Journal club critical appraisal White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries.pptx
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This study aimed to examine the association between white rice consumption and risk of diabetes. The study included 132,373 individuals from 21 countries who were followed for 9.5 years on average. Higher white rice intake of 450g/day or more was associated with a 20% increased risk of diabetes compared to less than 150g/day. The highest risk was seen in South Asia, where rice intake was linked to a 61% greater risk. In China, no significant association was found between rice consumption and diabetes. While this large prospective study across many countries found a link between high white rice intake and diabetes, limitations include lack of accounting for dietary changes over time and residual confounding from unmeasured factors.
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Diabetes mellitus is a major global public health problem. The rise in global prevalence is expected to reach 5.4% or 300 million worldwide by 2025, with developed countries carrying a larger burden (1). Malaysia is not spared from this phenomena, with an alarming rise in prevalence of Type 2 diabetes mellitus (T2DM) over the past fifteen years, from 8.3% (NHMS 1, 1996) to 20.8% (NHMS IV, 2011) (2). What is most worrying is the figure for undiagnosed diabetics, which recorded almost a ten-fold increase (from 1.8% to 10.1%) within the same period. The national economic burden for provision of ambulatory or outpatient care for diabetes patients alone was estimated to cost the Ministry of Health RM 836 million, which took up 2.2% of the nation’s total health expenditure for 2009 (3). The average provider cost per outpatient visit for diabetes treatment at primary care was RM393.24, compared to RM 2707.44 at Specialist diabetic clinics. Treatment at primary care health centres was also highly cost effective compared to Specialist diabetic clinics (4). Due to the chronic nature of the disease, its many related complications and the progress in medical expertise, the costs to provide health care for the this group can only be expected to escalate in years to come. Strategies to effectively treat the chronic diseases (i.e. NCDs and T2DM) have been in place since the 1990s, however, the National Strategic Planning for Non-Communicable Diseases, (NSPNCD)(5) recommends that efforts should be channeled towards primary prevention, early NCD risk factor identification and NCD risk factor intervention or “clinical preventive services”. The clinical preventive services however, need to be emphasised, as early preventive measures can reduce long-term complications and morbidity related to diabetes. The risk factors which should trigger clinicians to provide clinical preventive measures include: obesity, sedentary lifestyles, dietary indiscretions, elderly (for late onset diabetes, pancreas insufficiency), family history of diabetes (risk in offspring of one diabetic parent: 30%, both parents: 60%). The 10th Malaysian Plan : Country Health Plan aims to restructure the national healthcare financing and healthcare delivery system to ensure universal health coverage of healthcare services to be provided at minimal cost using the existing infrastructure in delivering continuity of care across programmes, across healthcare settings and across healthcare providers (6). To reduce the fragmentation of care which commonly occurs in most NCD programmes, there is a need to involve healthcare providers within the healthcare service to be orientated in their roles and contribution in providing a seamless long-term care programme. It is hoped that this effort will benefit not only the patients but also provide relevant feedback on quality of healthcare service provision by the stakeholders. The current public health centre set up which combines Outpatient Primary Care
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1. The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention aimed at 7% weight loss was more effective than metformin or placebo at preventing diabetes in patients with prediabetes over 3 years, with a 58% reduction in relative risk.
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Journal club critical appraisal White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries.pptx
- 1. Journal club (prognosis paper) Presented by Abdulaziz Bagasi R4 Family Medicine NGH-Jeddah Supervised by Dr.Faisal Algawos November 2020
- 2. 2
- 3. 3 3 Objectives • Why this study ? • PICO • Study overview • Critical appraisal • Conclusion
- 4. 4 Why this study ? 4
- 5. 5 5
- 6. 6 PICO P: Population 132,373 individuals aged 35–70 years from 21 countries I : Intervention White rice consumption 450 g/day or more C : Comparison White rice consumption less than 150 g/day O : Outcome Incidence of diabetes after 9.5 years follow up
- 8. 8 Study overview Methodology • 132.373 individuals from 21 countries • (Argentina, Bangladesh, Brazil, Canada, Chile, China, Colombia, India, Iran, Malaysia, occupied Palestine territory, Pakistan, Philippines, Poland, South Africa, Saudi Arabia, Sweden, Tanzania, Turkey, United Arab Emirates, and Zimbabwe) • Using standardized questionnaires • White rice consumption was categorized as • <150 g/day • 150 to <300 g/day • 300 to <450 g/day • 450 g/day or more
- 9. 9 Result • The mean follow-up period was 9.5 years • 6,129 individuals without baseline diabetes developed incident diabetes. • Higher intake of white rice (<450 g/day compared with <150 g/day) was associated with increased risk of diabetes • The highest risk was seen in South Asia followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) • In China there was no significant association
- 10. 10
- 11. 11 Validity Result Applicability Critical appraisal
- 12. 12 Validity 1 12 • Representative sample
- 13. 13 Validity 2 13 • Follow up sufficient (mean 9.5 years) but no in information about drop out (Not complete) !
- 14. 14 Validity 3 14 • The primary outcome is clear which is the incidence of DM. • It is objective ,not blinded
- 15. 15 Validity 4 15
- 16. 16 Result 1 16
- 17. 17 • The HR is a comparison between the probability of events in a treatment group, compared to the probability of events in a control group. • It’s used to see if patients receiving a treatment progress faster (or slower) than those not receiving treatment. • The hazard ratio, which can be defined as the relative risk of an event happening at time
- 18. 18 • In the overall cohort, higher intake of white rice was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02–1.40) • The highest risk was seen in South Asia (HR 1.61; 95% CI 1.13–2.30) • Other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08–1.86) • In China there was no significant association (HR 1.04; 95% CI 0.77–1.40) • In the overall Higher intake of rice is relatively increasing the incidence of DM by 20% CI (2%-40%), acceptable (The narrower the CI the more precise the HR) • In the South Asia Higher intake of rice is relatively increasing the incidence of DM by 61% CI (13%-130%), wide • Other regions Higher intake of rice is relatively increasing the incidence of DM by 41% • In China Higher intake of rice is relatively increasing the incidence of DM by 4%
- 20. 20 ADA 2020 20
- 22. 22 Summary of Critical appraisal Applicability Result Validity 22
- 23. 23 Strengths of the study 1. The largest prospective study on rice and incident diabetes, and it covers 21 countries from five continents. 2. Several potential confounders have been included in the multivariable analysis. 3. A fairly long period of follow-up. 23
- 24. 24 Weaknesses/Limitations of the study 1. Measurement of diet was done only at baseline and changes in diet and other lifestyle factors could have subsequently occurred. 2. Residual confounding due to unmeasured dietary factors, such as alcohol use, or the newly emerging risk factors like air pollution or use of pesticides cannot be completely ruled out. 3. The majority of the participants in the study (97.3%) were tested for diabetes using fasting blood glucose due to the costs. Glucose tolerance tests or A1C tests in all participants could not be done. 4. Information on different types of white rice would have further enhanced the results of this study. 5. Drop out not mentioned in the study. 6. Study design and methods of the participants not clear and not available. 24
- 25. 25 Conclusion 25
- 26. 26 Thank you !