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Florian M Karl,1,2 Rolf Holle,1,2 Lars Schwettmann,1 Annette Peters,2,3 Michael Laxy1,2 1Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany; 2German Center for Diabetes Research (DZD), Neuherberg, Germany; 3Institute of Epidemiology II, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany Background: Patient self-management is crucial to prevent complications and mortality in type 2 diabetes. From an economic perspective, time preference predicts short-sighted decision making and thus might help to explain non-adherence to self-anagement recommendations. However, recent studies on this association have shown mixed results. Purpose: In this study, we tested whether the combination of time preference and outcome expectancy can improve the predictions of self-management behavior. Patients and methods: Data from 665 patients with type 2 diabetes were obtained from the cross-sectional KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 study. Time preference and outcome expectancy were measured by one question each, which were answered on a 4-point Likert scale. Their association with six self-managing behaviors was tested in logistic and linear regression analyses. Likewise, we examined the association between self-management and the interaction of outcome expectancy and time preference. Results: A high time preference was associated with a significantly lower sum of self-management behaviors (β=-0.29, 95% CI [-0.54, -0.04]). Higher outcome expectancy was associated with a higher self-management score (β=0.21, 95% CI [-0.03, 0.45]). The interaction model showed that low time preference was only associated with better self-management when combined with a high outcome expectancy (β=0.05, 95% CI [-0.28, 0.39] vs β=0.27, 95% CI [-0.09, 0.63]). Conclusion: Time preference and outcome expectancy are interrelated predictors of patient self-management and could be used to identify and to intervene on patients with a potentially poor self-management. Keywords: behavioral economics, adherence, temporal discounting, health behavior

The article discusses the ARISE-NUTRINT initiative, which aims to improve adolescent and youth health through nutrition fluency in Sub-Saharan Africa. The initiative focuses on addressing the high rates of undernutrition and diet-related obesity in this population, as well as the increased risk of non-communicable diseases. The ARISE-NUTRINT consortium includes partners from Europe, North America, and Sub-Saharan Africa, and will conduct research and interventions in seven countries. The initiative aims to generate evidence on the effectiveness and implementation of community-based interventions and policies to promote healthy diets among adolescents, with the goal of informing decision-making, policy adoption, and practice in reducing the burden of non-communicable diseases. [Extracted from the article]

We examined the association of baseline serum 25-hydroxyvitamin D (25(OH)D) with change in weight and total body fat in a cohort of community-dwelling older adults from Southern Germany. A total of 735 participants of the population-based KORA-Age Study (2009-2012), aged 65-90 years, were followed for 2.9 [+ or -]0.1 years. Body fat was assessed with bioelectrical impedance analysis. Linear and multinomial logistic models, adjusted for baseline covariables, were used to examine the association of 25(OH)D with percentage weight and body fat change during follow-up. 25(OH)D levels were not associated with overall weight change or body fat loss. Higher 25(OH)D levels were associated with a lower likelihood of having gained > 3% of body fat in women but not in men. As we cannot exclude residual confounding by outdoor physical activity and diet, our results are not sufficient to support a causal role of 25(OH)D in the etiology of obesity in Caucasian older adults. doi:10.1038/ejcn.2015.89; published online 22 July 2015, INTRODUCTION In older adults, obesity is associated with severe health consequences. (1) As weight loss, however, is only restrictively recommended to this age group, as it may have adverse effects [...]

Aim: This cross‐sectional study used a large nationwide claims data set to assess the excess medical costs of people with type 2 diabetes according to age group in 2015. Methods: Data from 291 709 people with diabetes and 291 709 age‐ and sex‐matched controls were analysed. Total costs (expressed as 2015 euros) of outpatient and inpatient services, medication, rehabilitation, and the provision of aids and appliances were examined. Overall and age‐stratified excess costs of people with diabetes were estimated using gamma regression with a log‐link. Results: Overall, the estimated total direct costs of a person with type 2 diabetes are approximately double those of a person without diabetes: €4727 vs. €2196, respectively. Absolute excess costs were approximately the same in all age groups (around €2500), however, relative excess costs of persons with diabetes were much higher in younger (~ 334% for < 50 years) than in older age groups (~ 156% for ≥ 80 years). Regional costs, both absolute and excess, partly differed from the national level. Conclusions: This study complements and updates previous studies on the excess medical costs of people with diabetes in Germany. The results indicate the importance of preventing the development of type 2 diabetes, especially in younger age groups. Longitudinal and regional studies examining changes in prevalence and the development of excess costs in groups with different types of diabetes, and according to age, would be of interest to validate our findings and better understand the avoidable burden of having diabetes. What's new?: Overall and complication‐related excess medical costs of people with type 2 diabetes have been examined previously. However, relative excess medical costs according to age group have not been determined.We found that relative excess costs of people with diabetes were much higher in younger (~ 334% for < 50 years) than older age groups (~ 156% for ≥ 80 years), but absolute cost differences were similarly high across all age groups.Thus, prevention and efforts to reverse diabetes in affected persons, especially those in younger age groups who have a longer prospect of generating healthcare costs could be valuable. [ABSTRACT FROM AUTHOR]

