender gaps for Australian women in the provision of cardiovascular risk assessment and management; however, there is little understanding of whether these gaps are also present for Aboriginal and Torres Strait Islander women. A mixed-method systematic review was utilised to synthesise existing evidence on the provision of assessment and management against guideline-recommended care for Aboriginal and Torres Strait Islander women, and determine whether gender disparities in provision of care exist for this population. Sixteen studies that report gender-specific data indicate there are significant gaps in the provision of assessment and management for Aboriginal and Torres Strait Islander women and men alike. There is no evidence of incorporation of social and emotional wellbeing into cardiovascular care and limited studies outlining the assessment and management of behaviours and factors that may be protective of cardiovascular health. Furthermore, little is known about the provision of care in mainstream primary health services for Aboriginal and Torres Strait Islander peoples.

Background: Adverse social circumstances are a key factor in health outcomes. Hospitals are an opportune setting for assessing and addressing the unmet social needs of patients, however, the readiness of healthcare workers in hospitals to undertake such tasks requires further exploration in the Australian context. This study aimed to generate a theory of doctors' and nurses' readiness to assess and address patients' social needs in a hospital setting., Methods: A constructivist grounded theory methodology was applied, with purposive and theoretical sampling used to gather diverse perspectives of readiness during semi-structured interviews with twenty senior doctors and nurses from a variety of clinical specialties working in hospitals serving communities experiencing inequitable social and health outcomes. Line-by-line coding, memo writing, and diagramming were used in analysis to construct an interpretive theory of readiness. Application of constant comparison analytic processes were used to test the robustness of the theory., Results: The readiness of doctors and nurses varies across individuals and departments, and is founded upon a state of being comfortable and confident to assess social need as determined by a range of personal attributes (e.g. knowledge of social need; skills to assess social need); a state of being willing and prepared to assess and address social need facilitated by supportive environments (e.g. departmental culture); and enabling characteristics of the clinical encounter (e.g. time, rapport)., Conclusions: We found that the readiness of doctors and nurses is dynamic and impacted by a complex interplay of personal attributes along with contextual and situational factors. These findings indicate that any efforts to strengthen the readiness of doctors and nurses to assess and address social needs must target personal capabilities in addition to characteristics of the working environment., (© 2022. The Author(s).)

Aboriginal and Torres Strait Islander holistic health represents the interconnection of social, emotional, spiritual and cultural factors on health and well-being. Social factors (education, employment, housing, transport, food and financial security) are internationally described and recognised as the social determinants of health. The social determinants of health are estimated to contribute to 34% of the overall burden of disease experienced by Aboriginal and Torres Strait Islander people. Primary health care services currently 'do what it takes' to address social and emotional well-being needs, including the social determinants of health, and require culturally relevant tools and processes for implementing coordinated and holistic responses. Drawing upon a research-setting pilot program, this manuscript outlines key elements encapsulating a strengths-based approach aimed at addressing Aboriginal and Torres Strait Islander holistic social and emotional well-being.The Cultural Pathways Program is a response to community identified needs, designed and led by Aboriginal and Torres Strait Islander people and informed by holistic views of health. The program aims to identify holistic needs of Aboriginal and Torres Strait Islander people as the starting point to act on the social determinants of health. Facilitators implement strengths-based practice to identify social and cultural needs (e.g. cultural and community connection, food and financial security, housing, mental health, transport), engage in a goal setting process and broker connections with social and health services. An integrated culturally appropriate clinical supervision model enhances delivery of the program through reflective practice and shared decision making. These embedded approaches enable continuous review and improvement from a program and participant perspective. A developmental evaluation underpins program implementation and the proposed culturally relevant elements could be further tailored for delivery within primary health care services as part of routine care to strengthen systematic identification and response to social and emotional well-being needs.

High prevalence of chronic and infectious diseases in Indigenous populations is a major public health concern both in global and Australian contexts. Limited research has examined the role of built environments in relation to Indigenous health in remote Australia. This study engaged stakeholders to understand their perceptions of the influence of built environmental factors on chronic and infectious diseases in remote Northern Territory (NT) communities. A preliminary set of 1120 built environmental indicators were systematically identified and classified using an Indigenous Indicator Classification System. The public and environmental health workforce was engaged to consolidate the classified indicators ( n = 84), and then sort and rate the consolidated indicators based on their experience with living and working in remote NT communities. Sorting of the indicators resulted in a concept map with nine built environmental domains. Essential services and Facilities for health/safety were the highest ranked domains for both chronic and infectious diseases. Within these domains, adequate housing infrastructure, water supply, drainage system, reliable sewerage and power infrastructure, and access to health services were identified as the most important contributors to the development of these diseases. The findings highlight the features of community environments amenable to public health and social policy actions that could be targeted to help reduce prevalence of chronic and infectious diseases.

The high prevalence of preventable infectious and chronic diseases in Australian Indigenous populations is a major public health concern. Existing research has rarely examined the role of built and socio-political environmental factors relating to remote Indigenous health and wellbeing. This research identified built and socio-political environmental indicators from publicly available grey literature documents locally-relevant to remote Indigenous communities in the Northern Territory (NT), Australia. Existing planning documents with evidence of community input were used to reduce the response burden on Indigenous communities. A scoping review of community-focused planning documents resulted in the identification of 1120 built and 2215 socio-political environmental indicators. Indicators were systematically classified using an Indigenous indicator classification system (IICS). Applying the IICS yielded indicators prominently featuring the "community infrastructure" domain within the built environment, and the "community capacity" domain within the socio-political environment. This research demonstrates the utility of utilizing existing planning documents and a culturally appropriate systematic classification system to consolidate environmental determinants that influence health and disease occurrence. The findings also support understanding of which features of community-level built and socio-political environments amenable to public health and social policy actions might be targeted to help reduce the prevalence of infectious and chronic diseases in Indigenous communities.

