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BACKGROUND: Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior. METHODS: Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant's demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression. RESULTS: Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84). CONCLUSIONS: We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.

BACKGROUND: Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior. METHODS: Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant's demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression. RESULTS: Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84). CONCLUSIONS: We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.

2020 Elsevier GmbH Studies from high income, mostly westernised countries tend to report health benefits from urban green spaces. Generalizability of this evidence for the 125 low and middle-income countries (LMICs) is debatable. This systematic review explored and synthesized the quality of green space-health studies reported from LMICs. Following PRISMA guidelines, 22 studies were found through a systematic search and after applying inclusion criteria by two researchers. Quantitative and qualitative synthesis of these studies included a study quality assessment using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. The 22 studies were conducted in 11 LMICs and mostly of the cross-sectional design. Health outcomes include mental and physical health, wellbeing. Green space and health outcomes were mostly measured by the subjective tool, such as by the perception of the sample population; most reporting green space benefits except the study conducted on a slum population and two studies measured physical health outcomes. Only 14 studies adjusted different moderating variables in the quantitative analysis. Three studies explored mediation analyses and reported physical activity and perceived restorativeness of UGS to be the strongest potential pathways to better health. Lack of adherence to observation study design protocols resulted in the studies to have moderate to low quality. The enquiry on the potential health benefits of green space in LMICs is an important gap in knowledge. The evidence in the LMICs is limited by the quality of the studies. More research, especially longitudinal studies that make use of objective indicators of green space design, utilisation and health indicators in a wider range of LMICs is warranted.

2020 The Author(s). Background: For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time. Methods: Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, 'at risk' alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately. Results: Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57). Conclusions: We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

2020 Putra, Astell-Burt, Cliff, Vella, John and Feng. The plausible role of nearby green space in influencing prosocial behaviour among children and adolescents has been studied recently. However, no review has been conducted of the evidence testing the association between green space and prosocial behaviour. This systematic review addresses this gap among children and adolescents. Within this review, we propose a conceptual framework describing potential pathways linking green space to prosocial behaviour, discuss the direction, magnitude, moderators, and mediators of the association, and develop a narrative synthesis of future study directions. Out of 63 extracted associations from 15 studies, 44 were in the positive or expected direction, of which 18 were reported to be statistically significant (p < 0.05). Overall, the current evidence shows that exposure to green space may potentially increase prosocial behaviour among children and adolescents, with some contingencies (e.g., child's sex and ethnic background). However, the volume and quality of this evidence is not yet sufficient to draw conclusions on causality. Further, heterogeneity in the indicators of green space exposure could lead to mixed findings. In addition, none of the included studies investigated potential mediators. Nevertheless, this review provides preliminary evidence and a basis for further investigation with rigorous study methodology capable of drawing causal inferences and testing potential effect modifiers, linking pathways, and relevant green space measures.

2019 Introduction: To investigate association between urban green space and prevalent and incident cases of insufficient sleep (<6 h sleep per day). Methods: This longitudinal study examined the odds of prevalent and incident insufficient sleep in relation to indicators of total green space, tree canopy, open grass and other low-lying vegetation in the Sax Institute's 45 and Up Study (baseline 2006-2009; follow-up 2012-2015). Association between green space within 1.6 km road distances and insufficient sleep among 38,982 participants living in Sydney, Wollongong or Newcastle were analysed using multilevel logistic regressions adjusted for confounding. Results: Participants with more total green space had lower odds of prevalent insufficient sleep (e.g. ≥30% compared with 0-4% total green space odds ratio (OR) = 0.68, 95% credible interval (95%CI) = 0.53, 0.85). The odds of prevalent insufficient sleep were lower among participants with more tree canopy (e.g. ≥30% compared with 0-9% tree canopy OR = 0.78, 95%CI 0.69, 0.88). The odds of incident insufficient sleep were also lower with more tree canopy (e.g. ≥30% compared with 0-9% tree canopy OR = 0.87, 95%CI = 0.75, 0.99). There were no statistically significant associations between prevalent or incident insufficient sleep with open grass or other low-lying vegetation, nor incident sufficient sleep with total green space. Conclusions: Prioritising restoration and protection of urban tree canopy may help to promote population-wide prevention of insufficient sleep in middle-to-older aged adults.

Not feeling sharp? Finding it hard to concentrate? About 12-19% of adults in Australia regularly don't get enough sleep, defined as less than 5.5-6 hours each night. But who'd have thought the amount of tree cover in their neighbourhood could be a factor? Our latest research has found people with ample nearby green space are much more likely to get enough sleep than people in areas with less greenery. There's plenty of helpful advice online on sleep, of course. Apart from personal routines, many other things can affect our sleep. Aircraft and traffic noise isn't helpful. Other environmental factors at play include temperature, artificial light and air pollution. As a result of these factors and their interactions with others, such as age, occupation and socioeconomic circumstances, the chances of getting a decent night's kip are unevenly distributed across the population. So it is not simply a matter of personal responsibility and choosing to get more sleep.

2020 The Author(s). Background: Chronic, non-communicable diseases are a significant public health priority, requiring action at individual, community and population levels, and public and political will for such action. Exposure to media, including news, entertainment, and advertising media, is likely to influence both individual behaviours, and attitudes towards preventive actions at the population level. In recent years there has been a proliferation of research exploring how chronic diseases and their risk factors are portrayed across various forms of media. This scoping review aims to map the literature in this area to identify key themes, gaps, and opportunities for future research in this area. Methods: We searched three databases (Medline, PsycINFO and Global Health) in July 2016 and identified 499 original research articles meeting inclusion criteria: original research article, published in English, focusing on media representations of chronic disease (including how issues are framed in media, impact or effect of media representations, and factors that influence media representations). We extracted key data from included articles and examined the health topics, media channels and methods of included studies, and synthesised key themes across studies. Results: Our findings show that research on media portrayals of chronic disease increased substantially between 1985 and 2016. Smoking and nutrition were the most frequent health topics, and television and print were the most common forms of media examined, although, as expected, research on online and social media channels has increased in recent years. The majority of studies focused on the amount and type of media coverage, including how issues are framed, typically using content analysis approaches. In comparison, there was much less research on the influences on and consequences of media coverage related to chronic disease, suggesting an important direction for future work. Conclusions: The results highlig

Importance: The American Heart Association (AHA) introduced the Life's Simple 7 (LS7) metrics to assess and promote cardiovascular health. However, several shortcomings of these metrics have been identified. Therefore, a revised set of LS7 metrics was developed. Objectives: To evaluate national trends in the metrics addressed by the revised LS7 and the individual and combined associations of the revised LS7 metrics with all-cause and cause-specific mortality and to compare these measures with the AHA recommended LS7 metrics. Design, Setting, and Participants: This national cross-sectional study used data from the National Health and Nutrition Examination Survey from 1988 to 2016. The revised LS7 metrics included a combination of the body mass index and waist to hip ratio, Healthy Eating Index-2010, and a lower blood pressure threshold of greater than or equal to 130/80 mm Hg in addition to physical activity, smoking, total cholesterol, and fasting blood glucose. Data for this study were analyzed from June 1, 2017, to December 31, 2017. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcome was cancer and cardiovascular disease (CVD) mortality. Results: Data were available for 13 606 adults in 1988 to 1994 (7329 [53%] female; mean [SD] age, 47 [17.7] years), 6360 in 1999 to 2004 (3442 [54%] female; mean [SD] age, 47 [18.6] years), 10 618 in 2005 to 2010 (5428 [51%] female; mean [SD] age, 47 [17.5] years), and 10 773 in 2011 to 2016 (5474 [50%] female; mean [SD] age, 48 [17.4] years). Compared with a revised LS7 score of 0 to 1, the adjusted hazard ratios for a revised LS7 score of 5 to 7 were 0.46 (95% CI, 0.35-0.61) for all-cause mortality, 0.42 (95% CI, 0.25-0.68) for cancer mortality, and 0.37 (95% CI, 0.24-0.55) for CVD mortality, respectively. The adjusted hazard ratios for participants who met 6 or more AHA recommended ideal LS7 metrics were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.60 (95% CI, 0.29-1.25) for ca