Aims: Time needed for health‐related activities in people with diabetes is assumed to be substantial, yet available data are limited. Time spent on self‐management and associated factors was analysed using cross‐sectional data from people with diagnosed diabetes enrolled in a population‐based study. Methods: Mean total time spent on self‐management activities was estimated using a questionnaire for all participants with diagnosed diabetes in the KORA FF4 study (n = 227, 57% men, mean age 69.7, sd 9.9 years). Multiple two‐part regression models were fitted to evaluate associated factors. Multiple imputation was performed to adjust for bias due to missing values. Results: Some 86% of participants reported spending time on self‐management activities during the past week. Over the entire sample, a mean of 149 (sd 241) min/week were spent on self‐management‐activities. People with insulin or oral anti‐hyperglycaemic drug treatment, better diabetes education, HbA1c 48 to < 58 mmol/mol (6.5% to < 7.5%) or lower quality of life, spent more time on self‐management activities. For example, people without anti‐hyperglycaemic medication invested 66 min/week in self‐management, whereas those taking insulin and oral anti‐hyperglycaemic drugs invested 269 min/week (adjusted ratio 4.34, 95% confidence interval 1.85–10.18). Conclusions: Time spent on self‐management activities by people with diabetes was substantial and varied with an individual's characteristics. Because of the small sample size and missing values, the results should be interpreted in an explorative manner. Nevertheless, time needed for self‐management activities should be routinely considered because it may affect diabetes self‐care and quality of life. What's new?: Few studies have analysed time spent on self‐management activities in diabetes. Factors associated with patterns of health‐related activities remain under‐researched.This population‐based study analysed a comprehensive set of self‐management activities in people with diabetes. In our entire sample, an average of 2.5 h/week were spent on self‐management activities. Time investments differed according to diabetes treatment, diabetes education, HbA1c and quality of life.Time needed for self‐management activities should be routinely considered because it may affect diabetes self‐care and quality of life. [ABSTRACT FROM AUTHOR]

Background: The gold standard for evaluating interventions in medicine and health care is the randomized controlled trial (RCT). In practice, however, RCTs may be difficult to conduct because of high costs, ethical aspects, or practical considerations. This is particularly true of studies on the population level, e.g., for the evaluation of health policy measures., Methods: We present a type of study design called the interrupted time series (ITS) and its critical interpretation, with several illustrative examples. This discussion is based on selected methodological publications., Results: ITS are suitable for the assessment of interventions with a clear point of intervention (interruption). They are analyzed with the statistical methods of time-series analysis. One strength of ITS is that they can be used to estimate an immediate effect as well as a gradually developing effect. Under certain assumptions, the findings of an ITS analysis can be interpreted causally. The main assumption underlying an ITS is that the trend after the intervention would have been exactly the same as the trend before the intervention if the intervention had not taken place and all other conditions had remained unchanged. A further assumption is that there should be no differences in the pre- versus postintervention phases in the subjects or other entities being tested (e.g., hospitals) that might affect the measured endpoints (e.g., differences in mean age affecting measured mortality). Moreover, the intervention periods must be properly distinct from one another in order to prevent biased effect estimates. The robustness of the assumptions should also be checked with sensitivity analyses., Conclusion: As long as all sources of bias have been avoided and the findings are both plausible and robust, the effects revealed by ITS can be interpreted as causal. ITS may serve as an alternative method for evaluating intervention effects when an RCT cannot be performed.