Māori and Pacific women in New Zealand and Aboriginal and Torres Strait Islander women in Australia are recognised as nurturers and leaders within their families and communities. However, women's wellbeing, and that of their communities, are affected by a high burden of cardiovascular disease experienced at a younger age than women from other ethnic groups. There has been little focus on the cardiovascular outcomes and strategies to address heart health inequities among Māori, Pacific, Aboriginal and Torres Strait Islander women. The factors contributing to these inequities are complex and interrelated but include differences in exposure to risk and protective factors, rates of multi-morbidity, and substantial gaps within the health system, which include barriers to culturally responsive, timely and appropriate cardiovascular care. Evidence demonstrates critical treatment gaps across the continuum of risk and disease, including assessment and management of cardiovascular risk in young women and time-critical access to and receipt of acute services. Cardiovascular disease in women impacts not only the individual, but their family and community, and the burden of living with disease limits women's capacity to fulfil their roles and responsibilities which support and sustain families and communities. Our response must draw on the strengths of Māori, Pacific, Aboriginal and Torres Strait Islander women, acknowledge health and wellbeing holistically, address the health and social needs of individuals, families and communities, and recognise that Indigenous women in New Zealand, Australia and across the Pacific must be involved in the design, development and implementation of solutions affecting their own health., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Aboriginal and Torres Strait Islander peoples' perspectives of health and cultural wellbeing encapsulate the spiritual, social and environmental health of individuals, their communities and country. Strategies designed to reduce the cardiovascular burden of Aboriginal and Torres Strait Islander people often fail to consider their unique knowledge and worldview., Methods: This adapted, grounded theory study sought to explore Aboriginal women's views of cardiovascular protective and risk factors., Results: Twenty-eight (28) women from five women's groups across Central and South Australia participated. Women distinguished the heart as core to their spiritual and physical wellbeing. Women identified six attributes that keep a woman's heart strong, four that can make the heart sick, and eight socio-ecological factors which affect a woman's capacity to care for their heart. Women described having a healthy heart when able to identify as Aboriginal women, being connected to family and community, having a healthy life and body, and being engaged in their health and health care., Conclusions: There are gaps in the provision of cardiovascular risk assessment and management, gaps in the cultural safety of primary health care services, and gaps in the communication of the sex-specific warning signs of a heart attack, all of which must be addressed., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Type 2 diabetes mellitus (T2DM) poses significant challenges to individuals and broader society, much of which is borne by disadvantaged and marginalised population groups including Indigenous people. The increasing prevalence of T2DM among Indigenous people has meant that rates of diabetes-related complications such as blindness from end-stage diabetic retinopathy (DR) continue to be important health concerns. Australia, a high-income and resource-rich country, continues to struggle to adequately respond to the health needs of its Indigenous people living with T2DM. Trends among Indigenous Australians highlight that the prevalence of DR has almost doubled over two decades, and the prevalence of diabetes-related vision impairment is consistently reported to be higher among Indigenous Australians (5.2%-26.5%) compared to non-Indigenous Australians (1.7%). While Australia has collated reliable estimates of the eye health burden owing to T2DM in its Indigenous population, there is fragmentation of existing data and limited knowledge on the underlying risk factors. Taking a systems approach that investigates the social, environmental, clinical, biological and genetic risk factors, and-importantly-integrates these data, may give valuable insights into the most important determinants contributing to the development of diabetes-related blindness. This knowledge is a crucial initial step to reducing the human and societal impacts of blindness on Indigenous Australians, other priority populations and society at large.

Background: Aboriginal and Torres Strait Islander Australians have poorer cancer outcomes than other Australians. Comparatively little is known of the type and amount of cancer treatment provided to Aboriginal and Torres Strait Islander people and the consequences for cancer survival. This study quantifies the influence of surgical, systemic and radiotherapy treatment on risk of cancer death among matched cohorts of cancer cases and, the comparative exposure of cohorts to these treatments., Methods: Cancers registered among Aboriginal South Australians in 1990-2010 (N = 777) were matched with randomly selected non-Indigenous cases by sex, birth and diagnostic year, and primary site, then linked to administrative cancer treatment for the period from 2 months before to 13 months after diagnosis. Competing risk regression summarised associations of Indigenous status, geographic remoteness, comorbidities, cancer stage and treatment exposure with risk of cancer death., Results: Fewer Aboriginal cases had localised disease at diagnosis (37.2% versus 50.2%) and they were less likely to: experience hospitalisation with cancer diagnosis, unadjusted odds ratio (UOR) = 0.76; 95%CI = 0.59-0.98; have surgery UOR = 0.65; 95%CI = 0.53-0.80; systemic therapies UOR = 0.64; 95%CI = 0.52-0.78; or radiotherapy, UOR = 0.76; 95%CI = 0.63-0.94. Localised disease carried lower risk of cancer death compared to advanced cases receiving surgery or systemic therapies, SHR = 0.34; 95%CI = 0.25-0.47 and SHR = 0.35; 95%CI = 0.25-0.48. Advanced disease and no treatment carried higher risk of cancer death, SHR = 1.82; 95%CI = 1.26-2.63., Conclusion: The effects of treatment did not differ between Aboriginal and non-Indigenous cohorts. However, comparatively less exposure to surgical and systemic treatments among Aboriginal cancer cases further complicated the disadvantages associated with geographic remoteness, advanced stage of disease and co-morbid conditions at diagnosis and add to disparities in cancer death. System level responses to improving access, utilisation and quality of effective treatments are needed to improve survival after cancer diagnosis.

Remote Indigenous Australians experience disproportionately poor cardio-metabolic health, which is largely underpinned by adverse dietary intake related to social determinants. Little evidence exists about the community environmental-level factors that shape diet quality in this geographically isolated population group. This study aimed to explore the modifiable environmental-level factors associated with the features of dietary intake that underpin cardio-metabolic disease risk in this population group. Community-level dietary intake data were estimated from weekly store sales data collected throughout 2012 and linked with concurrent social, built, and physical environmental dimension data for 13 remote Indigenous Australian communities in the Northern Territory. Statistical analyses were performed to investigate associations. At the community level, store sales of discretionary foods were lower in communities with greater distance to a neighbouring store (r = -0.45 ( p < 0.05)). Sales of sugar-sweetened beverages were lower in communities with higher levels of household crowding (r = -0.55 ( p < 0.05)), higher levels of Indigenous unemployment (r = -0.62 ( p = 0.02)), and greater distance to neighbouring stores (r = -0.61 ( p = 0.004)). Modifiable environmental-level factors may be associated with adverse diet quality in remote Indigenous Australian communities and further investigations of these factors should be considered when developing policies to improve dietary intake quality in geographically isolated populations., Competing Interests: The authors had full access to all data in the study (including statistical reports and tables). The funding sources played no role in the conception, design or conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript. The contents of the published material are solely the responsibility of the individual authors and do not reflect the views of the NHMRC, ARC, NHF, the University of South Australia, Menzies School of Health Research, the University of Canberra, the Queensland University of Technology, or Monash University. The authors report no actual or potential conflicts of interest relevant to this article.

