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Aims: This study explores perspectives of on-pack alcohol warning labels, and how they might influence alcohol purchase and/or consumption behavior to inform culturally appropriate label design for effective behavior change., Methods: New Zealand participants ≥18 years, who reported having purchased and consumed alcoholic beverages in the last month were recruited via a market research panel and grouped into 10 focus groups (n = 53) by ethnicity (general population, Māori, and Pacific peoples), age group, and level of alcohol consumption. Participants were shown six potential alcohol health warning labels, with design informed by relevant literature, label framework, and stakeholder feedback. Interviews were transcribed and analyzed via qualitative (directed) content analysis., Results: Effective alcohol labels should be prominent, featuring large red and/or black text with a red border, combining text with visuals, and words like "WARNING" in capitals. Labels should contrast with bottle color, be easily understood, and avoid excessive text and confusing imagery. Participants preferred specific health outcomes, such as heart disease and cancer, increasing message urgency and relevance. Anticipated behavior change included reduced drinking and increased awareness of harms, but some may attempt to mitigate warnings by covering or removing labels. Contextual factors, including consistent design and targeted labels for different beverages and populations, are crucial. There was a strong emphasis on collective health impacts, particularly among Māori and Pacific participants., Conclusions: Our findings indicate that implementing alcohol warning labels, combined with comprehensive strategies like retail and social marketing campaigns, could effectively inform and influence the behavior of New Zealand's varied drinkers., (© The Author(s) 2024. Medical Council on Alcohol and Oxford University Press.)

Background: As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence., Methods: Underpinned by indigenous Māori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti kōrero wānanga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wānanga and observation methods. Methods used to capture change will be reported separately., Findings: Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings., Conclusions: Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs., (© 2024. The Author(s).)

Background: Cardiometabolic diseases are highly prevalent in Aotearoa New Zealand. Dietary intake is a modifiable risk factor for such diseases and certain dietary patterns, specifically the Mediterranean diet (MedDiet), are associated with improved metabolic health. This study aims to test whether an intervention including a Mediterranean dietary pattern incorporating high quality New Zealand foods (NZMedDiet pattern) and behavior change science can improve the metabolic health of participants and their household/whānau., Methods and Analysis: This is a multi-center, three-stage trial with two parallel group superiority randomized controlled trials (RCTs), and a longitudinal cohort study embedded within the trial design. The first RCT (RCT 1) is a comparison of the NZMedDiet pattern compared to usual diet for 12 weeks. The Behavior Change Wheel was used to select and implement strategies to support participant adherence to the NZMedDiet, such as web-based nutrition education on healthy shopping and cooking. The second (RCT 2) compares online social support to no online social support for 12 weeks, administered to participants immediately following RCT 1. The third stage is a longitudinal cohort study where all participants are followed from the beginning of their start of the active intervention for 12 months in total. The primary outcome measure for each stage is the metabolic syndrome severity score (MetSSS). The duration of enrolment is 12-15 months. The total recruitment target is 200 index participants and their household/whānau members who participate with them, and the primary analyses will be intention to treat on index participants., Discussion: The trial will test whether the NZMedDiet pattern and behavior change support improves the cardiometabolic health of people in Aotearoa New Zealand., Clinical Trial Registration: https://www.anzctr.org.au/Default.aspx, identifier ACTRN12622000906752 and https://www.isrctn.com/, identifier ISRCTN89011056 (Spirit 2)., Competing Interests: MF was employed by Edible Research Ltd. DC was employed by the New Zealand Institute for Plant & Food Research Ltd. The remaining 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 Lithander, Parry Strong, Braakhuis, Worthington, Foster, Rolleston, Davies, Mullaney, Ross, Conroy, Merry, Gearry, Weatherall and Krebs.)

Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda., Competing Interests: Nil., (© PMA.)

Background: In the general population, an increase in low-density lipoprotein cholesterol (LDL-C) predicts higher cardiovascular disease risk, and lowering LDL-C can prevent cardiovascular disease and reduces mortality risk. Interestingly, in cohort studies that include very old populations, no or inverse associations between LDL-C and mortality have been observed. This study aims to investigate whether the association between LDL-C and mortality in the very old is modified by a composite fitness score., Methods: A 2-stage meta-analysis of individual participant data from the 5 observational cohort studies. The composite fitness score was operationalized by performance on a combination of 4 markers: functional ability, cognitive function, grip strength, and morbidity. We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality risk for a 1 mmol/L increase in LDL-C. Models were stratified by high/low composite fitness score., Results: Composite fitness scores were calculated for 2 317 participants (median 85 years, 60% females participants), of which 994 (42.9%) had a high composite fitness score, and 694 (30.0%) had a low-composite fitness score. There was an inverse association between LDL-C and 5-year mortality risk (HR 0.87 [95% CI: 0.80-0.94]; p < .01), most pronounced in participants with a low-composite fitness score (HR 0.85 [95% CI: 0.75-0.96]; p = .01), compared to those with a high composite fitness score (HR = 0.98 [95% CI: 0.83-1.15]; p = .78), the test for subgroups differences was not significant., Conclusions: In this very old population, there was an inverse association between LDL-C and all-cause mortality, which was most pronounced in participants with a low-composite fitness scores., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Objective: The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported., Methods: First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity., Results: Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log 2 (NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084., Conclusions: In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score., Trial Registration Number: ACTRN12615000676516., Competing Interests: Competing interests: JH is a full-time employee of Novo Nordisk Research Centre Oxford Ltd. KKP and AMR are on the Editorial Board for BMJ Heart., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians., Objective: To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up., Design: Longitudinal Cohort Study., Setting: Bay of Plenty and Lakes health regions of New Zealand., Subjects: Eight-hundred-seventy-seven (379 indigenous Māori, 498 non-Māori) were included in the analysis., Methods: AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA., Results: AF was present in 21% at baseline (Māori 26%, non-Māori 18%), the prevalence doubled over 5-years (Māori 50%, non-Māori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Māori was twice that of non-Māori. Five-year stroke/TIA prevalence was 23% (22% in Māori and 24% non- Māori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Māori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians., (© 2023. The Author(s).)

Objectives: While randomized controlled trials have proven the benefits of blood pressure (BP) lowering in participating octogenarians, population-based observational studies suggest an association between low systolic blood pressure (SBP) and faster overall decline. This study investigates the effects of BP-lowering treatment, a history of cardiovascular diseases (CVD), and cognitive and physical fitness on the associations between SBP and health outcomes in the very old., Methods: Five cohorts from the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included in a two-step individual participant data meta-analysis (IPDMA). We pooled hazard ratios (HR) from Cox proportional-hazards models for 5-year mortality and estimates of linear mixed models for change in cognitive and functional decline. Models were stratified by BP-lowering treatment, history of CVD, Mini-Mental State Examination scores, grip strength (GS) and body mass index (BMI)., Results: Of all 2480 participants (59.9% females, median 85 years), median baseline SBP was 149 mmHg, 64.3% used BP-lowering drugs and 47.3% had a history of CVD. Overall, higher SBP was associated with lower all-cause mortality (pooled HR 0.91 [95% confidence interval 0.88-0.95] per 10 mmHg). Associations remained irrespective of BP-lowering treatment, history of CVD and BMI, but were absent in octogenarians with above-median MMSE and GS. In pooled cohorts, SBP was not associated with cognitive and functional decline., Conclusion: While in the very old with low cognitive or physical fitness a higher SBP was associated with a lower all-cause mortality, this association was not evident in fit octogenarians. SBP was not consistently associated with cognitive and functional decline., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