Importance: The American Heart Association (AHA) introduced the Life's Simple 7 (LS7) metrics to assess and promote cardiovascular health. However, several shortcomings of these metrics have been identified. Therefore, a revised set of LS7 metrics was developed. Objectives: To evaluate national trends in the metrics addressed by the revised LS7 and the individual and combined associations of the revised LS7 metrics with all-cause and cause-specific mortality and to compare these measures with the AHA recommended LS7 metrics. Design, Setting, and Participants: This national cross-sectional study used data from the National Health and Nutrition Examination Survey from 1988 to 2016. The revised LS7 metrics included a combination of the body mass index and waist to hip ratio, Healthy Eating Index-2010, and a lower blood pressure threshold of greater than or equal to 130/80 mm Hg in addition to physical activity, smoking, total cholesterol, and fasting blood glucose. Data for this study were analyzed from June 1, 2017, to December 31, 2017. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcome was cancer and cardiovascular disease (CVD) mortality. Results: Data were available for 13 606 adults in 1988 to 1994 (7329 [53%] female; mean [SD] age, 47 [17.7] years), 6360 in 1999 to 2004 (3442 [54%] female; mean [SD] age, 47 [18.6] years), 10 618 in 2005 to 2010 (5428 [51%] female; mean [SD] age, 47 [17.5] years), and 10 773 in 2011 to 2016 (5474 [50%] female; mean [SD] age, 48 [17.4] years). Compared with a revised LS7 score of 0 to 1, the adjusted hazard ratios for a revised LS7 score of 5 to 7 were 0.46 (95% CI, 0.35-0.61) for all-cause mortality, 0.42 (95% CI, 0.25-0.68) for cancer mortality, and 0.37 (95% CI, 0.24-0.55) for CVD mortality, respectively. The adjusted hazard ratios for participants who met 6 or more AHA recommended ideal LS7 metrics were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.60 (95% CI, 0.29-1.25) for ca

Importance: Recent studies indicate that living near more green space may support mental and general health and may also prevent depression. However, most studies are cross-sectional, and few have considered whether some types of green space matter more for mental health. Objective: To assess whether total green space or specific types of green space are associated with better mental health. Design, Setting, and Participants: This cohort study included a residentially stable, city-dwelling sample of 46786 participants from Sydney, Wollongong, and Newcastle, Australia, in the baseline of the Sax Institute's 45 and Up Study (data collected from January 1, 2006, to December 31, 2009). Follow-up was conducted from January 1, 2012, to December 31, 2015. Analyses were conducted in January 2019. Exposures: Percentage of total green space, tree canopy, grass, and other low-lying vegetation measured within 1.6-km (1-mile) road network distance buffers around residential addresses at baseline. Main Outcomes and Measures: Three outcome variables were examined at baseline (prevalence) and follow-up (incidence without baseline affirmatives): (1) risk of psychological distress (10-item Kessler Psychological Distress Scale), (2) self-reported physician-diagnosed depression or anxiety, and (3) fair to poor self-rated general health. Results: This study included 46786 participants (mean [SD] age, 61.0 [10.2] years; 25 171 [53.8%] female). At baseline, 5.1% of 37775 reported a high risk of psychological distress, 16.0% of 46786 reported depression or anxiety, and 9.0% of 45577 reported fair to poor self-rated health. An additional 3.3% of 32991 experienced psychological distress incidence, 7.5% of 39277 experienced depression or anxiety incidence, and 7.3% of 40741 experienced fair to poor self-rated health incidence by follow-up (mean [SD] of 6.2 [1.62] years later). Odds ratios (ORs) adjusted for age, sex, income, economic status, couple status, and educational level indicated that

Engagement with nature is an important part of many people's lives, and the health and wellbeing benefits of nature-based activities are becoming increasingly recognised across disciplines from city planning to medicine. Despite this, urbanisation, challenges of modern life and environmental degradation are leading to a reduction in both the quantity and the quality of nature experiences. Nature-based health interventions (NBIs) can facilitate behavioural change through a somewhat structured promotion of nature-based experiences and, in doing so, promote improved physical, mental and social health and wellbeing. We conducted a Delphi expert elicitation process with 19 experts from seven countries (all named authors on this paper) to identify the different forms that such interventions take, the potential health outcomes and the target beneficiaries. In total, 27 NBIs were identified, aiming to prevent illness, promote wellbeing and treat specific physical, mental or social health and wellbeing conditions. These interventions were broadly categorized into those that change the environment in which people live, work, learn, recreate or heal (for example, the provision of gardens in hospitals or parks in cities) and those that change behaviour (for example, engaging people through organized programmes or other activities). We also noted the range of factors (such as socioeconomic variation) that will inevitably influence the extent to which these interventions succeed. We conclude with a call for research to identify the drivers influencing the effectiveness of NBIs in enhancing health and wellbeing.

Background: Postpartum weight gain is a well-known challenge for many mothers, but associations with green space quantity and quality have not been investigated. Methods: This longitudinal study used data on 3843 mothers living in Australia tracked biennially for 15 years post partum from 2004 onwards. Multilevel growth curve models adjusted for confounding were used to examine the patterning of body mass index (BMI) in relation to green space quantity, measured by percentage land use, and green space quality, measured by self-report. Two-way interaction terms were fitted to investigate time-contingent associations between BMI and green space. Results: Compared with mothers in areas with ≤5% green space, adjusted BMI coefficients were -0.43 kg/m2 (SE 0.37), -0.69 kg/m2 (SE 0.32) -0.86 kg/m2 (SE 0.33) and -0.80 kg/m2 (SE 0.41) among mothers in areas with 6%-10%, 11%-20%, 21%-40% and ≥41% green space, respectively. There were no independent associations between BMI and green space quality. Evidence suggested mothers living in areas with 21%-40% green space had the lowest BMI, whether they agreed that local parks were good quality (-0.89 kg/m2 (SE 0.34)) or not (-0.93 kg/m2 (SE 0.35)). Mothers in the greenest areas only had statistically significantly lower BMI if they perceived local parks as high quality (-0.89 kg/m2 (SE 0.41)). There was limited evidence that these associations varied with respect to the number of years post partum. Conclusion: These findings may suggest that urban greening strategies to achieve a threshold of at least 21% or more green space in an area may help reduce, but not fully prevent postpartum weight gain. Potential mechanisms warrant investigation.