Background : Perceptions of neighbourhood attributes such as proximity of food retailers that are discordant with objective measures of the same are associated with poor health behaviours and weight gain. Factors associated with discordant perceptions are likely relevant to planning more effective interventions to improve health. Purpose : Analysis of cross-sectional relationships between individual and neighbourhood factors and overestimations of walking distances to local fruit/vegetable retailers (FVR). Methods : Perceived walking times, converted to distances, between participant residences and FVR were compared with objectively-assessed road network distances calculated with a Geographic Information System for n = 1305 adults residing in Adelaide, South Australia. Differences between perceived and objective distances were expressed as 'overestimated' distances and were analysed relative to perceptions consistent with objective distances. Cross-sectional associations were evaluated between individual socio-demographic, health, and area-level characteristics and overestimated distances to FVR using multilevel logistic regression. Results : Agreement between objective and perceived distances between participants' residence and the nearest FVR was only fair (weighted kappa = 0.22). Overestimated distances to FVR were positively associated with mental well-being, and were negatively associated with household income, physical functioning, sense of community, and objective distances to greengrocers. Conclusions : Individual characteristics and features of neighbourhoods were related to overestimated distances to FVR. Sense of connectivity and shared identity may shape more accurate understandings of local resource access, and offer a focal point for tailored public health initiatives that bring people together to achieve improved health behaviour.

Evidence exists of an increasing prevalence of chronic conditions within developed and developing nations, notably for priority population groups. The need for the collection of geospatial data to monitor the health impact of rapid social-environmental and economic changes occurring in these countries is being increasingly recognized. Rigorous accuracy assessment of such geospatial data is required to enable error estimation, and ultimately, data utility for exploring population health. This research outlines findings from a field-based evaluation exercise of the SOMAARTH DDESS geospatial-health platform. Participatory-based mixed methods have been employed within Palwal-India to capture villager perspectives on built infrastructure across 51 villages. This study, conducted in 2013, included an assessment of data element position and attribute accuracy undertaken in six villages, documenting mapping errors and land parcel changes. Descriptive analyses of 5.1% ( n  = 455) of land parcels highlighted some discrepancies in position (6.4%) and attribute (4.2%) accuracy, and land parcel changes (17.4%). Furthermore, the evaluation led to a refinement of the existing geospatial health platform incorporating ground-truthed reflections from the participatory field exercise. The evaluation of geospatial data accuracies contributes to understandings on global public health surveillance systems, outlining the need to systematically consider assessment of environmental features in relation to lifestyle-related diseases.

Background: Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps., Objective: This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting., Methods: The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner., Results: The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings., Conclusions: The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health., (©Shikha Dixit, Narendra K Arora, Atiqur Rahman, Natasha J Howard, Rakesh K Singh, Mayur Vaswani, Manoja K Das, Faruqueuddin Ahmed, Prashant Mathur, Nikhil Tandon, Rajib Dasgupta, Sanjay Chaturvedi, Jaishri Jethwaney, Suresh Dalpath, Rajendra Prashad, Rakesh Kumar, Rakesh Gupta, Laurette Dube, Mark Daniel. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 05.10.2018.)

Much research has considered the relationship between neighbourhood crime and physical activity, but few studies have assessed clinical outcomes consequent to behaviour, such as cardiometabolic risk. Fewer still have simultaneously assessed perceived and objective measures of crime. Perceptions of crime and actual victimisation vary according to gender; thus, this study sought to assess: 1) correspondence between perceived and objective neighbourhood crime; and 2) gender-specific associations between perceived and reported crime and metabolic syndrome, representing cardiometabolic risk. The indirect effect of neighbourhood crime on metabolic syndrome via walking was additionally evaluated. An Australian population-based biomedical cohort study (2004-2007) collected biomedical, socio-demographic, and neighbourhood perceptions data from n = 1,172 urban-dwelling, adults. Area-level reported crime rates were standardised and linked to individual data based on participants' residential location. Correspondence between actual and perceived crime measures was assessed using Pearson correlation coefficients. Cross-sectional associations between crime and metabolic syndrome were analysed using generalised estimating equations regression models accounting for socio-demographic factors and area-level income. Correspondence between perceived and objective crime was small to medium among men and women (r = 0.17 to 0.33). Among men, metabolic syndrome was related to rates of violent (OR = 1.21, 95% CI 1.08-1.35) and total crime (OR = 1.17, 95% CI 1.04-1.32), after accounting for perceived crime. Among women, metabolic syndrome was related to perceived crime (OR = 1.35, 95% CI 1.14-1.60) after accounting for total reported crime. Among women, there were indirect effects of perceived crime and property crime on metabolic syndrome through walking. Results indicate that crime, an adverse social exposure, is linked to clinical health status. Crime rates, and perceptions of crime and safety, differentially impact upon cardiometabolic health according to gender. Social policy and public health strategies targeting crime reduction, as well as strategies to increase perceptions of safety, have potential to contribute to improved cardiometabolic outcomes., Competing Interests: The authors have declared that no competing interests exist.

Perceived and objective measures of neighbourhood features have shown limited correspondence. Few studies have examined whether discordance between objective measures and individual perceptions of neighbourhood environments relates to individual health. Individuals with mismatched perceptions may benefit from initiatives to improve understandings of resource availability. This study utilised data from n = 1491 adult participants in a biomedical cohort to evaluate cross-sectional associations between measures of access (perceived, objective, and perceived-objective mismatch) to fruit and vegetable retailers (FVR) and public open space (POS), and clinically-measured metabolic syndrome and its component risk factors: central obesity, dyslipidaemia, hypertension and pre-diabetes/diabetes. Access measures included perceived distances from home to the nearest FVR and POS, corresponding objectively-assessed road network distances, and the discordance between perceived and objective distances (overestimated (i.e., mismatched) distances versus matched perceived-objective distances). Individual and neighbourhood measures were spatially joined using a geographic information system. Associations were evaluated using multilevel logistic regression, accounting for individual and area-level covariates. Hypertension was positively associated with perceived distances to FVR (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.02, 1.28) and POS (OR = 1.19, 95% CI = 1.05, 1.34), after accounting for covariates and objective distances. Hypertension was positively associated with overestimating distances to FVR (OR = 1.36, 95% CI = 1.02, 1.80). Overestimating distances to POS was positively associated with both hypertension (OR = 1.42, 95% CI = 1.11, 1.83) and dyslipidaemia (OR = 1.25, 95% CI = 1.00, 1.57). Results provide new evidence for specific associations between perceived and overestimated distances from home to nearby resources and cardiometabolic risk factors., Competing Interests: The authors declare no conflict of interest. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Place and health are inextricably entwined. Whilst insights have been gained into the associations between places, such as neighbourhoods, and health, the understanding of these relationships remains only partial. One of the reasons for this relates to time and change and the inter-relationships between the dynamic nature of both neighbourhoods and health. This paper argues that the lifecourse of place can be used as a conceptual framework to understand the evolution and ongoing development of neighbourhoods, and their impact on the geographies of health, past, present and future. Moreover, this paper discusses the capacity of a longitudinal form of enquiry - latent transition analysis - that is able to operationalise conceptual models of the lifecourse of place. To date, latent transition analysis has not been applied to the study of neighbourhoods and health. Drawing on research across a range of disciplines including developmental psychology, sociology, geography and epidemiology, this paper also considers praxis-based implications and recommendations for applications of latent transition analysis that aim to advance understanding of how neighbourhoods affect health in and over time., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