Introduction: To examine the long-term health and economic impact of a lifestyle diabetes prevention program in people with high risk of developing type 2 diabetes in Germany., Research Design and Methods: We assessed the lifetime cost-effectiveness of a 2-year pragmatic lifestyle program for preventing type 2 diabetes targeting German adults aged 35-54 and 55-74 years old with hemoglobin A1c (HbA1c) from 6.0% to 6.4%. We used the Centers for Disease Control and Prevention RTI Diabetes Cost-Effectiveness Model to run a simulation on the program effectiveness. We estimated incremental health benefits in quality-adjusted life years (QALYs) and costs using an established simulation model adapted to the German context, from a healthcare system and societal perspective. The cost-effectiveness of the program was measured by incremental cost-effectiveness ratios (ICERs) in cost per QALY. We projected the number of type 2 diabetes cases prevented by participation rate if the program was implemented nationwide., Results: The lifestyle program would result to more QALYs and higher costs. The lifetime ICERs were 14 690€ (35-54 years old) and 14 372€ (55-74 years old) from a healthcare system perspective and cost saving (ICER=-3805€) and cost-effective (ICER=4579€), respectively, from a societal perspective. A total of 10 527 diabetes cases would be prevented over lifetime if the program was offered to all eligible people nationwide and 25% of those would participate in the program., Conclusions: Implementing the lifestyle intervention for people with HbA1c from 6.0% to 6.4% could be a cost-effective at standard willingness to pay level strategy for type 2 diabetes prevention. The intervention in the younger cohort could be cost saving from a societal perspective. The successful implementation of a lifestyle-based diabetes prevention program could be an important component of a successful National Diabetes Strategy in Germany., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: HIV clinical guidelines recommend hypertension detection and management to lower cardiovascular disease risk, but these have not been effectively implemented for people living with HIV (PWH). Addressing this implementation gap requires community-engaged implementation studies focused on addressing implementation barriers specific to the HIV care context., Methods: This protocol describes a type 2 effectiveness-implementation hybrid study conducted in nine primary care clinics in Johannesburg. The study will evaluate the effect of implementation strategies on guideline-recommended blood pressure assessment and management in HIV clinics and the effects of assessment/management on patient blood pressure. A stepped-wedge, cluster randomized study design was used to randomize clinics to the time at which they receive the implementation strategies and patient intervention. The implementation strategies tested include identifying and preparing care champions, changing record systems, conducting ongoing training, providing audit and feedback, and changing the physical structure/equipment. The patient intervention tested includes detection of elevated blood pressure, educational materials, lifestyle modification advice, and medication where needed. Implementation outcomes include adoption, fidelity (co-primary outcome), cost, and maintenance of the blood pressure assessment protocol in participating clinics, while patient outcomes include reach, effectiveness (co-primary outcome), and long-term effects of the intervention on patient blood pressure. These will be assessed via direct observation, study records, staff logs, medical chart reviews, and patient and healthcare worker surveys. To examine effects on the implementation (intervention fidelity) and effectiveness (patient blood pressure changes) co-primary outcomes, we will use the standard Hussey and Hughes model for analysis of stepped-wedge designs which includes fixed effects for both interventions and time periods, and a random effect for sites. Finally, we will examine the costs for the implementation strategies, healthcare worker time, and patient-facing intervention materials, as well as the cost-effectiveness and cost-utility of the intervention using study records, patient surveys, and a time and motion assessment., Discussion: This study will address knowledge gaps around implementation of cardiovascular disease preventive practices in HIV care in South Africa. In doing so, it will provide a dual opportunity to promote evidence-based care in the South African HIV care context and help refine implementation research methods to better serve HIV populations globally., Trial Registration: ClinicalTrials.gov: NCT05846503. Registered on May 6, 2023. https://classic., Clinicaltrials: gov/ct2/show/NCT05846503 ., (© 2024. The Author(s).)

Rising temperatures affect human behavior and risk-taking in several domains. However, it is not yet well understood just how ambient temperature shapes risk attitudes. Using data from the large population-based KORA-Fit study (Cooperative Health Research in the Region of Augsburg) of older people (N=2454), we identify a statistically significant, but very small, positive association between short-term ambient temperature changes and individuals' general willingness to take risks. Health-related risk attitudes, however, show no significant relationship with temperature. These findings support a domain-specific view of risk attitudes, with results remaining consistent for vulnerable individuals with the chronic conditions diabetes, hypertension, and asthma. Overall, our findings suggest that risk attitudes are somewhat stable towards changes in ambient temperature., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)