Importance: The American Heart Association (AHA) introduced the Life's Simple 7 (LS7) metrics to assess and promote cardiovascular health. However, several shortcomings of these metrics have been identified. Therefore, a revised set of LS7 metrics was developed. Objectives: To evaluate national trends in the metrics addressed by the revised LS7 and the individual and combined associations of the revised LS7 metrics with all-cause and cause-specific mortality and to compare these measures with the AHA recommended LS7 metrics. Design, Setting, and Participants: This national cross-sectional study used data from the National Health and Nutrition Examination Survey from 1988 to 2016. The revised LS7 metrics included a combination of the body mass index and waist to hip ratio, Healthy Eating Index-2010, and a lower blood pressure threshold of greater than or equal to 130/80 mm Hg in addition to physical activity, smoking, total cholesterol, and fasting blood glucose. Data for this study were analyzed from June 1, 2017, to December 31, 2017. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcome was cancer and cardiovascular disease (CVD) mortality. Results: Data were available for 13 606 adults in 1988 to 1994 (7329 [53%] female; mean [SD] age, 47 [17.7] years), 6360 in 1999 to 2004 (3442 [54%] female; mean [SD] age, 47 [18.6] years), 10 618 in 2005 to 2010 (5428 [51%] female; mean [SD] age, 47 [17.5] years), and 10 773 in 2011 to 2016 (5474 [50%] female; mean [SD] age, 48 [17.4] years). Compared with a revised LS7 score of 0 to 1, the adjusted hazard ratios for a revised LS7 score of 5 to 7 were 0.46 (95% CI, 0.35-0.61) for all-cause mortality, 0.42 (95% CI, 0.25-0.68) for cancer mortality, and 0.37 (95% CI, 0.24-0.55) for CVD mortality, respectively. The adjusted hazard ratios for participants who met 6 or more AHA recommended ideal LS7 metrics were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.60 (95% CI, 0.29-1.25) for ca

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. Objectives To investigate potential geographical and socioeconomic patterning of allostatic load (AL) in China. Design Multilevel longitudinal study of the 2010 Chronic Disease Risk Factor Surveillance linked to the National Death Surveillance up to 31 December 2015. Setting All 31 provinces in China, not including Hong Kong, Macao or Taiwan. Participants 96 466 ≥ 18 years old (women=54.3%). Exposures Person-level educational attainment and mean years of education in counties. Outcome AL was measured using clinical guidelines for nine biomarkers: body mass index; waist circumference; systolic blood pressure; diastolic blood pressure; fasting blood glucose; total cholesterol; triglycerides; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol. Results Multilevel logistic regressions adjusted for sex, age, marital status, person-level education, county mean years of education and urban/rural reported ORs of 1.22 (95% CI 1.08 to 1.38) for 5-year all-cause mortality (n=3284) and 1.20 (1.04-1.37) for deaths from non-communicable diseases (n=2891) among people in AL quintile 5 (high) compared with quintile 1 (low). The median rate ratio estimated from unadjusted multilevel negative binomial regression showed AL clustered geographically (province=1.14; county=1.12; town=1.11; village=1.14). After adjusting for aforementioned confounders, AL remained higher with age (rate ratio 1.02, 95% CI 1.02 to 1.02), higher in women compared with men (1.17, 1.15 to 1.19), lower among singletons (0.83, 0.81 to 0.85) and widowers (0.96, 0.94 to 0.98). AL was lower among people with university-level compared with no education (0.92, 0.89 to 0.96), but higher in counties with higher mean education years (1.03, 1.01 to 1.05). A two-way interaction suggested AL was higher (1.04, 1.02 to 1.06) among those with university-level compare

Cities are constantly evolving and so are the living conditions within and between them. Rapid urbanization and the ever-growing need for housing have turned large areas of many cities into concrete landscapes that lack greenery. Green infrastructure can support human health, provide socio-economic and environmental benefits, and bring color to an otherwise grey urban landscape. Sometimes, benefits come with downsides in relation to its impact on air quality and human health, requiring suitable data and guidelines to implement effective greening strategies. Air pollution and human health, as well as green infrastructure and human health, are often studied together. Linking green infrastructure with air quality and human health together is a unique aspect of this article. A holistic understanding of these links is key to enabling policymakers and urban planners to make informed decisions. By critically evaluating the link between green infrastructure and human health via air pollution mitigation, we also discuss if our existing understanding of such interventions is sufficient to inform their uptake in practice. Natural science and epidemiology approach the topic of green infrastructure and human health very differently. The pathways linking health benefits to pollution reduction by urban vegetation remain unclear and the mode of green infrastructure deployment is critical to avoid unintended consequences. Strategic deployment of green infrastructure may reduce downwind pollution exposure. However, the development of bespoke design guidelines is vital to promote and optimize greening benefits, and measuring green infrastructure's socio-economic and health benefits are key for their uptake. Greening cities to mitigate pollution effects is on the rise and these need to be matched by scientific evidence and appropriate guidelines. We conclude that urban vegetation can facilitate broad health benefits, but there is little empirical evidence linking these benefits to air

Importance: The self-perception of weight and weight loss attempts might promote weight loss and maintenance. Objective: To examine trends in current measured body mass index (BMI) and weight, self-reported weight, self-perceived weight status, weight loss attempts, and weight loss strategies among adults in the United States. Design, Setting, and Participants: This national cross-sectional study used data from continuous National Health and Nutrition Examination Survey (NHANES) data sets (1999-2000 to 2015-2016). Participants were US residents older than 20 years. Data were analyzed from January 2018 to December 2018. Main Outcomes and Measures: Current measured BMI and weight, self-reported weight, self-perceived weight status, weight loss attempts, and applied weight loss strategies. Adjusted, self-reported, prior-year weight was calculated using correction equations that considered age, sex, race/ethnicity, and quartile of self-reported prior-year weight. Results: Data were collected from 48 026 participants (19 792 [41.2%] aged 40-64 years; 24 255 [50.5%] women; 21 725 [45.2%] white) through 9 surveys from 1999-2000 to 2015-2016. Increasing trends were observed in current measured BMI (difference, 1.20; 95% CI, 0.92-1.47; P for trend < .001), current measured weight (difference 2.77 kg; 95% CI, 1.92-3.61 kg; P for trend < .001), adjusted, self-reported, prior-year weight (difference, 2.36 kg; 95% CI, 1.52-3.21 kg; P for trend < .001), and the difference between measured and adjusted self-reported weight (difference 0.70 kg; 95% CI, 0.34-1.07 kg; P for trend < .001). During this period, the proportion of overall participants who had attempted to lose weight increased from 34.3% to 42.2% (difference, 8.0%; 95% CI, 4.1%-10.5%; P for trend < .001). The most commonly reported weight loss strategies with the most rapidly increasing prevalence during the study period were reduced food consumption (21.2%-31.9%; difference, 11.1%; 95% CI, 8.2%-13.3%; P for trend < .001)