An underrepresentation of stakeholder perspectives within urban health research arguably limits our understanding of what is a multi-dimensional and complex relationship between the built environment and health. By engaging a wide range of stakeholders using a participatory concept mapping approach, this study aimed to achieve a more holistic and nuanced understanding of the built environments shaping disease risk, specifically cardiometabolic risk (CMR). Moreover, this study aimed to ascertain the importance and changeability of identified environments through government action. Through the concept mapping process, community members, researchers, government and non-government stakeholders collectively identified eleven clusters encompassing 102 built environmental domains related to CMR, a number of which are underrepresented within the literature. Among the identified built environments, open space, public transportation and pedestrian environments were highlighted as key targets for policy intervention. Whilst there was substantive convergence in stakeholder groups' perspectives concerning the built environment and CMR, there were disparities in the level of importance government stakeholders and community members respectively assigned to pedestrian environments and street connectivity. These findings support the role of participatory methods in strengthening how urban health issues are understood and in affording novel insights into points of action for public health and policy intervention.

Background: Individual-level health outcomes are shaped by environmental risk conditions. Norms figure prominently in socio-behavioural theories yet spatial variations in health-related norms have rarely been investigated as environmental risk conditions. This study assessed: 1) the contributions of local descriptive norms for overweight/obesity and dietary behaviour to 10-year change in glycosylated haemoglobin (HbA 1c ), accounting for food resource availability; and 2) whether associations between local descriptive norms and HbA 1c were moderated by food resource availability., Methods: HbA 1c , representing cardiometabolic risk, was measured three times over 10 years for a population-based biomedical cohort of adults in Adelaide, South Australia. Residential environmental exposures were defined using 1600 m participant-centred road-network buffers. Local descriptive norms for overweight/obesity and insufficient fruit intake (proportion of residents with BMI ≥ 25 kg/m 2 [n = 1890] or fruit intake of <2 serves/day [n = 1945], respectively) were aggregated from responses to a separate geocoded population survey. Fast-food and healthful food resource availability (counts) were extracted from a retail database. Separate sets of multilevel models included different predictors, one local descriptive norm and either fast-food or healthful food resource availability, with area-level education and individual-level covariates (age, sex, employment status, education, marital status, and smoking status). Interactions between local descriptive norms and food resource availability were tested., Results: HbA 1c concentration rose over time. Local descriptive norms for overweight/obesity and insufficient fruit intake predicted greater rates of increase in HbA 1c . Neither fast-food nor healthful food resource availability were associated with change in HbA 1c . Greater healthful food resource availability reduced the rate of increase in HbA 1c concentration attributed to the overweight/obesity norm., Conclusions: Local descriptive health-related norms, not food resource availability, predicted 10-year change in HbA 1c . Null findings for food resource availability may reflect a sufficiency or minimum threshold level of resources such that availability poses no barrier to obtaining healthful or unhealthful foods for this region. However, the influence of local descriptive norms varied according to food resource availability in effects on HbA 1c . Local descriptive health-related norms have received little attention thus far but are important influences on individual cardiometabolic risk. Further research is needed to explore how local descriptive norms contribute to chronic disease risk and outcomes.

Consistent associations have been observed between macro-level urban sprawl and overweight/obesity, but whether residential proximity to urban centres predicts adiposity change over time has not been established. Further, studies of local-area walkability and overweight/obesity have generated mixed results. This study examined 4-year change in adults' waist circumference in relation to proximity to city centre, proximity to closest suburban centre, and local-area walkability. Data were from adult participants (n=2080) of a cohort study on chronic conditions and health risk factors in Adelaide, Australia. Baseline data were collected in 2000-03 with a follow-up in 2005-06. Multilevel regression models examined in 2015 the independent and joint associations of the three environmental measures with change in waist circumference, accounting for socio-demographic covariates. On average, waist circumference rose by 1.8cm over approximately 4years. Greater distance to city centre was associated with a greater increase in waist circumference. Participants living in distal areas (20km or further from city centre) had a greater increase in waist circumference (mean increase: 2.4cm) compared to those in proximal areas (9km or less, mean increase: 1.2cm). Counterintuitively, living in the vicinity of a suburban centre was associated with a greater increase in adiposity. Local-area walkability was not significantly associated with the outcome. Residential proximity to city centre appears to be protective against excessive increases in waist circumference. Controlled development and targeted interventions in the urban fringe may be needed to tackle obesity. Additional research needs to assess behaviours that mediate relationships between sprawl and obesity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Descriptive norms vary between places. Spatial variation in health-related descriptive norms may predict individual-level health outcomes. Such relationships have rarely been investigated. This study assessed 10-year change in glycosylated haemoglobin (HbA1c) in relation to local descriptive norms for overweight/obesity (n = 1890) and physical inactivity (n = 1906) in models accounting for features of the built environment. HbA1c was measured three times over 10 years for a population-based biomedical cohort of adults in Adelaide, South Australia. Environmental exposures were expressed for cohort participants using 1600 m road-network buffers centred on participants' residential address. Local descriptive norms (prevalence of overweight/obesity [body mass index ≥25 kg/m(2)] and of physical inactivity [<150 min/week]) were aggregated from responses to a separate geocoded population survey. Built environment measures were public open space (POS) availability (proportion of buffer area) and walkability. Separate sets of multilevel models analysed different predictors of 10-year change in HbA1c. Each model featured one local descriptive norm and one built environment variable with area-level education and individual-level covariates (age, sex, employment status, education, marital status, and smoking status). Interactions between local descriptive norms and built environment measures were assessed. HbA1c increased over time. POS availability and local descriptive norms for overweight/obesity and physical inactivity were each associated with greater rates of HbA1c increase. Greater walkability was associated with a reduced rate of HbA1c increase, and reduced the influence of the overweight/obesity norm on the rate of increase in HbA1c. Local descriptive health-related norms and features of the built environment predict 10-year change in HbA1c. The impact of local descriptive norms can vary according to built environment features. Little researched thus far, local descriptive norms may play an important role in the evolution of HbA1c and thus cardiometabolic risk, over time. Further empirical research on local descriptive norms is necessary to understand how residential environments shape chronic disease risk., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Understanding how health outcomes are spatially distributed represents a first step in investigating the scale and nature of environmental influences on health and has important implications for statistical power and analytic efficiency. Using Australian and French cohort data, this study aimed to describe and compare the extent of geographic variation, and the implications for analytic efficiency, across geographic units, countries and a range of cardiometabolic parameters (Body Mass Index (BMI) waist circumference, blood pressure, resting heart rate, triglycerides, cholesterol, glucose, HbA1c). Geographic clustering was assessed using Intra-Class Correlation (ICC) coefficients in biomedical cohorts from Adelaide (Australia, n = 3893) and Paris (France, n = 6430) for eight geographic administrative units. The median ICC was 0.01 suggesting 1% of risk factor variance attributable to variation between geographic units. Clustering differed by cardiometabolic parameters, administrative units and countries and was greatest for BMI and resting heart rate in the French sample, HbA1c in the Australian sample, and for smaller geographic units. Analytic inefficiency due to clustering was greatest for geographic units in which participants were nested in fewer, larger geographic units. Differences observed in geographic clustering across risk factors have implications for choice of geographic unit in sampling and analysis, and highlight potential cross-country differences in the distribution, or role, of environmental features related to cardiometabolic health.