We examined the importance of understanding and incorporating cultural context within Aotearoa/New Zealand when engaging in clinical research and practice. This paper reports on the qualitative findings of a mixed methods study aimed at determining what effect a cardiac risk reduction exercise and lifestyle management programme, embedded within a kaupapa Māori methodological approach, had on Māori participants. This methodology saw participants able to redevelop a western model cardiac risk reduction programme by introducing a Māori worldview. Our study revealed how the kaupapa Māori approach empowered participants to examine and evaluate not only their own health and lifestyle choices, but those of family and the wider community. Combining biomedical and kaupapa Māori components into the programme was found to benefit participants' mental, physical, spiritual and family well-being., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Maintaining independence is of key importance to older people. Ways to enable health strategies, strengthen and support whanāu (family) at the community level are needed. The Ageing Well through Eating, Sleeping, Socialising and Mobility (AWESSOM) programme in Aotearoa/New Zealand (NZ) delivers five integrated studies across different ethnicities and ages to optimise well-being and to reverse the trajectory of functional decline and dependence associated with ageing., Methods: Well-being, independence and the trajectory of dependence are constructs viewed differently according to ethnicity, age, and socio-cultural circumstance. For each AWESSoM study these constructs are defined and guide study development through collaboration with a wide range of stakeholders, and with reference to current evidence. The Compression of Functional Decline model (CFD) underpins aspects of the programme. Interventions vary to optimise engagement and include a co-developed whānau (family) centred initiative (Ngā Pou o Rongo), the use of a novel LifeCurve™App to support behavioural change, development of health and social initiatives to support Pacific elders, and the use of a comprehensive oral health and cognitive stimulation programme for cohorts in aged residential care. Running parallel to these interventions is analysis of large data sets from primary care providers and national health databases to understand complex multi-morbidities and identify those at risk of adverse outcomes. Themes or target areas of sleep, physical activity, oral health, and social connectedness complement social capital and community integration in a balanced programme involving older people across the ability spectrum., Discussion: AWESSoM delivers a programme of bespoke yet integrated studies. Outcomes and process analysis from this research will inform about novel approaches to implement relevant, socio-cultural interventions to optimise well-being and health, and to reverse the trajectory of decline experienced with age., Trial Registration: The At-risk cohort study was registered by the Australian New Zealand Clinical Trials registry on 08/12/2021 (Registration number ACTRN 12621001679875 )., (© 2022. The Author(s).)

Objective: To determine the association between dietary protein intake and change in grip strength (GS) over time among Māori and non-Māori of advanced age., Methods: Protein intake was estimated from 2×24h multiple pass recall (MPR) in 554 participants, and GS was measured yearly over five years. Anthropometric, physical activity and health data were collected., Results: The median weight-adjusted protein intake was low (for Māori and non-Māori men 1.05 and 0.98g/kg/day; for Māori and non-Māori women 0.87 and 0.91g/kg/day, respectively). There was a general decrease in GS over five years (mean % change of -2.38 ± 15.32 and -4.49 ± 21.92 for Māori and non-Māori women and -5.47 ± 16.09 and -1.81 ± 13.16 for Māori and non-Māori men yearly). Intake of protein was not related to GS at any of the five-year assessment points nor was it related to change over time., Conclusion: Protein intake was low in this cohort of octogenarians and was not protective against loss of GS over five years., (© 2021 AJA Inc.)

For older people gardens may be paradoxical sites. Whilst gardening is associated in multiple ways with wellbeing and health, gardens may also become a source of frustration and worry as ageing bodies limit gardening activities. Yet determination remains. However, little of the well-established body of work on gardens and old age includes people in advanced age. In this paper, we draw on interviews with Māori and non-Māori 85-90-year olds in Aotearoa, New Zealand, focusing on how they talk about their wellbeing in relation to past, present, and future experiences of home gardening. Our research shows home gardens and gardening figure prominently and positively in the narratives of people in advanced age. Most of our participants described themselves as active gardeners; most also lived with multimorbidity, sometimes severe and complex. Applying positioning theory, we examine how our participants connect gardens and gardening to identity; connectedness; and adaptation and renegotiation of health and wellbeing in ageing bodies. Home gardens are 'more than therapeutic'; while they are protective of health and wellbeing, they are also enabling places for the expression and performance of agency in advanced age. These understandings have practical implications for supporting wellbeing amongst those in advanced age., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Competing Interests: KFM is supported by the National Health and Medical Research Council under a Postgraduate Scholarship (1134198). AR declares no competing interests.

Physical activity and protein intake are associated with ageing-related outcomes, including loss of muscle strength and functional decline, so may contribute to strategies to improve healthy ageing. We investigated the cross-sectional associations between physical activity or sedentary behaviour and protein intake patterns in community-dwelling older adults across five countries. Self-reported physical activity and dietary intake data were obtained from two cohort studies (Newcastle 85+ Study, UK; LiLACS, New Zealand Māori and Non-Māori) and three national food consumption surveys (DNFCS, The Netherlands; FINDIET, Finland; INRAN-SCAI, Italy). Associations between physical activity and total protein intake, number of eating occasions providing protein, number of meals with specified protein thresholds, and protein intake distribution over the day (calculated as a coefficient of variance) were assessed by regression and repeated measures ANOVA models adjusting for covariates. Greater physical activity was associated with higher total protein intake and more eating occasions containing protein, although associations were mostly explained by higher energy intake. Comparable associations were observed for sedentary behaviour in older adults in Italy. Evidence for older people with higher physical activity or less sedentary behaviour achieving more meals with specified protein levels was mixed across the five countries. A skewed protein distribution was observed, with most protein consumed at midday and evening meals without significant differences between physical activity or sedentary behaviour levels. Findings from this multi-study analysis indicate there is little evidence that total protein and protein intake patterns, irrespective of energy intake, differ by physical activity or sedentary behaviour levels in older adults.

This study aimed to describe the diet quality of pre-frail community-dwelling older adults to extend the evidence of nutrition in frailty prevention. Pre-frailty, the transition state between a robust state and frailty, was ascertained using the FRAIL scale. Socio-demographic, health status, and 24-h dietary recalls were collected from 465 community-dwelling adults aged 75+ (60 years for Māori and Pacific people) across New Zealand. Diet quality was ascertained with the Diet Quality Index-International (DQI-I). Participants (median (IQR) age 80 (77-84), 59% female) had a moderately healthful diet, DQI-I score: 60.3 (54.0-64.7). Women scored slightly higher than men ( p = 0.042). DQI-I components identified better dietary variety in men ( p = 0.044), and dietary moderation in women ( p = 0.002); both sexes performed equally well in dietary adequacy and poorly in dietary balance scores (73% and 47% of maximum scores, respectively). Low energy 20.3 (15.4-25.3) kcal/kg body weight (BW) and protein intakes 0.8 (0.6-1.0) g/kg BW were coupled with a high prevalence of mineral inadequacies: calcium (86%), magnesium (68%), selenium (79%), and zinc (men 82%). In conclusion, the diet quality of pre-frail older adults was moderately high in variety and adequacy but poor in moderation and balance. Our findings support targeted dietary interventions to ameliorate frailty.