Importance: The self-perception of weight and weight loss attempts might promote weight loss and maintenance. Objective: To examine trends in current measured body mass index (BMI) and weight, self-reported weight, self-perceived weight status, weight loss attempts, and weight loss strategies among adults in the United States. Design, Setting, and Participants: This national cross-sectional study used data from continuous National Health and Nutrition Examination Survey (NHANES) data sets (1999-2000 to 2015-2016). Participants were US residents older than 20 years. Data were analyzed from January 2018 to December 2018. Main Outcomes and Measures: Current measured BMI and weight, self-reported weight, self-perceived weight status, weight loss attempts, and applied weight loss strategies. Adjusted, self-reported, prior-year weight was calculated using correction equations that considered age, sex, race/ethnicity, and quartile of self-reported prior-year weight. Results: Data were collected from 48 026 participants (19 792 [41.2%] aged 40-64 years; 24 255 [50.5%] women; 21 725 [45.2%] white) through 9 surveys from 1999-2000 to 2015-2016. Increasing trends were observed in current measured BMI (difference, 1.20; 95% CI, 0.92-1.47; P for trend < .001), current measured weight (difference 2.77 kg; 95% CI, 1.92-3.61 kg; P for trend < .001), adjusted, self-reported, prior-year weight (difference, 2.36 kg; 95% CI, 1.52-3.21 kg; P for trend < .001), and the difference between measured and adjusted self-reported weight (difference 0.70 kg; 95% CI, 0.34-1.07 kg; P for trend < .001). During this period, the proportion of overall participants who had attempted to lose weight increased from 34.3% to 42.2% (difference, 8.0%; 95% CI, 4.1%-10.5%; P for trend < .001). The most commonly reported weight loss strategies with the most rapidly increasing prevalence during the study period were reduced food consumption (21.2%-31.9%; difference, 11.1%; 95% CI, 8.2%-13.3%; P for trend < .001)

Importance: The American Heart Association (AHA) introduced the Life's Simple 7 (LS7) metrics to assess and promote cardiovascular health. However, several shortcomings of these metrics have been identified. Therefore, a revised set of LS7 metrics was developed. Objectives: To evaluate national trends in the metrics addressed by the revised LS7 and the individual and combined associations of the revised LS7 metrics with all-cause and cause-specific mortality and to compare these measures with the AHA recommended LS7 metrics. Design, Setting, and Participants: This national cross-sectional study used data from the National Health and Nutrition Examination Survey from 1988 to 2016. The revised LS7 metrics included a combination of the body mass index and waist to hip ratio, Healthy Eating Index-2010, and a lower blood pressure threshold of greater than or equal to 130/80 mm Hg in addition to physical activity, smoking, total cholesterol, and fasting blood glucose. Data for this study were analyzed from June 1, 2017, to December 31, 2017. Main Outcomes and Measures: The primary outcome was all-cause mortality. The secondary outcome was cancer and cardiovascular disease (CVD) mortality. Results: Data were available for 13 606 adults in 1988 to 1994 (7329 [53%] female; mean [SD] age, 47 [17.7] years), 6360 in 1999 to 2004 (3442 [54%] female; mean [SD] age, 47 [18.6] years), 10 618 in 2005 to 2010 (5428 [51%] female; mean [SD] age, 47 [17.5] years), and 10 773 in 2011 to 2016 (5474 [50%] female; mean [SD] age, 48 [17.4] years). Compared with a revised LS7 score of 0 to 1, the adjusted hazard ratios for a revised LS7 score of 5 to 7 were 0.46 (95% CI, 0.35-0.61) for all-cause mortality, 0.42 (95% CI, 0.25-0.68) for cancer mortality, and 0.37 (95% CI, 0.24-0.55) for CVD mortality, respectively. The adjusted hazard ratios for participants who met 6 or more AHA recommended ideal LS7 metrics were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.60 (95% CI, 0.29-1.25) for ca

Increasing tree canopy and green cover across Greater Sydney and increasing the proportion of homes in urban areas within 10 minutes' walk of quality green, open and public space are among the New South Wales premier's new priorities. Cities around Australia have similar goals. In our latest study, we asked if more of any green space will do? Or does the type of green space matter for our mental health?

Importance: Recent studies indicate that living near more green space may support mental and general health and may also prevent depression. However, most studies are cross-sectional, and few have considered whether some types of green space matter more for mental health. Objective: To assess whether total green space or specific types of green space are associated with better mental health. Design, Setting, and Participants: This cohort study included a residentially stable, city-dwelling sample of 46786 participants from Sydney, Wollongong, and Newcastle, Australia, in the baseline of the Sax Institute's 45 and Up Study (data collected from January 1, 2006, to December 31, 2009). Follow-up was conducted from January 1, 2012, to December 31, 2015. Analyses were conducted in January 2019. Exposures: Percentage of total green space, tree canopy, grass, and other low-lying vegetation measured within 1.6-km (1-mile) road network distance buffers around residential addresses at baseline. Main Outcomes and Measures: Three outcome variables were examined at baseline (prevalence) and follow-up (incidence without baseline affirmatives): (1) risk of psychological distress (10-item Kessler Psychological Distress Scale), (2) self-reported physician-diagnosed depression or anxiety, and (3) fair to poor self-rated general health. Results: This study included 46786 participants (mean [SD] age, 61.0 [10.2] years; 25 171 [53.8%] female). At baseline, 5.1% of 37775 reported a high risk of psychological distress, 16.0% of 46786 reported depression or anxiety, and 9.0% of 45577 reported fair to poor self-rated health. An additional 3.3% of 32991 experienced psychological distress incidence, 7.5% of 39277 experienced depression or anxiety incidence, and 7.3% of 40741 experienced fair to poor self-rated health incidence by follow-up (mean [SD] of 6.2 [1.62] years later). Odds ratios (ORs) adjusted for age, sex, income, economic status, couple status, and educational level indicated that

Aims: Examining pre-diabetes and diabetes rates using glycated haemoglobin (HbA 1c ) in emergency department (ED) and in general practice (GP) in western Sydney. Methods: Epidemiological study of HbA1c measurements in individuals ≥18 years receiving a blood test (1) in the hospital setting of the ED at Blacktown/Mt Druitt hospital (1/06/2016 to 31/05/2018) and (2) in primary care involving Bridgeview Medical Practice (BVMP) (1/03/2017 to 01/02/2018) as well as other general practices (June 2018 only). Results: Totals of 55,568 individuals from ED and 5911 individuals from GP. The prevalence of diabetes in tested individuals was 17.3% (n = 9704) in ED and 17.4% (n = 1027) in GP. The prevalence of pre-diabetes in ED was 30.2% (n = 16,854) and 26.6% (n = 1576) in GP. Regression controlling for age, season, and gender revealed a weekly increase of 1.1% in odds for diabetes and 1.5% for pre-diabetes (p < 0.001), in line with the yearly absolute increase of 1% in rate for both tested and coded hospital patients. In BVMP the rate of diabetes rose by 22% during the testing period from 8.9% to 11%. Conclusions: There exists a high burden of diabetes both in hospitals and general practice. Testing in ED and general practice revealed similarly high burdens of diabetes across different areas of the healthcare system. In the appropriate hospital and primary care setting, HbA1c can be used to identify individuals with diabetes that may benefit from targeted intervention.

People who live in regional or remote areas may be at lower risk of developing Alzheimer's disease, according to our recent research. Using data from more 260,000 adults in New South Wales who were aged 45 and over, we found those living in regional or remote areas of the state had a 6% to 19% lower risk of being diagnosed with Alzheimer's disease over 11 years, compared with their city counterparts.

Much of the existing studies on the built environment and type 2 diabetes are cross-sectional and prone to residential self-selection bias. Using multilevel logistic regression analysis of 36,224 participants from a longitudinal study, we examined whether perceived built environment characteristics are associated with type 2 diabetes. We found that the odds of diabetes incidence varied geographically. Those who reported that there were no local amenities and reported day- and night-time crime rates made walking unsafe in the neighbourhood had higher odds of developing incident type 2 diabetes. These associations persisted after accounting for some predictors of residential self-selection. More longitudinal studies are needed to corroborate the findings. Changing the features of the residential built environment may be an important point of intervention for type 2 diabetes prevention.