Residents of areas with lower socioeconomic status (SES) are known to be less physically active during leisure time. Neighborhood walkability has been shown to be related to recreational walking equally in low and high SES areas. This cross-sectional study tested whether associations of specific environmental attributes, measured objectively and subjectively, with walking for recreation were moderated by area-level SES. The data of the North West Adelaide Health Study collected in 2007 (n = 1500, mean age 57) were used. Self-reported walking frequency was the outcome of the study. Environmental exposure measures included objectively measured walkability components (residential density, intersection density, land use mix, and net retail area ratio) and perceived attributes (access to destinations, neighborhood esthetics, walking infrastructure, traffic/barriers, and crime safety). Participants' suburbs were categorized into low and high SES areas using an indicator of socioeconomic disadvantage. Low SES areas had lower scores in residential density, neighborhood esthetics, walking infrastructure, traffic/barriers, and crime safety. Recreational walking was associated with residential density, access to destinations, esthetics, traffic/barriers, and crime safety. Effect modification was observed for two attributes (out of nine): residential density was associated with walking only in low SES areas, while walking infrastructure was associated with walking only in high SES areas. The associations of neighborhood environmental attributes with recreational walking were largely consistent across SES groups. However, low SES areas were disadvantaged in most perceived environmental attributes related to recreational walking. Improving such attributes in low SES neighborhoods may help close socioeconomic disparities in leisure time physical activity.

Background: Global incidence of childhood type 2 diabetes has increased, with a greater rise amongst certain ethnic groups., Objectives: To examine the change in the incidence of type 1 and type 2 diabetes in Australian youth, aged 10-18 yr, in New South Wales, Australia., Methods: Prospective population-based incidence study (2001-2008). Primary case ascertainment was from the Australasian Paediatric Endocrine Group Diabetes Register, secondary independent ascertainment from the National Diabetes Register., Results: There were 202 incident cases of type 2 diabetes (96 boys, 48%). The mean age at diagnosis (±SD) was 14.6 ± 2.5 yr; 93% were overweight (International Obesity Taskforce Grade ≥1). Mean HbA1c was 8.8 ± 2.8%. Ethnicity was Caucasian 31%, Indigenous Australian 20%, Southeast Asian 11%, North African/Middle Eastern 9%, and NewZealander/Melanesian/Polynesian 8%. The mean annual incidence of type 2 diabetes was 3.0 per 100 000 per year (95% confidence interval (CI): 2.6-3.4) and did not change over time. The mean annual incidence of type 1 diabetes was 22.0 per 100 000 per year (95% CI: 20.8-23.1), and increased by 3.8% per year [incidence rate ratio IRR: 1.04, 95% CI: 1.02-1.06, p = 0.001]. Incidence was higher in Indigenous vs. non-Indigenous youth, IRR: 6.9 (95% CI: 4.7-10.2, p < 0.001)., Conclusion: In 10-18 yr old youth, in Australia, the incidence of type 2 diabetes has remained steady during the last decade; however, the incidence of type 1 diabetes continues to rise. Most common diabetes in Australian youth is type 1 diabetes., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We investigated whether residential environment characteristics related to food (unhealthful/healthful food sources ratio), walkability and public open spaces (POS; number, median size, greenness and type) were associated with incidence of four cardio-metabolic risk factors (pre-diabetes/diabetes, hypertension, dyslipidaemia, abdominal obesity) in a biomedical cohort (n=3205). Results revealed that the risk of developing pre-diabetes/diabetes was lower for participants in areas with larger POS and greater walkability. Incident abdominal obesity was positively associated with the unhealthful food environment index. No associations were found with hypertension or dyslipidaemia. Results provide new evidence for specific, prospective associations between the built environment and cardio-metabolic risk factors., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: This study examined whether attributes of pedestrian environments moderate the relationships between access to public open spaces (POS) and adults' recreational walking., Methods: Data were collected from participants of the North West Adelaide Health Study in 2007. Recreational walking was determined using self-reported walking frequency. Measures of POS access (presence, count, and distance to the nearest POS) were assessed using a Geographic Information System. Pedestrian environmental attributes included aesthetics, walking infrastructure, barrier/traffic, crime concern, intersection density, and access to walking trails. Regression analyses examined whether associations between POS access and recreational walking were moderated by pedestrian environmental attributes., Results: The sample included 1574 participants (45% men, mean age: 55). POS access measures were not associated with recreational walking. However, aesthetics, walking infrastructure, and access to walking trail were found to moderate the POS-walking relationships. The presence of POS was associated with walking among participants with aesthetically pleasing pedestrian environments. Counter-intuitively, better access to POS was associated with recreational walking for those with poorer walking infrastructure or no access to walking trails., Conclusion: Local pedestrian environments moderate the relationships between access to POS and recreational walking. Our findings suggest the presence of complex relationships between POS availability and pedestrian environments., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Indicators of cardiometabolic risk typically include non-clinical factors (e.g., smoking). While the incorporation of non-clinical factors can improve absolute risk prediction, it is impossible to study the contribution of non-clinical factors when they are both predictors and part of the outcome measure. Metabolic syndrome, incorporating only clinical measures, seems a solution yet provides no information on risk severity. The aims of this study were: 1) to construct two continuous clinical indices of cardiometabolic risk (cCICRs), and assess their accuracy in predicting 10-year incident cardiovascular disease and/or type 2 diabetes; and 2) to compare the predictive accuracies of these cCICRs with existing risk indicators that incorporate non-clinical factors (Framingham Risk Scores)., Methods: Data from a population-based biomedical cohort (n = 4056) were used to construct two cCICRs from waist circumference, mean arteriole pressure, fasting glucose, triglycerides and high density lipoprotein: 1) the mean of standardised risk factors (cCICR-Z); and 2) the weighted mean of the two first principal components from principal component analysis (cCICR-PCA). The predictive accuracies of the two cCICRs and the Framingham Risk Scores were assessed and compared using ROC curves., Results: Both cCICRs demonstrated moderate accuracy (AUCs 0.72 - 0.76) in predicting incident cardiovascular disease and/or type 2 diabetes, among men and women. There were no significant differences between the predictive accuracies of the cCICRs and the Framingham Risk Scores., Conclusions: cCICRs may be useful in research investigating associations between non-clinical factors and health by providing suitable alternatives to current risk indicators which include non-clinical factors.