Background: Mobile health technologies have the potential to improve the reach and delivery of interventions for promoting long-term secondary prevention of coronary heart disease., Objective: This study aims to determine the effectiveness of an SMS text messaging intervention (Text4HeartII) for improving adherence to medication and lifestyle changes over and above usual care in people with coronary heart disease at 24 and 52 weeks., Methods: A two-arm, parallel, randomized controlled trial was conducted in New Zealand. Participants with a recent acute coronary syndrome were randomized to receive usual cardiac services alone (control, n=153) or a 24-week SMS text message program for supporting self-management plus usual cardiac services (n=153). The primary outcome was adherence to medication at 24 weeks, defined as a medication possession ratio of 80% or more for aspirin, statin, and antihypertensive therapy. Secondary outcomes included medication possession ratio at 52 weeks, self-reported medication adherence, adherence to healthy lifestyle behaviors, and health-related quality of life at 24 and 52 weeks., Results: Participants were predominantly male (113/306, 80.3%) and European New Zealanders (210/306, 68.6%), with a mean age of 61 years (SD 11 years). Groups were comparable at baseline. National hospitalization and pharmacy dispensing records were available for all participants; 92% (282/306, 92.1%) of participants completed a 24-week questionnaire and 95.1% (291/306) of participants completed a 52-week questionnaire. Adherence with 3 medication classes were lower in the intervention group than in the control group (87/153, 56.8% vs 105/153, 68.6%, odds ratio 0.60, 95% CI 0.38-0.96; P=.03) and 52 weeks (104/153, 67.9% vs 83/153, 54.2%; odds ratio 0.56, 95% CI 0.35-0.89; P=.01). Self-reported medication adherence scores showed the same trend at 52 weeks (mean difference 0.3; 95% CI 0.01-0.59; P=.04). Moreover, self-reported adherence to health-related behaviors was similar between groups., Conclusions: Text4HeartII did not improve dispensed medication or adherence to a favorable lifestyle over and above usual care. This finding contrasts with previous studies and highlights that the benefits of text interventions may depend on the context in which they are used., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000422426; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370398., International Registered Report Identifier (irrid): RR2-10.1186/s13063-018-2468-z., (©Ralph Maddison, Yannan Jiang, Ralph Stewart, Tony Scott, Andrew Kerr, Robyn Whittaker, Jocelyn Benatar, Anna Rolleston, Paul Estabrooks, Leila Dale. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 09.06.2021.)

Background: Acute coronary syndrome (ACS) events and the ongoing burden of disease can have a significant impact on the subsequent life-course of working age people., Methods: We report 12-month clinical outcomes for 10,822 patients hospitalized with first-time ACS between 2015-2016 and enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry, with a focus on people of working age (defined as <65 years)., Results: Nearly half (48%) of first-time ACS occurred in people of working age. Compared to those >65 years, these patients had a high burden of cardiovascular risk factors, and were more likely to be male (75% vs 60%), to be of non-European ethnicity (36% vs 15%), and to be living in areas of high deprivation. Subsequent clinical events were common in the younger patients, with 15% dying or being readmitted for cardiovascular causes within 12 months despite high rates of angiography (96%), revascularization (74%) and evidence-based medical therapy at the time of the index ACS event., Conclusions: The high risk factor burden and subsequent high rate of clinical events in working age patients reinforces the need for a longer-term focus on strategies to improve clinical outcomes following first-time ACS., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Subclinical and overt thyroid dysfunction is easily detectable, often modifiable, and, in younger age groups, has been associated with clinically relevant outcomes. Robust associations in very old persons, however, are currently lacking. This study aimed to investigate the associations between (sub-)clinical thyroid dysfunction and disability in daily living, cognitive function, depressive symptoms, physical function, and mortality in people aged 80 years and older. Methods: Four prospective cohorts participating in the Towards Understanding Longitudinal International older People Studies (TULIPS) consortium were included. We performed a two-step individual participant data meta-analysis on source data from community-dwelling participants aged 80 years and older from the Netherlands, New Zealand, United Kingdom, and Japan. Outcome measures included disability in daily living (disability in activities of daily living [ADL] questionnaires), cognitive function (Mini-Mental State Examination [MMSE]), depressive symptoms (Geriatric Depression Scale [GDS]), physical function (grip strength) at baseline and after 5 years of follow-up, and all-cause five-year mortality. Results: Of the total 2116 participants at baseline (mean age 87 years, range 80-109 years), 105 participants (5.0%) were overtly hypothyroid, 136 (6.4%) subclinically hypothyroid, 1811 (85.6%) euthyroid, 60 (2.8%) subclinically hyperthyroid, and 4 (0.2%) overtly hyperthyroid. Participants with thyroid dysfunction at baseline had nonsignificantly different ADL scores compared with euthyroid participants at baseline and had similar MMSE scores, GDS scores, and grip strength. There was no difference in the change of any of these functional measures in participants with thyroid dysfunction during five years of follow-up. Compared with the euthyroid participants, no 5-year survival differences were identified in participants with overt hypothyroidism (hazard ratio [HR] 1.0, 95% confidence interval [CI 0.6-1.6]), subclinical hypothyroidism (HR 0.9 [CI 0.7-1.2]), subclinical hyperthyroidism (HR 1.1 [CI 0.8-1.7]), and overt hyperthyroidism (HR 1.5 [CI 0.4-5.9]). Results did not differ after excluding participants using thyroid-influencing medication. Conclusions: In community-dwelling people aged 80 years and older, (sub-)clinical thyroid dysfunction was not associated with functional outcomes or mortality and may therefore be of limited clinical significance.

Objective: The objective of this research was to document the barriers to early presentation and diagnosis of lung cancer within primary healthcare, identified by Māori whānau (families) and primary healthcare providers in the Midland region of Aotearoa New Zealand., Methods: This project used a kaupapa Māori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Each community hui included cancer patients, whānau, and other community members. Each healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed., Results: Barriers and enablers to early diagnosis of lung cancer were categorised into three key themes: GP relationship and position in the community, health literacy and pathways to diagnosis., Conclusion: This study demonstrates that culturally responsive, patient-centred healthcare, and positive GP-patient relationships are significant factors for Māori patients and whānau serving as barriers and enablers to early diagnosis of lung cancer., (© 2020 John Wiley & Sons Ltd.)

Background: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Māori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Māori communities., Methods: This project used a kaupapa Māori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whānau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed., Results: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whānau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whānau journey focused on agency and the impact on whānau., Conclusions: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whānau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Māori and the active efforts of whānau as carers to foster health literacy in future generations.

Objective: To determine the physical and mental health of very old people (aged 80+) with anaemia., Methods: Individual level meta-analysis from five cohorts of octogenarians (n = 2,392): LiLACS NZ Māori, LiLACS NZ non-Māori, Leiden 85-plus Study, Newcastle 85+ Study, and TOOTH. Mixed models of change in functional ability, cognitive function, depressive symptoms, and self-rated health over time were separately fitted for each cohort. We combined individual cohort estimates of differences according to the presence of anaemia at baseline, adjusting for age at entry, sex, and time elapsed. Combined estimates are presented as differences in standard deviation units (i.e. standardised mean differences-SMDs)., Results: The combined prevalence of anaemia was 30.2%. Throughout follow-up, participants with anaemia, on average, had: worse functional ability (SMD -0.42 of a standard deviation across cohorts; CI -0.59,-0.25); worse cognitive scores (SMD -0.27; CI -0.39,-0.15); worse depression scores (SMD -0.20; CI -0.31,-0.08); and lower ratings of their own health (SMD -0.36; CI -0.47,-0.25). Differential rates of change observed were: larger declines in functional ability for those with anaemia (SMD -0.12 over five years; CI -0.21,-0.03) and smaller mean difference in depression scores over time between those with and without anaemia (SMD 0.18 over five years; CI 0.05,0.30)., Conclusion: Anaemia in the very old is a common condition associated with worse functional ability, cognitive function, depressive symptoms, and self-rated health, and a more rapid decline in functional ability over time. The question remains as to whether anaemia itself contributes to worse outcomes or is simply a marker of chronic diseases and nutrient deficiencies., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Māori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Māori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairāwhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Māori and Indigenous patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

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.)