Poor mental health is strongly associated with disability acquisition. Social capital and healthier lifestyles pre-disability onset may help promote mental health resilience (i.e. a state of seemingly being unaffected by the event), or the capacity to 'bounce back', post-acquisition. This paper used a novel methodology (discrete trajectory mixture models) to examine discrete trajectories in mental health before and after disability acquisition in the Household Income Labour Dynamics in Australia (HILDA) survey. Group membership in association with pre-onset social capital and healthy lifestyles were then examined using multinomial logistic regressions. Four discrete trajectory groups were identified in 2904 Australians reporting onset of ongoing disability, with about 28.4% demonstrating mental health resilience. Three other groups were identified, each demonstrating increasingly severe reductions in mental health. No clear 'bounce back' group was observed. Group membership was associated with participants who felt they had 'no-help from others' prior to disability acquisition. Pre-disability acquisition measures of social capital and unhealthy behaviours moderated the association between disability acquisition and mental health trajectories. Social capital was protective only for the respondents who had poorer mental health before disability onset and had less resilience after onset, and long working hours and less resilience were positively associated. Public policies that help to enhance levels of social capital and reduce unhealthy behaviours at a population level may help to promote mental health resilience to adversities such as the acquisition of disability.

Engagement with nature is an important part of many people's lives, and the health and wellbeing benefits of nature-based activities are becoming increasingly recognised across disciplines from city planning to medicine. Despite this, urbanisation, challenges of modern life and environmental degradation are leading to a reduction in both the quantity and the quality of nature experiences. Nature-based health interventions (NBIs) can facilitate behavioural change through a somewhat structured promotion of nature-based experiences and, in doing so, promote improved physical, mental and social health and wellbeing. We conducted a Delphi expert elicitation process with 19 experts from seven countries (all named authors on this paper) to identify the different forms that such interventions take, the potential health outcomes and the target beneficiaries. In total, 27 NBIs were identified, aiming to prevent illness, promote wellbeing and treat specific physical, mental or social health and wellbeing conditions. These interventions were broadly categorized into those that change the environment in which people live, work, learn, recreate or heal (for example, the provision of gardens in hospitals or parks in cities) and those that change behaviour (for example, engaging people through organized programmes or other activities). We also noted the range of factors (such as socioeconomic variation) that will inevitably influence the extent to which these interventions succeed. We conclude with a call for research to identify the drivers influencing the effectiveness of NBIs in enhancing health and wellbeing.

Much of the existing studies on the built environment and type 2 diabetes are cross-sectional and prone to residential self-selection bias. Using multilevel logistic regression analysis of 36,224 participants from a longitudinal study, we examined whether perceived built environment characteristics are associated with type 2 diabetes. We found that the odds of diabetes incidence varied geographically. Those who reported that there were no local amenities and reported day- and night-time crime rates made walking unsafe in the neighbourhood had higher odds of developing incident type 2 diabetes. These associations persisted after accounting for some predictors of residential self-selection. More longitudinal studies are needed to corroborate the findings. Changing the features of the residential built environment may be an important point of intervention for type 2 diabetes prevention.

Poor mental health is strongly associated with disability acquisition. Social capital and healthier lifestyles pre-disability onset may help promote mental health resilience (i.e. a state of seemingly being unaffected by the event), or the capacity to 'bounce back', post-acquisition. This paper used a novel methodology (discrete trajectory mixture models) to examine discrete trajectories in mental health before and after disability acquisition in the Household Income Labour Dynamics in Australia (HILDA) survey. Group membership in association with pre-onset social capital and healthy lifestyles were then examined using multinomial logistic regressions. Four discrete trajectory groups were identified in 2904 Australians reporting onset of ongoing disability, with about 28.4% demonstrating mental health resilience. Three other groups were identified, each demonstrating increasingly severe reductions in mental health. No clear 'bounce back' group was observed. Group membership was associated with participants who felt they had 'no-help from others' prior to disability acquisition. Pre-disability acquisition measures of social capital and unhealthy behaviours moderated the association between disability acquisition and mental health trajectories. Social capital was protective only for the respondents who had poorer mental health before disability onset and had less resilience after onset, and long working hours and less resilience were positively associated. Public policies that help to enhance levels of social capital and reduce unhealthy behaviours at a population level may help to promote mental health resilience to adversities such as the acquisition of disability.

Background: Postpartum weight gain is a well-known challenge for many mothers, but associations with green space quantity and quality have not been investigated. Methods: This longitudinal study used data on 3843 mothers living in Australia tracked biennially for 15 years post partum from 2004 onwards. Multilevel growth curve models adjusted for confounding were used to examine the patterning of body mass index (BMI) in relation to green space quantity, measured by percentage land use, and green space quality, measured by self-report. Two-way interaction terms were fitted to investigate time-contingent associations between BMI and green space. Results: Compared with mothers in areas with ≤5% green space, adjusted BMI coefficients were -0.43 kg/m2 (SE 0.37), -0.69 kg/m2 (SE 0.32) -0.86 kg/m2 (SE 0.33) and -0.80 kg/m2 (SE 0.41) among mothers in areas with 6%-10%, 11%-20%, 21%-40% and ≥41% green space, respectively. There were no independent associations between BMI and green space quality. Evidence suggested mothers living in areas with 21%-40% green space had the lowest BMI, whether they agreed that local parks were good quality (-0.89 kg/m2 (SE 0.34)) or not (-0.93 kg/m2 (SE 0.35)). Mothers in the greenest areas only had statistically significantly lower BMI if they perceived local parks as high quality (-0.89 kg/m2 (SE 0.41)). There was limited evidence that these associations varied with respect to the number of years post partum. Conclusion: These findings may suggest that urban greening strategies to achieve a threshold of at least 21% or more green space in an area may help reduce, but not fully prevent postpartum weight gain. Potential mechanisms warrant investigation.

Prevalence of end-stage renal disease (ESRD) in the US increased by 74% from 2000 to 2013. To investigate the role of the broader environment on ESRD survival time, we evaluated average distance to the nearest hospital by county (as a surrogate for access to healthcare) and the Environmental Quality Index (EQI), an aggregate measure of ambient environmental quality composed of five domains (air, water, land, built, and sociodemographic), at the county level across the US. Associations between average hospital distance, EQI, and survival time for 1,092,281 people diagnosed with ESRD between 2000 and 2013 (age 18+, without changes in county residence) from the US Renal Data System were evaluated using proportional-hazards models adjusting for gender, race, age at first ESRD service date, BMI, alcohol and tobacco use, and rurality. The models compared the average distance to the nearest hospital (20 miles) and overall EQI percentiles [0-5), [5-20), [20-40), [40-60), [60-80), [80-95), and [95-100], where lower percentiles are interpreted as better EQI. In the full, non-stratified model with both distance and EQI, there was increased survival for patients over 20 miles from a hospital compared to those under 10 miles from a hospital (hazard ratio = 1.14, 95% confidence interval = 1.12-1.15) and no consistent direction of association across EQI strata. In the full model stratified by average hospital distance, under 10 miles from a hospital had increased survival in the worst EQI strata (median survival 3.0 vs. 3.5 years for best vs. worst EQI, respectively), however for people over 20 miles from a hospital, median survival was higher in the best (4.2 years) vs worst (3.4 years) EQI. This association held across different rural/urban categories and age groups. These results demonstrate the importance of considering multiple factors when studying ESRD survival and future efforts should consider additional components of the broader environment.