This study examines the relationships between area-level socioeconomic position (SEP) and the prevalence and trajectories of metabolic syndrome (MetS) and the count of its constituents (i.e., disturbed glucose and insulin metabolism, abdominal obesity, dyslipidemia, and hypertension). A cohort of 4,056 men and women aged 18+ living in Adelaide, Australia was established in 2000-2003. MetS was ascertained at baseline, four and eight years via clinical examinations. Baseline area-level median household income, percentage of residents with a high school education, and unemployment rate were derived from the 2001 population Census. Three-level random-intercepts logistic and Poisson regression models were performed to estimate the standardized odds ratio (SOR), prevalence risk ratio (SRR), ratio of SORs/SRRs, and (95% confidence interval (CI)). Interaction between area- and individual-level SEP variables was also tested. The odds of having MetS and the count of its constituents increased over time. This increase did not vary according to baseline area-level SEP (ratios of SORs/SRRs ≈ 1; p ≥ 0.42). However, at baseline, after adjustment for individual SEP and health behaviours, median household income (inversely) and unemployment rate (positively) were significantly associated with MetS prevalence (SOR (95%CI) = 0.76 (0.63-0.90), and 1.48 (1.26-1.74), respectively), and the count of its constituents (SRR (95%CI) = 0.96 (0.93-0.99), and 1.06 (1.04-1.09), respectively). The inverse association with area-level education was statistically significant only in participants with less than post high school education (SOR (95%CI) = 0.58 (0.45-0.73), and SRR (95%CI) = 0.91 (0.88-0.94)). Area-level SEP does not predict an elevated trajectory to developing MetS or an elevated count of its constituents. However, at baseline, area-level SEP was inversely associated with prevalence of MetS and the count of its constituents, with the association of area-level education being modified by individual-level education. Population-level interventions for communities defined by area-level socioeconomic disadvantage are needed to reduce cardiometabolic risks.

Background: The evidence linking socioeconomic environments and metabolic syndrome (MetS) has primarily been based on cross-sectional studies. This study prospectively examined the relationships between area-level socioeconomic position (SEP) and the incidence of MetS., Methods: A prospective cohort study design was employed involving 1,877 men and women aged 18+ living in metropolitan Adelaide, Australia, all free of MetS at baseline. Area-level SEP measures, derived from Census data, included proportion of residents completing a university education, and median household weekly income. MetS, defined according to International Diabetes Federation, was ascertained after an average of 3.6 years follow up. Associations between each area-level SEP measure and incident MetS were examined by Poisson regression Generalised Estimating Equations models. Interaction between area- and individual-level SEP variables was also tested., Results: A total of 156 men (18.7%) and 153 women (13.1%) developed MetS. Each percentage increase in the proportion of residents with a university education corresponded to a 2% lower risk of developing MetS (age and sex-adjusted incidence risk ratio (RR)=0.98; 95% confidence interval (CI) =0.97-0.99). This association persisted after adjustment for individual-level income, education, and health behaviours. There was no significant association between area-level income and incident MetS overall. For the high income participants, however, a one standard deviation increase in median household weekly income was associated with a 29% higher risk of developing MetS (Adjusted RR=1.29; 95%CI=1.04-1.60)., Conclusions: While area-level education was independently and inversely associated with the risk of developing MetS, the association between area-level income and the MetS incidence was modified by individual-level income.

Background: Residential property is reported as the most valuable asset people will own and therefore provides the potential to be used as a socio-economic status (SES) measure. Location is generally recognised as the most important determinant of residential property value.Extending the well-established relationship between poor health and socio-economic disadvantage and the role of residential property in the overall wealth of individuals, this study tested the predictive value of the Relative Location Factor (RLF), a SES measure designed to reflect the relationship between location and residential property value, and six cardiometabolic disease risk factors, central obesity, hypertriglyceridemia, reduced high density lipoprotein (HDL), hypertension, impaired fasting glucose, and high low density lipoprotein (LDL). These risk factors were also summed and expressed as a cumulative cardiometabolic risk (CMR) score., Methods: RLF was calculated using a global hedonic regression model from residential property sales transaction data based upon several residential property characteristics, but deliberately blind to location, to predict the selling price of the property. The predicted selling price was divided by the actual selling price and the results interpolated across the study area and classified as tertiles. The measures used to calculate CMR were collected via clinic visits from a population-based cohort study. Models with individual risk factors and the cumulative cardiometabolic risk (CMR) score as dependent variables were respectively tested using log binomial and Poisson generalised linear models., Results: A statistically significant relationship was found between RLF, the cumulative CMR score and all but one of the risk factors. In all cases, participants in the most advantaged and intermediate group had a lower risk for cardio-metabolic diseases. For the CMR score the RR for the most advantaged was 19% lower (RR = 0.81; CI 0.76-0.86; p <0.0001) and the middle group was 9% lower (RR = 0.91; CI 0.86-0.95; p <0.0001) than the least advantaged group., Conclusions: This paper advances the understanding of the nexus between place, health and SES by providing an objective spatially informed SES measure for testing health outcomes and reported a robust association between RLF and several health measures.

Socioeconomic status is a strong predictor of cardiovascular disease. Pulse pressure, the difference between systolic and diastolic blood pressure, has been identified as an important predictor of cardiovascular risk even after accounting for absolute measures of blood pressure. However, little is known about the social determinants of pulse pressure. The aim of this study was to examine individual- and area-level socioeconomic gradients of pulse pressure in a sample of 2,789 Australian adults. Using data from the North West Adelaide Health Study we estimated the association between pulse pressure and three indices of socioeconomic status (education, income and employment status) at the area and individual level for hypertensive and normotensive participants, using Generalized Estimating Equations. In normotensive individuals, area-level education (estimate: -0.106; 95% CI: -0.172, -0.041) and individual-level income (estimate: -1.204; 95% CI: -2.357, -0.050) and employment status (estimate: -1.971; 95% CI: -2.894, -1.048) were significant predictors of pulse pressure, even after accounting for the use of medication and lifestyle behaviors. In hypertensive individuals, only individual-level measures of socioeconomic status were significant predictors of pulse pressure (education estimate: -2.618; 95% CI: -4.878, -0.357; income estimate: -1.683, 95% CI: -3.743, 0.377; employment estimate: -2.023; 95% CI: -3.721, -0.326). Further research is needed to better understand how individual- and area-level socioeconomic status influences pulse pressure in normotensive and hypertensive individuals.