Introduction: Natural experiments are considered a priority for examining causal associations between the built environment (BE) and physical activity (PA) because the randomised controlled trial design is rarely feasible. Few natural experiments have examined the effects of walking and cycling infrastructure on PA and active transport in adults, and none have examined the effects of such changes on PA and active transport to school among adolescents. We conducted the Built Environment and Active Transport to School (BEATS) Study in Dunedin city, New Zealand, in 2014-2017. Since 2014, on-road and off-road cycling infrastructure construction has occurred in some Dunedin neighbourhoods, including the neighbourhoods of 6 out of 12 secondary schools. Pedestrian-related infrastructure changes began in 2018. As an extension of the BEATS Study, the BEATS Natural Experiment (BEATS-NE) (2019-2022) will examine the effects of BE changes on adolescents' active transport to school in Dunedin, New Zealand., Methods and Analysis: The BEATS-NE Study will employ contemporary ecological models for active transport that account for individual, social, environmental and policy factors. The published BEATS Study methodology (surveys, accelerometers, mapping, Geographic Information Science analysis and focus groups) and novel methods (environmental scan of school neighbourhoods and participatory mapping) will be used. A core component continues to be the community-based participatory approach with the sustained involvement of key stakeholders to generate locally relevant data, and facilitate knowledge translation into evidence-based policy and planning., Ethics and Dissemination: The BEATS-NE Study has been approved by the University of Otago Ethics Committee (reference: 17/188). The results will be disseminated through scientific publications and symposia, and reports and presentations to stakeholders., Trial Registration Number: ACTRN12619001335189., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The prescribing of medications with anticholinergic and/or sedative properties is considered potentially inappropriate in older people (due to their side-effect profile), and the Drug Burden Index (DBI) is an evidence-based tool which measures exposure to these medications. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is an ongoing longitudinal study investigating the determinants of healthy ageing. Using data from LiLACS NZ, this study aimed to determine whether a higher DBI was associated with poorer outcomes (hospitalisation, falls, mortality and cognitive function and functional status) over 36 months follow-up., Methods: LiLACS NZ consists of two cohorts: Māori (the indigenous population of New Zealand) aged ≥ 80 years and non-Māori aged 85 years at the time of enrolment. Data relating to regularly prescribed medications at baseline, 12 months and 24 months were used in this study. Medications with anticholinergic and/or sedative properties (i.e. medications with a DBI > 0) were identified using the Monthly Index of Medical Specialities (MIMS) medication formulary, New Zealand. DBI was calculated for everyone enrolled at each time point. The association between DBI at baseline and outcomes was evaluated throughout a series of 12-month follow-ups using negative binomial (hospitalisations and falls), Cox (mortality) and linear (cognitive function and functional status) regression analyses (significance p < 0.05). Regression models were adjusted for age, gender, general practitioner (GP) visits, socioeconomic deprivation, number of medicines prescribed and one of the following: prior hospitalisation, history of falls, baseline cognitive function [Modified Mini-Mental State Examination (3MS)] or baseline functional status [Nottingham Extended Activities of Daily Living (NEADL)]., Results: Full demographic data were obtained for 671, 510 and 403 individuals at baseline, 12 months and 24 months, respectively. Overall, 31%, 30% and 34% of individuals were prescribed a medication with a DBI > 0 at baseline, 12 months and 24 months, respectively. At baseline and 12 months, non-Māori had a greater mean DBI (0.28 ± 0.5 and 0.27 ± 0.5, respectively) compared to Māori (0.16 ± 0.3 and 0.18 ± 0.5, respectively). At baseline, the most commonly prescribed medicines with a DBI > 0 were zopiclone, doxazosin, amitriptyline and codeine. In Māori, a higher DBI was significantly associated with a greater risk of mortality: at 36 months follow-up, adjusted hazard ratio [95% confidence interval (CI)] 1.89 (1.11-3.20), p = 0.02. In non-Māori, a higher DBI was significantly associated with a greater risk of mortality [at 12 months follow-up, adjusted hazard ratio (95% CIs) 2.26 (1.09-4.70), p = 0.03] and impaired cognitive function [at 24 months follow-up, adjusted mean difference in 3MS score (95% CIs) 0.89 (- 3.89 to - 0.41), p = 0.02)., Conclusions: Using data from LiLACS NZ, a higher DBI was significantly associated with a greater risk of mortality (in Māori and non-Māori) and impaired cognitive function (in non-Māori). This highlights the importance of employing strategies to manage the prescribing of medications with a DBI > 0 in older adults.

Background: Potentially inappropriate prescribing (PIP) is associated with negative health outcomes, including hospitalisation and mortality. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is a longitudinal study of Māori (the indigenous population of New Zealand) and non-Māori octogenarians. Health disparities between indigenous and non-indigenous populations are prevalent internationally and engagement of indigenous populations in health research is necessary to understand and address these disparities. Using LiLACS NZ data, this study reports the association of PIP with hospitalisations and mortality prospectively over 36-months follow-up., Methods: PIP, from pharmacist applied criteria, was reported as potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs). The association between PIP and hospitalisations (all-cause, cardiovascular disease-specific and ambulatory-sensitive) and mortality was determined throughout a series of 12-month follow-ups using binary logistic (hospitalisations) and Cox (mortality) regression analysis, reported as odds ratios (ORs) and hazard ratios (HRs), respectively, and the corresponding confidence intervals (CIs)., Results: Full demographic data were obtained for 267 Māori and 404 non-Māori at baseline, 178 Māori and 332 non-Māori at 12-months, and 122 Māori and 281 non-Māori at 24-months. The prevalence of any PIP (i.e. ≥1 PIM and/or PPO) was 66, 75 and 72% for Māori at baseline, 12-months and 24-months, respectively. In non-Māori, the prevalence of any PIP was 62, 71 and 73% at baseline, 12-months and 24-months, respectively. At each time-point, there were more PPOs than PIMs; at baseline Māori were exposed to a significantly greater proportion of PPOs compared to non-Māori (p = 0.02). In Māori: PPOs were associated with a 1.5-fold increase in hospitalisations and mortality. In non-Māori, PIMs were associated with a double risk of mortality., Conclusions: PIP was associated with an increased risk of hospitalisation and mortality in this cohort. Omissions appear more important for Māori in predicting hospitalisations, and PIMs were more important in non-Māori in predicting mortality. These results suggest understanding prescribing outcomes across and between population groups is needed and emphasises prescribing quality assessment is useful.

Background: Prescribing for older people is complex, and many studies have highlighted that appropriate prescribing in this cohort is not always achieved. However, the long-term effect of inappropriate prescribing on outcomes such as hospitalisation and mortality has not been demonstrated. The aim of this study was to determine the level of potentially inappropriate prescribing (PIP) for participants of the Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) study at baseline and examine the association between PIP and hospitalisation and mortality at 12-months follow-up., Methods: PIP was determined using STOPP/START. STOPP identified potentially inappropriate medicines (PIMs) prescribed, START identified potential prescribing omissions (PPOs). STOPP/START were applied to all LiLACS NZ study participants, a longitudinal study of ageing, which includes 421 Māori aged 80-90 years and 516 non-Māori aged 85 years. Participants' details (e.g. age, sex, living arrangements, socioeconomic status, physical functioning, medical conditions) were gathered by trained interviewers. Some participants completed a core questionnaire only, which did not include medications details. Medical conditions were established from a combination of self-report, review of hospital discharge and general practitioner records. Binary logistic regression, controlled for multiple potential confounders, was conducted to determine if either PIMs or PPOs were associated with hospital admissions and mortality (p < 0.05 was considered significant)., Results: Full data were obtained for 267 Māori and 404 non-Māori. The mean age for Māori was 82.3(±2.6) years, and 84.6(±0.53) years for non-Māori. 247 potentially inappropriate medicines were identified, affecting 24.3% Māori and 28.0% non-Māori. PIMs were not associated with 12-month mortality or hospitalisation for either cohort (p > 0.05; adjusted models). 590 potential prescribing omissions were identified, affecting 58.1% Māori and 49.0% non-Māori. PPOs were associated with hospitalisation (p = 0.001 for Māori), but were not associated with risk of mortality (p > 0.05) for either cohort within the 12-month follow-up (adjusted models)., Conclusion: PPOs were more common than PIMs and were associated with an increased risk of hospitalisation for Māori. This study highlights the importance of carefully considering all indicated medicines when deciding what to prescribe. Further follow-up is necessary to determine the long-term effects of PIP on mortality and hospitalisation.