Background: Few studies have reported the association between greenspace and academic performance at school level. We examined associations between both residential and school greenspace and individual school grades in German adolescents. Methods: German and maths grades from the latest school certificate, residential and school greenspace, and covariates were available for 1351 10 and 15 years old Munich children and 1078 Wesel children from two German birth cohorts - GINIplus and LISA. Residential and school greenspace was assessed by the Normalized Difference Vegetation Index (NDVI), tree cover, and (in Munich only) proportion of agricultural land, forest, and urban green space in 500-m and 1000-m circular buffers. Longitudinal associations between each exposure-outcome pair were assessed by logistic mixed effects models with person and school as random intercepts and adjusted for potential confounders. Results: No associations were observed between any of the greenspace variables and grades in Wesel children. Several statistically significant associations were observed with German and maths grades in Munich children, however associations were inconsistent across sensitivity analyses. Conclusions: There is no evidence of an association of higher greenspace at residence, school or combined with improved academic performance in German adolescents from the GINIplus and LISA longitudinal studies. Higher residential or school greenspace does not appear to improve academic performance in 10- and 15-years old children from two study areas in Germany.

Purpose: The objectives of this study were to determine whether longitudinal changes in accelerometer-assessed moderate-to-vigorous physical activity (MVPA) were associated with changes in educational outcomes (i.e., academic performance and mathematics engagement) and to examine whether the association was nonlinear. Methods: Longitudinal data were collected from 2,194 Australian adolescents (mean age = 13.40 years, standard deviation =.73) at two time points (Term 1, 2014, and Term 2, 2015). To measure the total MVPA, the adolescents wore an accelerometer for seven consecutive days. The participants responded to a questionnaire to measure mathematics engagement and completed a nationally administered numeracy test to assess academic performance. Results: Latent change score models indicated that increases in MVPA had a positive quadratic association with National Assessment Program-Literacy and Numeracy (NAPLAN) scores in girls (β =.39, p < .001) but not boys. In comparison, cross-sectional regression analyses indicated that MVPA had a positive quadratic association with NAPLA N scores in grade 7 (β =.92, p =.04) boys and in grade 9 boys (β =.60, p =.06), but not in girls. There was also a positive quadratic association between MVPA and school engagement in grade 9 boys (β =.77, p =.03). Conclusions: Cross-sectional evidence indicated that boys who were more physically active had better educational outcomes than their less active peers, and girls who increased their regular physical activity showed improvements in academic performance. All students need to increase their physical activity levels for health and educational benefits, without compromising the time spent on study and homework.

A type 2 diabetes (T2DM) diagnosis has been referred to as a "wake-up call" but subsequent behavioural change may be influenced by place of residence. Random effects within-between regressions were applied to 130,926 participants in the 45 and Up Study. T2DM diagnoses effected change in the odds of short sleeps and meeting vegetable and alcohol consumption guidelines, but not changes in physical activity. Each of these behaviours varied geographically and were patterned by area disadvantage and geographic remoteness. Impacts of T2DM diagnosis on behavioural change were not found to be geographically contingent, though analysis of specific environmental attributes is warranted.

Objectives: Hypertension has been the most important risk factor for disease burden in China. We aimed to conduct the first national spatial analysis of hypertension status, awareness, treatment and control in China. Methods: Choropleth maps were used to examine the spatial patterning of hypertension, awareness, treatment and control in a nationally and provincially representative sample of 174389 adults from the 2013 to 2014 China Chronic Disease and Risk Factors Surveillance. Multilevel regressions were used to analyze each outcome across provinces, counties, towns and villages/residential committees and to test the proportion of area-level variances explained by known risk factors. Results: Hypertension prevalence was highest in the north (e.g. Liaoning=37.7%) and lowest in the south (e.g. Hainan=17.9%). Among participants found to have hypertension, awareness was generally low, especially in the south (e.g. Guizhou=18.0%). Receipt of treatment among those who were aware of their hypertension status was above 70% in all provinces except for Tibet (37.7%) and Guizhou (54.5%). Control of hypertension among those receiving treatment (SBP < 140 and DBP < 90mmHg) was generally low, especially in northeastern and southwestern provinces. Adjustment for demographic, socioeconomic and behavioral factors, weight status, healthcare use and urbanization of residence accounted for 57.7% of variation between provinces in hypertension status, 48.5% in awareness, 47.6% in treatment and 18.0% in control. Conclusion: Hypertension is spatially patterned in China and there is an unmet need at each step from diagnosis to receiving treatment and achieving controlled hypertension. Geographically targeted strategies are required to enhance hypertension prevention and management in China.

Objective: To in vestigate potential gender differences in the odds of overweight/obese, weight-related perceptions, and behaviors among Chinese school children. Methods: Height, weight, and a survey of weight-related perceptions and behaviors were measured in a nationally representative survey of 12,811 children in primary schools in China. Logistic regression analyses were used to assess gender differences, adjusting for confounders. Results: Boys had higher odds of being overweight/obese compared to girls within both urban [adjusted odds ratio (OR) 2.30, 95% CI 2.00 to 2.65] and rural areas (OR = 1.85, 95% CI 1.55 to 2.20). Girls reported healthier diets (e.g., daily vegetables OR = 0.79, 95% CI 0.73 to 0.85) whereas boys consumed fried food (OR = 1.21, 95% CI 1.06 to 1.38) and sugar-sweetened drinks more often (OR = 1.49, 95% CI 1.34 to 1.65). Gender differences included higher odds of boys perceiving themselves as overweight if they had more highly educated mothers (OR = 1.35, 95% CI 1.09 to 1.68), less educated fathers (OR = 0.79, 95% CI 0.63 to 0.99), and if they frequently consumed carbonated drinks (OR = 1.48, 95% CI 1.07 to 2.05). Conclusion: Childhood obesity prevention in China should be gender-focused, particularly for boys who reported an unhealthier diet but were less likely to see they were fat, even though more boys were overweight or obese than girls.

A type 2 diabetes (T2DM) diagnosis has been referred to as a "wake-up call" but subsequent behavioural change may be influenced by place of residence. Random effects within-between regressions were applied to 130,926 participants in the 45 and Up Study. T2DM diagnoses effected change in the odds of short sleeps and meeting vegetable and alcohol consumption guidelines, but not changes in physical activity. Each of these behaviours varied geographically and were patterned by area disadvantage and geographic remoteness. Impacts of T2DM diagnosis on behavioural change were not found to be geographically contingent, though analysis of specific environmental attributes is warranted.