Objective: To evaluate the effect of a diabetes awareness campaign on the incidence of diabetic ketoacidosis (DKA) at the first presentation of type 1 diabetes in children (0-18 yr)., Methods: This study was a controlled population intervention study with a 2-yr baseline period and a 2-yr intervention period. Data were collected on all children presenting with their initial diagnosis of type 1 diabetes [pH, bicarbonate, base excess, blood glucose level (BGL), urea, and creatinine] at Gosford, Newcastle, and Sydney (Sydney Children's Hospital and Royal North Shore Hospital). During the intervention period, diabetes education occurred in the intervention region (Gosford). Child care centers, schools, and doctor's offices were offered education and posters about the symptoms of type 1 diabetes. Doctor's offices were given glucose and ketone testing equipment. The control regions (Newcastle and Sydney) did not receive any educational intervention or test equipment. DKA was defined as pH < 7.3 or bicarbonate < 15 mmol/L., Results: In Gosford, the proportion of children presenting in DKA decreased from 37.5% (15/40) during the 2-yr baseline period to 13.8% (4/29) during the 2-yr intervention (p < 0.03). There was no significant change in the control regions during the same time periods, 37.4% (46/123) and 38.6% (49/127), respectively. In Gosford, the average BGL at presentation was 27.5 mmol/L during the baseline and 21.2 mmol/L during the intervention (p < 0.01)., Conclusion: During the diabetes awareness campaign, the rate of DKA at initial diagnosis of type 1 diabetes in children decreased by 64%., (© 2012 John Wiley & Sons A/S.)

Cytokines are upregulated in prediabetes, but their relationship with Enterovirus (EV) infection and development of islet autoimmunity is unknown. Cytokines (n = 65) were measured using Luminex xMAP technology in a nested case-control study of 67 children with a first-degree relative with type 1 diabetes: 27 with islet autoantibodies (Ab(+)) and 40 age-matched persistently autoantibody negative (Ab(-)) control subjects. Of 74 samples, 37 (50%) were EV-PCR(+) in plasma and/or stool (EV(+)) and the remainder were negative for EV and other viruses (EV(-)). Fifteen cytokines, chemokines, and growth factors were elevated (P ≤ 0.01) in Ab(+) versus Ab(-) children (interleukin [IL]-1β, IL-5, IL-7, IL-12(p70), IL-16, IL-17, IL-20, IL-21, IL-28A, tumor necrosis factor-α, chemokine C-C motif ligand [CCL]13, CCL26, chemokine C-X-C motif ligand 5, granulocyte-macrophage colony-stimulating factor, and thrombopoietin); most have proinflammatory effects. In EV(+) versus EV(-) children, IL-10 was higher (P = 0.005), while IL-21 was lower (P = 0.008). Cytokine levels did not differ between Ab(+)EV(+) and Ab(+)EV(-) children. Heat maps demonstrated clustering of some proinflammatory cytokines in Ab(+) children, suggesting they are coordinately regulated. In conclusion, children with islet autoimmunity demonstrate higher levels of multiple cytokines, consistent with an active inflammatory process in the prediabetic state, which is unrelated to coincident EV infection. Apart from differences in IL-10 and IL-21, EV infection was not associated with a specific cytokine profile.

Developing neocortical progenitors express transcription factors in gradients that induce programs of region-specific gene expression. Our previous work identified anteriorly upregulated expression gradients of a number of corticofugal neuron-associated gene probe sets along the anterior-posterior axis of the human neocortex (8-12 postconceptional weeks [PCW]). Here, we demonstrate by real-time polymerase chain reaction, in situ hybridization and immunohistochemistry that 3 such genes, ROBO1, SRGAP1, and CTIP2 are highly expressed anteriorly between 8-12 PCW, in comparison with other genes (FEZF2, SOX5) expressed by Layer V, VI, and subplate neurons. All 3 were prominently expressed by early postmitotic neurons in the subventricular zone, intermediate zone, and cortical plate (CP) from 8 to 10 PCW. Between 12 and 15 PCW expression patterns for ER81 and SATB2 (Layer V), TBR1 (Layer V/VI) and NURR1 (Layer VI) revealed Layer V forming. By 15 PCW, ROBO1 and SRGAP1 expression was confined to Layer V, whereas CTIP2 was expressed throughout the CP anteriorly. We observed ROBO1 and SRGAP1 immunoreactivity in medullary corticospinal axons from 11 PCW onward. Thus, we propose that the coexpression of these 3 markers in the anterior neocortex may mark the early location of the human motor cortex, including its corticospinal projection neurons, allowing further study of their early differentiation.

We describe three patients with congenital disorder of glycosylation (CDG) type Ia, all of whom had persistent hyperinsulinaemic hypoglycaemia responding to diazoxide therapy as a common feature. The first patient, an infant girl, presented with recurrent vomiting, failure to thrive, liver impairment, hypothyroidism and a pericardial effusion. The second patient, also female, had a milder disease with single organ involvement, presenting as isolated hyperinsulinaemic hypoglycaemia, not associated with any cognitive impairment. The third patient, a boy presented with multi-organ manifestations including congenital hypothyroidism, persistent hyperinsulinaemic hypoglycaemia, coagulopathy, olivopontocerebellar hypoplasia and recurrent pancreatitis. All three patients had a type 1 serum transferrin isoform pattern, and were subsequently found to have low phosphomannomutase activity, confirming the diagnosis of CDG type Ia. Our findings emphasize that CDG should be considered as a differential diagnosis in patients with persistent hyperinsulinaemic hypoglycaemia and that it may even occasionally be the leading symptom in CDG Ia.