Introduction: We assessed the sensitivity and specificity of the Modified Mini-Mental State Examination (3MS) in predicting dementia and cognitive impairment in Māori (indigenous people of New Zealand) and non-Māori octogenarians., Methods: A subsample of participants from Life and Living in Advanced Age: a Cohort Study in New Zealand were recruited to determine the 3MS diagnostic accuracy compared with the reference standard., Results: Seventy-three participants (44% Māori) completed the 3MS and reference standard assessments. The 3MS demonstrated strong diagnostic accuracy to detect dementia with areas under the curve of 0.87 for Māori and 0.9 for non-Māori. Our cutoffs displayed ethnic variability and are approximately 5 points greater than those commonly applied. Cognitive impairment yielded low accuracy, and discriminatory power was not established., Discussion: Cutoffs that are not age or ethnically appropriate may compromise the accuracy of cognitive screens. Consequently, older age and indigeneity increase the risk of mislabeled cognitive status., (© 2019 The Authors.)

Background: Frailty is a multidimensional geriatric syndrome associated with functional loss. The Senior Chef (SC, nutrition) and SAYGO (strength and balance exercise) programmes are well accepted among older adults but the impact of each, or a combination of both, on the frailty syndrome in pre-frail older adults is unknown., Aims: To determine the effectiveness and cost-effectiveness of a complex intervention consisting of the SC and/or SAYGO programmes to prevent progression of frailty in pre-frail older adults., Methods: A multi-centre randomised controlled assessor-blinded study. The four intervention groups are SC, an 8-week nutrition education and cooking class; SAYGO, a 10-week strength and balance exercise class; SC plus SAYGO, and a social group (Control). Community-dwelling adults aged 75+ (60 + Māori and Pasifika) in New Zealand are recruited through health providers. Participants are not terminally ill or with advanced dementia, and have a score of 1 or 2 on the FRAIL questionnaire. Baseline assessments are completed using standardised questionnaires prior to randomisation. Four follow-up assessments are completed: immediately after intervention, 6, 12 and 24 months post-intervention. The primary outcome is frailty score, secondary outcomes are falls, physical function, quality of life, food intake, physical activity, and sustainability of the strategy. Study outcomes will be analysed using intention-to-treat approach. Cost analyses will be completed to determine if interventions are cost effective relative to the control group., Discussion: This trial is designed to be a real world rigorous assessment of whether the two intervention strategies can prevent progression of frailty in older people. If successful, this will generate valuable information about effectiveness of this nutrition and exercise strategy, and provide insights for their implementation., Trial Registration: Australian and New Zealand Clinical Trials Registry number-ACTRN12614000827639.

In this paper we reflect on discussions with people of advanced age in Āotearoa New Zealand, and draw on theoretical frameworks of resilience and place in old age, to explore insights about the ways older people maintain quality of life and health. Twenty community-dwelling people of advanced age (85+) were recruited in 2015-16 from a large multidisciplinary longitudinal study of advanced age. These twenty participated in interviews about health in advanced age, impact of illnesses, interactions with clinicians, access to information, support for managing health, and perceptions of primary care, medications, and other forms of assistance. We use a positioning theory framework drawing on thematic and narrative analysis to understand the dynamic ways people in advanced age position themselves and the ways they age well through speech acts and storylines. People in advanced age saw themselves as challenged, rather than threatened, by adversities, and positioned themselves as able to draw on a lifetime of experience and resourcefulness and collaborations with supporters to deal with challenges. Key strategies include downplaying illness and resisting biomedical discourses of complexity, positioning embodied selves as having agency, and creative adaptation in the face of loss. People in advanced age exhibit resilience, maintaining wellbeing, autonomy and good physical and mental quality of life even while living with challenges such as functional decline and multi-morbidities. These findings have significance for supporters of older people, emphasising the need to move away from a narrow focus on problems to working together WITH people in advanced age to offer a more holistic approach that encourages and enhances adaptation and flexibility, rather than rigid and counterproductive coping patterns., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: Compare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD)., Methods: Participants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O 2 max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O 2 max at 12 weeks (inferiority margin=-1.25 mL/kg/min); inferiority margins were not set for secondary outcomes., Results: 162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O 2 max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI -0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=-61.5 (95% CI -117.8 to -5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20)., Conclusion: REMOTE-CR is an effective, cost-efficient alternative delivery model that could-as a complement to existing services-improve overall utilisation rates by increasing reach and satisfying unique participant preferences., Competing Interests: Competing interests: RM was supported by the New Zealand Health Research Council (Sir Charles Hercus health research fellowship). MM is supported by the Australian National Health and Medical Research Council (Centre for Research Excellence, 1041020). We declare no further competing interests., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Evaluate user experiences of an exercise-based cardiac telerehabilitation intervention (REMOTE-CR) that provided near universal access to real-time remote coaching and behavioral support from exercise specialists., Design: Secondary analysis (12-week follow-up) of a parallel group, single blind, randomized controlled noninferiority trial (ACTRN12614000843651)., Setting: Community-based cardiac rehabilitation., Participants: Adults (N=162) with coronary heart disease who were eligible for outpatient cardiac rehabilitation. Eighty-two of 162 trial participants were randomized to receive REMOTE-CR; 67 completed usability and acceptability assessment at 12-week follow-up., Intervention: REMOTE-CR comprised 12 weeks of individualized exercise prescription, real-time physiological monitoring, coaching, and behavioral support, delivered via a bespoke telerehabilitation platform., Outcomes: Ease of use, satisfaction with the technology platform and intervention content, and demand for real-world implementation as an alternative to traditional center-based programs were assessed at 12-week follow-up., Results: Components of usability and acceptability were positively evaluated by most participants (44-66 of 67, 66%-99%). Fifty-eight of 67 (87%) would choose REMOTE-CR if it was available as a usual care service, primarily because it provides convenient and flexible access to real-time individualized support from exercise specialists. Technology challenges were rare and had little effect on user experiences or demand for REMOTE-CR., Conclusions: REMOTE-CR can extend the reach and impact of existing cardiac rehabilitation services by overcoming traditional participation barriers while preserving expert oversight. Adoption of emerging technologies should be accelerated to support dynamic, engaging, individualized intervention delivery models, but optimizing overall cardiac rehabilitation participation rates will require multiple delivery models that are tailored to satisfy diverse participant preferences., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The relationship between physical activity, function, and mortality is not established in advanced age. Physical activity, function, and mortality were followed in a cohort of Māori and non-Māori adults living in advanced age for a period of 6 years. Generalized linear regression models were used to analyze the association between physical activity and Nottingham Extended Activities of Daily Living scale, whereas Kaplan-Meier survival analysis and Cox proportional hazard models were used to assess the association between the physical activity and mortality. The hazard ratio for mortality for those in the least active physical activity quartile was 4.1 for Māori and 1.8 for non-Māori compared with the most active physical activity quartile. There was an inverse relationship between physical activity and mortality, with lower hazard ratios for mortality at all levels of physical activity. Higher levels of physical activity were associated with lower mortality and higher functional status in advanced-aged adults.