Objective: To in vestigate potential gender differences in the odds of overweight/obese, weight-related perceptions, and behaviors among Chinese school children. Methods: Height, weight, and a survey of weight-related perceptions and behaviors were measured in a nationally representative survey of 12,811 children in primary schools in China. Logistic regression analyses were used to assess gender differences, adjusting for confounders. Results: Boys had higher odds of being overweight/obese compared to girls within both urban [adjusted odds ratio (OR) 2.30, 95% CI 2.00 to 2.65] and rural areas (OR = 1.85, 95% CI 1.55 to 2.20). Girls reported healthier diets (e.g., daily vegetables OR = 0.79, 95% CI 0.73 to 0.85) whereas boys consumed fried food (OR = 1.21, 95% CI 1.06 to 1.38) and sugar-sweetened drinks more often (OR = 1.49, 95% CI 1.34 to 1.65). Gender differences included higher odds of boys perceiving themselves as overweight if they had more highly educated mothers (OR = 1.35, 95% CI 1.09 to 1.68), less educated fathers (OR = 0.79, 95% CI 0.63 to 0.99), and if they frequently consumed carbonated drinks (OR = 1.48, 95% CI 1.07 to 2.05). Conclusion: Childhood obesity prevention in China should be gender-focused, particularly for boys who reported an unhealthier diet but were less likely to see they were fat, even though more boys were overweight or obese than girls.

Objectives: Hypertension has been the most important risk factor for disease burden in China. We aimed to conduct the first national spatial analysis of hypertension status, awareness, treatment and control in China. Methods: Choropleth maps were used to examine the spatial patterning of hypertension, awareness, treatment and control in a nationally and provincially representative sample of 174389 adults from the 2013 to 2014 China Chronic Disease and Risk Factors Surveillance. Multilevel regressions were used to analyze each outcome across provinces, counties, towns and villages/residential committees and to test the proportion of area-level variances explained by known risk factors. Results: Hypertension prevalence was highest in the north (e.g. Liaoning=37.7%) and lowest in the south (e.g. Hainan=17.9%). Among participants found to have hypertension, awareness was generally low, especially in the south (e.g. Guizhou=18.0%). Receipt of treatment among those who were aware of their hypertension status was above 70% in all provinces except for Tibet (37.7%) and Guizhou (54.5%). Control of hypertension among those receiving treatment (SBP < 140 and DBP < 90mmHg) was generally low, especially in northeastern and southwestern provinces. Adjustment for demographic, socioeconomic and behavioral factors, weight status, healthcare use and urbanization of residence accounted for 57.7% of variation between provinces in hypertension status, 48.5% in awareness, 47.6% in treatment and 18.0% in control. Conclusion: Hypertension is spatially patterned in China and there is an unmet need at each step from diagnosis to receiving treatment and achieving controlled hypertension. Geographically targeted strategies are required to enhance hypertension prevention and management in China.

A type 2 diabetes (T2DM) diagnosis has been referred to as a "wake-up call" but subsequent behavioural change may be influenced by place of residence. Random effects within-between regressions were applied to 130,926 participants in the 45 and Up Study. T2DM diagnoses effected change in the odds of short sleeps and meeting vegetable and alcohol consumption guidelines, but not changes in physical activity. Each of these behaviours varied geographically and were patterned by area disadvantage and geographic remoteness. Impacts of T2DM diagnosis on behavioural change were not found to be geographically contingent, though analysis of specific environmental attributes is warranted.

Cross-sectional studies of Alzheimer's disease tend to report higher risk in 'rural' areas. Multilevel longitudinal analysis of 261,669 participants in the Sax Institute's 45 and Up Study was conducted, tracking incidence of Alzheimer's disease defined by the first cholinesterase inhibitor prescription via linked records from the Department of Human Services in Australia. Alzheimer's disease was diagnosed in 3046 participants over 11 years. Adjusting for age, gender, education, income and area disadvantage, Alzheimer's disease risk was lower in 'outer regional and remote areas' (incident rate ratio 0.81, 95%CI 0.67-0.97) compared with 'major cities'. Further research on environmental factors is warranted.

A type 2 diabetes (T2DM) diagnosis has been referred to as a "wake-up call" but subsequent behavioural change may be influenced by place of residence. Random effects within-between regressions were applied to 130,926 participants in the 45 and Up Study. T2DM diagnoses effected change in the odds of short sleeps and meeting vegetable and alcohol consumption guidelines, but not changes in physical activity. Each of these behaviours varied geographically and were patterned by area disadvantage and geographic remoteness. Impacts of T2DM diagnosis on behavioural change were not found to be geographically contingent, though analysis of specific environmental attributes is warranted.

Objective: To in vestigate potential gender differences in the odds of overweight/obese, weight-related perceptions, and behaviors among Chinese school children. Methods: Height, weight, and a survey of weight-related perceptions and behaviors were measured in a nationally representative survey of 12,811 children in primary schools in China. Logistic regression analyses were used to assess gender differences, adjusting for confounders. Results: Boys had higher odds of being overweight/obese compared to girls within both urban [adjusted odds ratio (OR) 2.30, 95% CI 2.00 to 2.65] and rural areas (OR = 1.85, 95% CI 1.55 to 2.20). Girls reported healthier diets (e.g., daily vegetables OR = 0.79, 95% CI 0.73 to 0.85) whereas boys consumed fried food (OR = 1.21, 95% CI 1.06 to 1.38) and sugar-sweetened drinks more often (OR = 1.49, 95% CI 1.34 to 1.65). Gender differences included higher odds of boys perceiving themselves as overweight if they had more highly educated mothers (OR = 1.35, 95% CI 1.09 to 1.68), less educated fathers (OR = 0.79, 95% CI 0.63 to 0.99), and if they frequently consumed carbonated drinks (OR = 1.48, 95% CI 1.07 to 2.05). Conclusion: Childhood obesity prevention in China should be gender-focused, particularly for boys who reported an unhealthier diet but were less likely to see they were fat, even though more boys were overweight or obese than girls.

Objectives: Hypertension has been the most important risk factor for disease burden in China. We aimed to conduct the first national spatial analysis of hypertension status, awareness, treatment and control in China. Methods: Choropleth maps were used to examine the spatial patterning of hypertension, awareness, treatment and control in a nationally and provincially representative sample of 174389 adults from the 2013 to 2014 China Chronic Disease and Risk Factors Surveillance. Multilevel regressions were used to analyze each outcome across provinces, counties, towns and villages/residential committees and to test the proportion of area-level variances explained by known risk factors. Results: Hypertension prevalence was highest in the north (e.g. Liaoning=37.7%) and lowest in the south (e.g. Hainan=17.9%). Among participants found to have hypertension, awareness was generally low, especially in the south (e.g. Guizhou=18.0%). Receipt of treatment among those who were aware of their hypertension status was above 70% in all provinces except for Tibet (37.7%) and Guizhou (54.5%). Control of hypertension among those receiving treatment (SBP < 140 and DBP < 90mmHg) was generally low, especially in northeastern and southwestern provinces. Adjustment for demographic, socioeconomic and behavioral factors, weight status, healthcare use and urbanization of residence accounted for 57.7% of variation between provinces in hypertension status, 48.5% in awareness, 47.6% in treatment and 18.0% in control. Conclusion: Hypertension is spatially patterned in China and there is an unmet need at each step from diagnosis to receiving treatment and achieving controlled hypertension. Geographically targeted strategies are required to enhance hypertension prevention and management in China.