Objective: To compare self-reported perception of weight with biomedically measured body mass index in different socioeconomic and cultural groups., Method: Of the original North West Adelaide Health (Cohort) Study (n = 4060) 68.5% (n = 2780) underwent a computer assisted telephone interview (CATI) answering additional questions related to their social and health status. The participants were asked "In terms of your weight, do you consider yourself to be… too thin, a little thin, normal weight, a little overweight or very overweight". The self-perception of weight was compared to biomedically measured BMI (body mass index). Binary logistic regression was used to compare those participants who were obese (BMI ≥ 30) with the self-perceived weight status of 'a little overweight'. The outcome measures included the Socioeconomic Indexes for Areas Index of Relative Socioeconomic Disadvantage (SEIFA IRSD), country of birth and household income., Results: Of those that were underestimating their obese weight status, 41.5% were male and 32.2% female. The highest misclassification was for those who considered their weight to be 'a little overweight', with 59.6% biomedically measured with a BMI of over 30. The odds of being biomedically measured obese (BMI ≥ 30) were compared to those who considered themselves to be 'a little overweight'. Those that misreported their weight status and were biomedically obese, were more likely to be living in the lowest quintile of disadvantage, have a household income of less then $20,000 or be born in Eastern or Western Europe., Conclusion: There are psychosocial, sociocultural and social environmental influences related to the perception of weight status. Future research will need to understand the processes whereby people are not aware they have a weight problem., (© Crown Copyright 2008 Published by Elsevier Ltd on behalf of Asia Oceania Assoc. for the Study of Obesity. All rights reserved.)

A 10-month-old infant with multiple infantile hepatic hemangiomas and developmental delay is reported. He was found to be profoundly hypothyroid. Evaluation and management issues are discussed. This case emphasizes the importance of screening for hypothyroidism in patients with hemangiomas and the potential therapeutic benefit of prednisolone therapy in this condition.

Objective: To examine the trends in the prevalence of classes I, II and III obesity between 1991 and 2006 among the South Australian adult population. In addition, to explore the association of severe (class II and III) obesity with a range of socio-demographics, chronic conditions and risk factor variables., Method: Trends of self-reported obesity prevalence were examined using representative, annual, face-to-face South Australian Health Omnibus Surveys from 1991 to 2006 (n ≈ 3000 per year). Biomedical data, including measured height and weight, were collected in the North West Adelaide Health (cohort) Study (NWAHS), a representative random adult sample selected from the electronic white pages (EWP) (n = 4060)., Results: The age standardised prevalence of self-reported class II and III obesity among those aged 18 years and over increased from 2.4% in 1991 to 8.1% in 2006. The greatest relative percentage increase over this time was seen amongst those with class III obesity (452.3%). Using biomedical data, multivariate analysis results indicated that among those who were obese, women were more than two and a half times more likely than men to be of class II and III. Among those who were obese, those aged 20-54 years and living in the low/lowest quintiles of Socioeconomic Indexes for Areas, Index of Relative Socioeconomic Disadvantage (SEIFA IRSD) were statistically significantly more likely to be class II or III obese when compared to those in the highest categories., Conclusion: The prevalence of class II and III obesity increased significantly between 1991 and 2006. The socio-demographics of those who are class II and III obesity are different from those that are normally described for obesity as a whole especially in regard to the younger age cohort. The current prevalence of severe obesity within Australia is probably underestimated and these results highlight the need to address this sub-group of the population., (© Crown Copyright 2008 Published by Elsevier Ltd on behalf of Asia Oceania Assoc. for the Study of Obesity. All rights reserved.)

Objective: To determine the incidence of type 2 diabetes mellitus (T2DM) in 2001-2006 in young people < 19 years and the characteristics of T2DM in the Indigenous group., Design and Setting: Prospective population-based incidence study, New South Wales., Participants: Primary ascertainment was from the Australasian Paediatric Endocrine Group NSW Diabetes Register, with secondary ascertainment from the National Diabetes Register (Australian Institute of Health and Welfare)., Main Outcome Measures: Incidence of T2DM in young people in NSW; incidence of T1DM and T2DM in Indigenous young people; characteristics at diagnosis., Results: There were 128 incident cases of T2DM (62 boys, 66 girls) in the study period. The median age at diagnosis was 14.5 years (interquartile range, 13.0-16.4), and 90% were overweight or obese (body mass index > 85th percentile for age). Mean annual incidence was 2.5/100,000 person-years (95% CI, 2.1-3.0) in 10-18-year-olds. Of the ethnic groups represented, white Australian comprised 29%, Indigenous 22%, Asian 22%, North African/Middle Eastern 12% and Māori/Polynesian/Melanesian 10%. The incidence of T2DM was significantly higher in the Indigenous than the non-Indigenous group (incidence rate ratio, 6.1; 95% CI, 3.9-9.7; P<0.001), but incidence rates of T1DM were similar (15.5 v 21.4/100,000, respectively)., Conclusions: T2DM accounts for 11% of incident cases of diabetes in 10-18-year-olds, and the majority are overweight or obese. The high rate among Indigenous Australian children supports screening for T2DM in this population.

Objective: Cardiac autonomic nerve tests have predicted increased mortality in adults with diabetes, predominantly due to nephropathy, cardiac disease, and hypoglycemia. The significance of subclinical autonomic nerve test abnormalities has not been systematically studied in adolescents. We aimed to reassess an adolescent cohort, whose autonomic nervous system had been tested 12 years earlier by both pupillometry and cardiovascular tests., Research Design and Methods: From 1990 to 1993, adolescents with type 1 diabetes (n = 335) were assessed for autonomic neuropathy (median age 14.7 years [interquartile range 13.0-16.8], duration of diabetes 6.3 years [4.0-9.6], and A1C 8.3% [7.5-9.4]). Between 2003 and 2005, contact was made with 59% of the original group. Individual assessment 12 years later included completion of a validated hypoglycemia unawareness questionnaire (n = 123) and urinary albumin-to-creatinine ratio (n = 99) and retinal (n = 102) screening, as well as analysis of reports from external doctors (n = 35)., Results: At baseline, there was no difference in age, duration of diabetes, or complications between those who participated in the follow-up phase (n = 137) and those who did not participate (n = 196). However, baseline A1C was lower in the follow-up participants (8.2 vs. 8.5% for participants vs. nonparticipants, respectively, P = 0.031). At 12 years of follow-up, 93% were aware and 7% were unaware that they had hypoglycemia; 32 (31%) had no retinopathy, but 10% required laser therapy, and 80 (81%) had no microalbuminuria. Small pupil size at baseline was independently associated with the development of microalbuminuria (odds ratio 4.36 [95% CI 1.32-14.42], P = 0.016) and retinopathy (4.83 [1.3-17.98], P = 0.019) but not with the development of hypoglycemia unawareness. There was no association with baseline cardiovascular tests and the development of complications 12 years later., Conclusions: In this study, we found an association between baseline pupillometry tests and the presence of microalbuminuria and retinopathy at 12 years of follow-up. This suggests that pupillometry abnormalities may be early indicators of patients who are at high risk of future microvascular disease.

Objective: To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes., Research Design and Methods: We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes., Results: In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes., Conclusions: Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.