Precision medicine seeks to draw on data from both individuals and populations across disparate domains to influence and support diagnosis, management and prevention in healthcare at the level of the individual patient and their family/whānau. Central to this initiative is incorporating the effects of the inherent variation that lies within genomes and can influence health outcomes. Identifying and interpreting such variation requires an accurate, valid and representative dataset to firstly define what variants are present and then assess the potential relevance for the health of a person, their family/whānau and the wider community to which they belong. Globally the variation embedded within genomes differs enormously and has been shaped by the size, constitution, historical origins and evolutionary history of their source populations. Māori, and more broadly Pacific peoples, differ substantially in terms of genomic variation compared to the more closely studied European and Asian populations. In the absence of accurate genomic information from Māori and Pacific populations, the precise interpretation of genomic data and the success and benefits of genomic medicine will be disproportionately less for those Māori and Pacific peoples. In this viewpoint article we, as a group of healthcare professionals, researchers and scientists, present a case for assembling genomic resources that catalogue the characteristics of the genomes of New Zealanders, with an emphasis on peoples of Māori and Polynesian ancestry, as a healthcare imperative. In proposing the creation of these resources, we note that their governance and management must be led by iwi and Māori and Pacific representatives. Assembling a genomic resource must be informed by cultural concepts and values most especially understanding that, at a physical and spiritual level, whakapapa is embodied within the DNA of a person. Therefore DNA and genomic data that connects to whakapapa (genealogy) is considered a taonga (something precious and significant), and its storage, utilisation and interpretation is a culturally significant activity. Furthermore, such resources are not proposed to primarily enable comparisons between those with Māori and broader Pacific ancestries and other Aotearoa peoples but to place an understanding of the genetic contributors to their health outcomes in a valid context. Ongoing oversight and governance of such taonga by Māori and Pacific representatives will maximise hauora (health) while also minimising the risk of misuse of this information., Competing Interests: Dr Doughty reports grants from NZ Heart Foundation, Health Research Council and Healthier Lives National Science Challenge during the conduct of the study. Dr Cameron reports grants from MBIE Healthier Lives National Science Challenge and Heart Foundation of New Zealand outside the submitted work.

Objectives: To investigate the association between domains of nutrition risk with hospitalisations and mortality for New Zealand Māori and non-Māori in advanced age., Methods: Within LiLACS NZ, 256 Māori and 399 non-Māori octogenarians were assessed for nutrition risk using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II) questionnaire according to three domains of risk. Sociodemographic and health characteristics were established. Five years from inception, survival analyses examined associations between nutrition risk from the three domains of SCREEN II with all-cause hospital admissions and mortality., Results: For Māori but not non-Māori, lower nutrition risk in the Dietary Intake domain was associated with reduced hospitalisations and mortality (Hazard Ratios [HR] [95%CI] 0.97 [0.95-0.99], p=0.009 and 0.91 [0.86-0.98], p=0.005, respectively). The 'Factors Affecting Intake' domain was associated with mortality (HR, [95%CI] 0.94 [0.89-1.00], p=0.048), adjusted for age, gender, socioeconomic deprivation, education, previous hospital admissions, comorbidities and activities of daily living., Conclusion: Improved dietary adequacy may reduce poor outcomes for older Māori. Implications for public health: Nutrition risk among older Māori is identifiable and treatable. Effort is needed to engage relevant community and whānau (family) support to ensure older Māori have food security and cultural food practices are met., (© 2018 The Authors.)

Background: Cardiovascular (CV) risk factor profiles of people experiencing acute coronary syndromes (ACS) vary with age, and in New Zealand (NZ), Māori and people of Pacific Island descent typically present with ACS at a younger age. We aimed to explore age- and ethnicity-related differences in CV risk factors in a large NZ cohort with first-time ACS., Methods: The All NZ Acute Coronary Syndrome Quality Improvement program (ANZACS-QI) registry collects comprehensive data for patients admitted with ACS at NZ hospitals. This analysis includes patients with no prior atherosclerotic CV disease enrolled from 1 July, 2012 to 30 June, 2015., Results: 14,190 patients had confirmed ACS, 8493 (60%) patients with no prior CVD comprised the study cohort. The mean age was 64 years, 25% were aged <55years, and 66% were male. Those aged <55years were more likely than older patients to be current smokers (48% vs 19%), have higher body mass index (BMI) (48% vs 34% with BMI≥30kg/m 2 ), and higher total cholesterol:HDL ratios (≥4.0, 70% vs 50%), all p<0.001. Sixteen per cent of those <55years had diabetes; these patients often had a BMI≥30kg/m 2 (67%) and higher median HbA1c than older patients with diabetes (69mmol/mol vs 55mmol/mol). Māori and people of Pacific Island descent were overrepresented in the younger age group; these patients had a very high risk factor burden., Conclusions: A quarter of NZ patients admitted to hospital with a first-time CV disease event are aged <55years. Younger patients have a very high risk factor burden: half are current smokers, half have a BMI≥30kg/m 2 , and 16% have diabetes., (Copyright © 2017 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: multi-morbidity is associated with poor outcomes and increased healthcare utilisation. We aim to identify multi-morbidity patterns and associations with potentially inappropriate prescribing (PIP), subsequent hospitalisation and mortality in octogenarians., Methods: life and Living in Advanced Age; a Cohort Study in New Zealand (LiLACS NZ) examined health outcomes of 421 Māori (indigenous to New Zealand), aged 80-90 and 516 non-Māori, aged 85 years in 2010. Presence of 14 chronic conditions was ascertained from self-report, general practice and hospitalisation records and physical assessments. Agglomerative hierarchical cluster analysis identified clusters of participants with co-existing conditions. Multivariate regression models examined the associations between clusters and PIP, 48-month hospitalisations and mortality., Results: six clusters were identified for Māori and non-Māori, respectively. The associations between clusters and outcomes differed between Māori and non-Māori. In Māori, those in the complex multi-morbidity cluster had the highest prevalence of inappropriately prescribed medications and in cluster 'diabetes' (20% of sample) had higher risk of hospitalisation and mortality at 48-month follow-up. In non-Māori, those in the 'depression-arthritis' (17% of the sample) cluster had both highest prevalence of inappropriate medications and risk of hospitalisation and mortality., Conclusions: in octogenarians, hospitalisation and mortality are better predicted by profiles of clusters of conditions rather than the presence or absence of a specific condition. Further research is required to determine if the cluster approach can be used to target patients to optimise resource allocation and improve outcomes., (© The Author(s) 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background: Atrial fibrillation (AF) is a major risk factor for ischaemic stroke and cardiovascular events. In New Zealand (NZ), Māori (indigenous New Zealanders) and Pacific people experience higher rates of AF compared with non-Māori/non-Pacific people., Aim: To describe a primary care population with AF in NZ. Stroke risk and medication adherence according to ethnicity are also detailed., Methods: Electronic medical records for adults (≥20 years, n = 135 840, including 19 918 Māori and 43 634 Pacific people) enrolled at 37 NZ general practices were analysed for AF diagnosis and associated medication prescription information., Results: The overall prevalence of non-valvular AF (NVAF) in this population was 1.3% (1769), and increased with age (4.4% in people ≥55 years). Māori aged ≥55 years were more likely to be diagnosed with NVAF (7.3%) than Pacific (4.0%) and non-Māori/non-Pacific people (4.1%, P < 0.001). Māori and Pacific NVAF patients were diagnosed with AF 10 years earlier than non-Māori/non-Pacific patients (median age of diagnosis: Māori = 60 years, Pacific = 61 years, non-Māori/non-Pacific = 71 years, P < 0.001). Overall, 67% of NVAF patients were at high risk for stroke (CHA 2 DS 2 -VASc ≥ 2) at the time of AF diagnosis. Almost half (48%) of Māori and Pacific NVAF patients aged <65 years were at high risk for stroke, compared with 22% of non-Māori/non-Pacific (P < 0.001). Irrespective of ethnic group, adherence to AF medication was suboptimal in those NVAF patients with a high risk of stroke or with stroke history., Conclusion: AF screening and stroke thromboprophylaxis in Māori and Pacific people could start below the age of 65 years in NZ., (© 2017 Royal Australasian College of Physicians.)