How can we communicate to the public that population level health interventions are effective at improving health? Perhaps the most familiar "currency" of effect is that which can be brought about via medication. Comparisons of effect sizes may be effective ways of communicating the benefits of population health interventions if they are seen and understood in the same way that medications are. We developed a series of comparisons to communicate benefits of population health interventions in terms of similar gains to be obtained from statins, metformin and antihypertensive medications for prevention of cardiovascular events, type 2 diabetes, obesity and hypertension. A purposive search identified evidence of population health intervention-related benefits. This evidence ranged from meta-analyses of RCTs to that from observational cohort studies. Population health interventions included implementation of national smoke free legislation, enhanced neighbourhood walkability, increased opportunities for active travel and protection of urban green space. In some cases, the benefits of population health interventions were found to be equivalent to, or even outweighed those of the medications to which they were compared. For example, RCT-based evidence suggested that exercise taken with a view of a green space was associated with 12 mmHg and 6 mmHg reductions in systolic and diastolic blood pressure, respectively, which was at least on par with the reductions associated with antihypertensive medications. Future work will test the effectiveness of these comparisons for increasing the familiarity, credibility and acceptability of population health interventions and, in particular, examine the importance of communicating putative mechanisms and potential co-benefits.

Purpose: Type 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes. Design/methodology/approach: The authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff. Findings: The authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs. Originality/value: This paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.

Background: Evidence of increased type 2 diabetes (T2D) risk associated with potatoes consumption is equivocal. We aimed to perform a meta-analyses on the association between potatoes consumption and T2D risk in prospective cohort studies. Methods: Studies published prior to 31 Aug 2016 were identified in PubMed, EMBASE, and Web of Science. Pooled relative risks (RR) and 95% confidence intervals (95%CI) based upon the highest vs. lowest category of potatoes consumption in each study were calculated in meta-analysis using random-effects models. Dose-response meta-analysis was fitted using generalized least squares regression in order to quantify the association between potatoes consumption and T2D risk. Results: The pooled RR comparing the highest vs. lowest category of potato consumption was 1.077 (95%CI: 1.005, 1.155). Dose-response meta-analysis revealed T2D risk increased 3.5% (RR=1.035, 95% CI: 1.004-1.067) for additional three serving per week serving of potato. The pooled RR comparing the highest vs. lowest category of French fries consumption was 1.362 (95%CI: 1.004, 1.850). Dose-response meta-analysis indicated T2D risk increased 18.7% (RR = 1.187, 95% CI: 1.067-1.321) for additional three serving per week of French fries. Conclusion: This meta-analysis support a significant positive association between high potatoes consumption and risk of T2D, especially the consumption of French fries.

Few studies have focused on clustering of unhealthy lifestyle behaviours among primary school children and potential associations with perceived and actual weight status. An index was constructed from adding up 13 unhealthy behaviours measured by survey responses. Multilevel linear regressions were used to analyse associations between child personal characteristics, perceived and actual weight status with the unhealthy lifestyle index among 11,157 children in primary schools across China. Parental and area factors were also taken into account, including education, weight status, physical activity, urban/rural and area socioeconomic circumstances. The unhealthy lifestyle index normally distributed, with 84.5% of children reporting between 2 and 6 unhealthy behaviours. Boys reported more unhealthy behaviours compared with girls (coefficient 0.32, 95%CI 0.26 to 0.37) and children in urban areas had fewer unhealthy behaviours than their rural counterparts (−0.29, 95%CI −0.56 to −0.03). An interaction revealed stronger 'protective' effects of living in cities for girls than boys, which were not explained by differences in child overweight/obesity. More unhealthy behaviours were characteristic of children in more affluent areas, and of those born to mothers and/or fathers with lower educational attainment. Children who perceived themselves as overweight or underweight both scored higher on the unhealthy lifestyle index. Unhealthy behaviours that could increase the risk of childhood obesity are common among Chinese primary school children, particularly among boys in cities, those in more affluent areas and with parents with lower education. There was no effect of actual weight status on number of unhealthy behaviours. Perceived, but not actual weight status, was also a significant correlate of unhealthy behaviours. Clustering of unhealthy lifestyle behaviours that could increase the risk of childhood obesity are common among Chinese primary school children, particularly am

How can we communicate to the public that population level health interventions are effective at improving health? Perhaps the most familiar "currency" of effect is that which can be brought about via medication. Comparisons of effect sizes may be effective ways of communicating the benefits of population health interventions if they are seen and understood in the same way that medications are. We developed a series of comparisons to communicate benefits of population health interventions in terms of similar gains to be obtained from statins, metformin and antihypertensive medications for prevention of cardiovascular events, type 2 diabetes, obesity and hypertension. A purposive search identified evidence of population health intervention-related benefits. This evidence ranged from meta-analyses of RCTs to that from observational cohort studies. Population health interventions included implementation of national smoke free legislation, enhanced neighbourhood walkability, increased opportunities for active travel and protection of urban green space. In some cases, the benefits of population health interventions were found to be equivalent to, or even outweighed those of the medications to which they were compared. For example, RCT-based evidence suggested that exercise taken with a view of a green space was associated with 12 mmHg and 6 mmHg reductions in systolic and diastolic blood pressure, respectively, which was at least on par with the reductions associated with antihypertensive medications. Future work will test the effectiveness of these comparisons for increasing the familiarity, credibility and acceptability of population health interventions and, in particular, examine the importance of communicating putative mechanisms and potential co-benefits.

Cross-sectional studies of Alzheimer's disease tend to report higher risk in 'rural' areas. Multilevel longitudinal analysis of 261,669 participants in the Sax Institute's 45 and Up Study was conducted, tracking incidence of Alzheimer's disease defined by the first cholinesterase inhibitor prescription via linked records from the Department of Human Services in Australia. Alzheimer's disease was diagnosed in 3046 participants over 11 years. Adjusting for age, gender, education, income and area disadvantage, Alzheimer's disease risk was lower in 'outer regional and remote areas' (incident rate ratio 0.81, 95%CI 0.67-0.97) compared with 'major cities'. Further research on environmental factors is warranted.

Background: Experiments and large-scale epidemiological studies indicate the importance of green space for mental health. However, little research has been conducted to elucidate whether these mental health benefits are more dependent upon the quantity or quality of the green space. Methods: Symptoms of psychological distress were measured in 3897 women who did not change neighbourhood up to 15 years postpartum using the Kessler 6 psychological distress scale from 2004 onwards. The percentage land-use of the neighbourhood was used to ascertain a measure of green space quantity. A Likert scale was used to measure green space quality in response to the statement "there are good parks, playgrounds and play spaces in this neighbourhood." Multilevel negative binomial growth curve regression models were used to examine the patterning of symptoms of psychological distress across the postpartum period in relation to green space quantity and quality, adjusting for person-level and geographical markers of confounding. The same variables were also fitted in multilevel logistic regressions to examine the odds of reporting serious mental illness (as defined by K6 scores ≥ 13 out of 24). Results: Symptoms of psychological distress were fewer among women who agreed (rate ratio (RR) 0.95, 95%CI 0.91 to 0.98) and strongly agreed (RR 0.89, 95%CI 0.85 to 0.93) local parks were good quality. The odds of reporting serious mental illness were also lower among women who agreed (odds ratio (OR) 0.88, 95%CI 0.77 to 1.00) and strongly agreed (OR 0.74, 95%CI 0.64 to 0.86) local parks were good quality. No association was found between green space quantity and symptoms of psychological distress or the odds of reporting serious mental illness. Conclusions: This study suggests it may be how mothers perceive green space nearby and what those spaces enable them to do, rather than simply how much there is overall, that is important for promoting mental health in the postpartum period. In conclusion