Background: Cardiac rehabilitation (CR) is an essential component of contemporary management for patients with coronary heart disease, including following an acute coronary syndrome (ACS). CR typically involves education and support to assist people following an ACS to make lifestyle changes and prevent subsequent events. Despite its benefits, uptake and participation in tradition CR programs is low. The use of mobile technologies (mHealth) offers the potential to improve reach, access, and delivery of CR support. We aim to determine the effectiveness and cost-effectiveness of a text-messaging intervention (Text4Heart II) to improve adherence to medication and lifestyle change in addition to usual care in people following an ACS. A second aim is to use the RE-AIM framework to inform the potential implementation of Text4Heart II within health services in New Zealand., Methods: Text4Heart II is a two-arm, parallel, superiority randomized controlled trial conducted in two large metropolitan hospitals in Auckland, New Zealand. Three hundred and thirty participants will be randomized to either a 24-week theory- and evidence-based personalized text message program to support self-management in addition to usual CR, or usual CR alone (control). Outcomes are assessed at 6 and 12 months. The primary outcome is the proportion of participants adhering to medication at 6 months as measured by dispensed records. Secondary outcomes include medication adherence at 12 months, the proportion of participants adhering to self-reported healthy behaviors (physical activity, fruit and vegetable consumption, moderating alcohol intake and smoking status) measured using a composite health behavior score, self-reported medication adherence, cardiovascular risk factors (lipids, blood pressure), readmissions and related hospital events at 6 and 12 months. A cost-effectiveness analysis will also be conducted. Using the RE-AIM framework, we will determine uptake and sustainability of the intervention., Discussion: The Text4Heart II trial will determine the effectiveness of a text-messaging intervention to improve adherence to medication and lifestyle behaviors at both 6 and 12 months. Using the RE-AIM framework this trial will provide much needed data and insight into the potential implementation of Text4Heart II. This trial addresses many limitations/criticisms of previous mHealth trials; it builds on our Text4Heart pilot trial, it is adequately powered, has sufficient duration to elicit behavior change, and the follow-up assessments (6 and 12 months) are long enough to determine the sustained effect of the intervention., Trial Registration: Australian New Zealand Clinical Trials Registry, ID: ACTRN12616000422426 . Registered retrospectively on 1 April 2016.

Background: Understanding end of life preferences amongst the oldest old is crucial to informing appropriate palliative and end of life care internationally. However, little has been reported in the academic literature about the end of life preferences of people in advanced age, particularly the preferences of indigenous older people, including New Zealand Māori., Methods: Data on end of life preferences were gathered from 147 Māori (aged >80 years) and 291 non- Māori aged (>85 years), during three waves of Te Puawaitangi O Nga Tapuwae Kia Ora Tonu, Life and Living in Advanced Age (LiLACs NZ). An interviewer-led questionnaire using standardised tools and including Māori specific subsections was used., Results: The top priority for both Māori and non-Māori participants at end of life was 'not being a burden to my family'. Interestingly, a home death was not a high priority for either group. End of life preferences differed by gender, however these differences were culturally contingent. More female Māori participants wanted spiritual practices at end of life than male Māori participants. More male non-Māori participants wanted to be resuscitated than female non- Māori participants., Conclusions: That a home death was not in the top three end of life priorities for our participants is not consistent with palliative care policy in most developed countries where place of death, and particularly home death, is a central concern. Conversely our participants' top concern - namely not being a burden - has received little research or policy attention. Our results also indicate a need to pay attention to diversity in end of life preferences amongst people of advanced age, as well as the socio-cultural context within which preferences are formulated.

This study explored active aging for older Māori and non-Māori by examining their self-nominated important everyday activities. The project formed part of the first wave of a longitudinal cohort study of aging well in New Zealand. Māori aged 80 to 90 and non-Māori aged 85 were recruited. Of the 937 participants enrolled, 649 answered an open question about their three most important activities. Responses were coded under the World Health Organization's International Classification of Functioning, Disability and Health (ICF), Activities and Participation domains. Data were analyzed by ethnicity and gender for first in importance, and all important activities. Activity preferences for Māori featured gardening, reading, walking, cleaning the home, organized religious activities, sports, extended family relationships, and watching television. Gendered differences were evident with walking and fitness being of primary importance for Māori men, and gardening for Māori women. Somewhat similar, activity preferences for non-Māori featured gardening, reading, and sports. Again, gendered differences showed for non-Māori, with sports being of first importance to men, and reading to women. Factor analysis was used to examine the latent structural fit with the ICF and whether it differed for Māori and non-Māori. For Māori, leisure and household activities, spiritual activities and interpersonal interactions, and communicating with others and doing domestic activities were revealed as underlying structure; compared to self-care, sleep and singing, leisure and work, and domestic activities and learning for non-Māori. These findings reveal fundamental ethnic divergences in preferences for active aging with implications for enabling participation, support provision and community design.

INTRODUCTION Falls and injury have the most devastating consequences for very old people. Depression may be a significant cause and consequence of falls. AIM To examine the association between falls and depression in octogenarians. METHODS LiLACS NZ (Life and Living in Advanced Age: A Cohort Study in New Zealand), cohort study data of Māori (aged 80-90 years, 11-year age band) and non-Māori (aged 85 years, 1-year age band) followed for 3 years was used to describe the incidence and prevalence of falls and depression. Falls by self-report were accumulated over 3 years. Geriatric depression score (GDS) was ascertained at baseline. RESULTS Over 3 years, fewer Māori (47%) than non-Māori (57%) fell; 19% of non-Māori and 20% of Māori scored 5+ (depressed) on the GDS. For non-Māori and Māori, people with depression were more likely to fall than Māori not diagnosed with depression (OR 2.72, CI 1.65-4.48 for non-Māori and OR 2.01, CI 1.25-3.25 for Māori). This remained significant, adjusted for age and sex. Depression was a significant predictor of hospitalisations from falls for Māori (OR 5.59, CI 2.4-12.72, adjusted for age and sex) and non-Māori (OR 4.21, 2.3-7.44, adjusted for sex). CONCLUSION Depression and falls are common and co-exist in octogenarians. GPs thinking about falls should also think about depression and vice versa.

Objectives: Serum testosterone (T) levels in men decline with age. Low T levels are associated with sarcopenia and frailty in men aged > 80 years. T levels have not previously been directly associated with disability in older men. We explored associations between T levels, frailty and disability in a cohort of octogenarian men., Setting: Data from all men from Life and Living in Advanced Age Cohort Study in New Zealand, a longitudinal cohort study in community-dwelling older adults., Participants: Community-dwelling ( > 80 years) adult men excluding those receiving T treatment or with prostatic carcinoma., Outcomes Measures: Associations between baseline total testosterone (TT) and calculated free testosterone (fT), frailty (Fried scale) and disability (Nottingham Extended Activities of Daily Living scale (NEADL)) (baseline and 24 months) were examined using multivariate regression and Wald's χ 2 techniques. Subjects with the lowest quartile of baseline TT and fT values were compared with those in the upper three quartiles., Results: Participants: 243 men, mean (SD) age 83.7 (2.0) years. Mean (SD) TT=17.6 (6.8) nmol/L and fT=225.3 (85.4) pmol/L. On multivariate analyses, lower TT levels were associated with frailty: β=0.41, p=0.017, coefficient of determination (R 2 )=0.10 and disability (NEADL) (β=-1.27, p=0.017, R 2 =0.11), low haemoglobin (β=-7.38, p=0.0016, R 2 =0.05), high fasting glucose (β=0.38, p=0.038, R 2 =0.04) and high C reactive protein (CRP) (β=3.57, p=0.01, R 2 =0.06). Low fT levels were associated with frailty (β=0.39, p=0.024, R 2 =0.09) but not baseline NEADL (β=-1.29, p=0.09, R 2 =0.09). Low fT was associated with low haemoglobin (β=-7.83, p=0.0008, R 2 =0.05) and high CRP (β=2.86, p=0.04, R 2 =0.05). Relationships between baseline TT and fT, and 24-month outcomes of disability and frailty were not significant., Conclusions: In men over 80 years, we confirm an association between T levels and baseline frailty scores. The new finding of association between T levels and disability is potentially relevant to debates on T supplementation in older men, though, as associations were not present at 24 months, further work is needed., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aims: To examine direct and indirect pathways between visual and cognitive function in advanced age., Methods: We analysed cross-sectional baseline data from Life and Living in Advanced Age: A Cohort Study in New Zealand, which recruited equal sample sizes of Māori (n=421) and non-Māori (n=516) octogenarians. The Modified Mini-Mental State Examination assessed cognitive function. Vision was assessed with self-report and measured distance visual acuity. Associations between visual and cognitive function were explored using general linear models and structural equation modelling., Results: Both Māori (mean age 82) and non-Māori (mean age 85) had good visual acuity [Māori: mean (standard deviation) 0.18 (0.20) logMAR; non-Māori 0.20 (0.17) logMAR] and cognitive function scores [Māori: median (interquartile range) 3MS=90 (11), non-Māori: 94 (8)]. Self-reported visual impairment was present almost 25% of the sample. Adjusting for confounders, no direct association was found between visual and cognitive function. For non-Māori, the path diagram showed the association between vision loss, and cognitive function was mediated by functional status., Conclusion: Findings indicate that cognitive function is a multifactorial entity; rather than a direct effect of vision loss, mediating factors appear to contribute to cognitive decline in advanced age., Competing Interests: Nil.

An extensive body of research theorises that attachment to place is positively associated with health, particularly for older people. Building on this, we measure how indicators of attachment to place are associated with health for in people of advanced age in New Zealand. We use data from a cohort study (LiLACS NZ), which includes an indigenous Māori cohort aged 80-90 years and a non-Māori cohort aged 85 years from a mixed urban/rural region in New Zealand. Each cohort undertook a comprehensive interview and health assessment (n = 267 Māori and n = 404 non-Māori). Using multivariate regression analyses, we explore participants' feelings for and connectedness with their home, community and neighbourhood; nature and the outdoors; expectations about and enthusiasm for residential mobility; and how all these are associated with measures of health (e.g., SF-12 physical and mental health related quality of life) and functional status (e.g., NEADL). We demonstrate that people in advanced age hold strong feelings of attachment to place. We also establish some positive associations between attachment to place and health in advanced age, and show how these differ for the indigenous and non-indigenous cohorts. For older Māori there were strong associations between various health measures and the importance of nature and the outdoors, and connectedness to neighbourhood and community. For older non-Māori, there were strong associations between health and liking home and neighbourhood, and feeling connected to their community and neighbourhood. Place attachment, and particularly its relationship to health, operates in different ways for different groups., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

A high prevalence of undernutrition has previously been reported in indigenous Māori (49 %) and non-Māori (38 %) octogenarians and may be associated with risk of micronutrient deficiencies. We examined vitamin and mineral intakes and the contributing food sources among 216 Māori and 362 non-Māori participating in Life and Living to Advanced age a Cohort Study in New Zealand, using a repeat 24-h multiple-pass recall. More than half of the Māori and non-Māori participants had intakes below the estimated average requirement from food alone for Ca, Mg and Se. Vitamin B 6 (Māori women only), folate (women only), vitamin E (Māori women; all men) and Zn (men only) were low in these ethnic and sex subgroups. Women had intakes of higher nutrient density in folate, vitamin C, Ca, Mg, K, vitamin A (non-Māori) and β -carotene (Māori) compared with men ( P <0·05). When controlling for age and physical function, β -carotene, folate, vitamin C, Ca and Mg were no longer significantly different, but vitamins B 2 , B 12 , E and D, Fe, Na, Se and Zn became significantly different for Māori between men and women. When controlling for age and physical function, vitamins A and C and Ca were no longer significantly different, but vitamin B 2 , Fe, Na and Zn became significantly different for non-Māori between men and women. For those who took nutritional supplements, Māori were less likely to be deficient in food alone intake of vitamin A, folate and Mg, whereas non-Maori were less likely to be deficient in intakes of Mg, K and Zn, but more likely to be deficient in vitamin B 12 intake. A lack of harmonisation in nutrient recommendations hinders the interpretation of nutrient adequacy; nonetheless, Ca, Mg and Se are key micronutrients of concern. Milk and cheese were important contributions to Ca intake, whereas bread was a key source of Mg and Se. Examination of dietary intake related to biochemical status and health outcomes will establish the utility of these observations.

As part of the 12-month follow-up of the longitudinal cohort study, Life and Living in Advanced Age: A Cohort Study in New Zealand, dietary intake was assessed in 216 Māori and 362 non-Māori octogenarians using repeat 24-h multiple pass recalls. Energy and macronutrient intakes were calculated, and food items reported were allocated to food groups used in the New Zealand Adult Nutrition Survey (NZANS). Intakes were compared with the nutrient reference values (NRV) for Australia and New Zealand. The median BMI was higher for Māori (28·3 kg/m2) than for non-Māori (26·2 kg/m2) P=0·007. For Māori, median energy intake was 7·44 MJ/d for men and 6·06 MJ/d for women with 16·3 % energy derived from protein, 43·3 % from carbohydrate and 38·5 % from fat. Median energy intake was 7·91 and 6·26 MJ/d for non-Māori men and women, respectively, with 15·4 % of energy derived from protein, 45 % from carbohydrate and 36·7 % from fat. For both ethnic groups, bread was the top contributor to energy and carbohydrate intakes. Protein came from beef and veal, fish and seafood, bread, milk and poultry with the order differing by ethnic groups and sex. Fat came mainly from butter and margarine. Energy-adjusted protein was higher for Māori than non-Māori (P=0·049). For both ethnic groups, the median energy levels were similar, percent carbohydrate tended to be lower and percent fat higher compared with adults aged >70 years in NZANS. These unique cross-sectional data address an important gap in our understanding of dietary intake in this growing section of our population and highlight lack of age-appropriate NRV.

Background: Little is known about the physical activity levels and behaviors of advanced age New Zealanders., Methods: A cross-sectional analysis of data from Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ), Te Puawaitanga O Nga Tapuwae Kia ora Tonu, measures of physical activity (PASE) (n = 664, aged 80-90 [n = 254, Maori, aged 82.5(2), n = 410 non-Maori, aged 85(.5)]) was conducted to determine physical activity level (PAL). A substudy (n = 45) was conducted to attain detailed information about PAL and behaviors via the Multimedia Activity Recall for Children and Adults (MARCA) and accelerometry. The main study was analyzed by sex for Maori and non-Maori., Results: Men consistently had higher levels of physical activity than women for all physical activity measures. Sex was significant for different domains of activity.