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| Table 1 Cohort study: Impact of weight changes on the incidence of diabetes mellitus: a Korean nationwide cohort study | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Did the study address a clearly focused issue? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study investigated the impact of weight changes on the prevalence of type-2 diabetes mellitus among 51,405 non-diabetic subjects in Korea. Subjects, who developed type 2 diabetes mellitus are probably male and older, have high blood pressure, low blood sugar, high body mass index, and high levels of cholesterol, frequent and heavy drinkers, current smokers, hyperlipidemic, hypertensive and have a relative or family member with a history of diabetes. Obese subjects had a higher chance of developing type 2 diabetes than their non-obese counterparts. After adjusting to confounding factors, subjects who later became obese or those that remained obese had a high incidence for diabetes. Lowering a subject’s Body Mass Index significantly lowered a patient’s incidence of developing diabetes mellitus particularly in non-obese subjects. However, there lacks a clear and significant association of high Body Mass Indexes with the incidence of diabetes mellitus. Therefore, lowering the Body Mass Index and weight loss is strongly linked to reduced risk of diabetes in obese and non-obese patients, especially in non-obese patients. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the cohort recruited in an acceptable way? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The Korean Government has developed a compulsory national medical insurance cover that insures the medical bills of all Korean residents. Additionally, the Korean National Health Insurance Service has developed universal and comprehensive health coverage in the country. The National Insurance Service has also developed a National Sample Cohort that lists public health records such as medical bills and expenses that health facilities claim from the patient. 1,025,340 subjects were selected to represent the national population for ten years. The patient’s medical life was monitored and recorded. The data collected included medical care institutions consulted, insurance eligibility, medications, heath screening data and medical treatments. The National Health Insurance Service offers regular medical checkups and cancer-screening programs. The National Health Insurance Service offers a chance for insured employees and self-employed people above 40 years to avail themselves and their dependents for a free health checkup at least twice every year. It also offers examinations and checkups for specific cancers at a reduced cost. The selected subjects in the cohort received examinations in 2002, 2004, 2006 and were examined until 2013. Excluding subjects who had diabetes prior to their enrollment in the study, another 51,405 subjects were introduced and monitored until the end of the study. Patients who had developed type-2 diabetes were diagnosed according to the World Health Organization’s International Classification of Diseases or their fasting blood glucose was revealed to exceed 126mg/dl. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the exposure accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The Study did not consider environmental exposure or other social factors in the results. Maybe, the subject’s exposure was not included or considered in the study’s objectives or hypothesis. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the outcome accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study revealed that weight loss significantly lowered the incidence of type-2 diabetes mellitus than weight maintenance. Additionally, a slight decrease in the Body Mass Index of a non-obese patient caused a significant decrease in the probability of developing type-2 diabetes compared to an obese patient. The introduction of the prevalence of type-2 diabetes and the association of change in the patient’s obesity status as a categorical variable, subjects who were actively decreasing their Body Mass Index were considered to significantly lower their probability of developing diabetes when compared to patients who were maintaining a high Body Mass Index. However, subjects who initially had a low Body Mass Index and were increasing their Body Mass Index were considered to have a high diabetes incidence. Ironically, the subjects exhibited a weight gain trend with the aim of inducing the development of type-2 diabetes. However, an evaluation of variations in the Body Mass Indices did not indicate a clear and distinguishable link between an increase in the Body Mass Index and a new incidence of diabetes. Large scale clinical trials have revealed that alterations in the lifestyle targeting weight loss can efficiently reduce the incidence of diabetes especially in subjects with prediabetes. The Finnish Diabetes Prevention Study 3 and U.S. Diabetes Prevention Program revealed a reduction of 58% in almost three years. The follow-ups of the studies confirmed the decreased incidence of diabetes before the end of 20 years. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have the authors identified all important confounding factors? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study revealed contradictory factors such as tobacco smoking among alcohol drinkers, which is common for Asian residents. Ironically, engagement in exercises seemed to raise the incidence of new-onset diabetes. However, the observed relation between new-onset diabetes and exercise was likely to be a result of contradictory bias of obesity, a well-recognized risk factor of diabetes and the presence of a positive relation between physical activity and obesity. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have they take account of the confounding factors in the design and/or analysis? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution Confounding factors have been catered for by excluding them, adopting a restricted analysis and performing a statistical analysis using a SAS version. However the author has not considered the treatment effect which may turn out to be a possible confounding factor. The author has not analyzed the treatment with regards to diabetes. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects complete enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The follow-up of 51,405 participants included after the commencement of the study in 2002 identified 2,749 incidences of diabetes. Follow up of the studies confirmed a decreased incidence of type 2 diabetes of about 40% before the end of 20 years. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects long enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The follow up of the subjects only lasted until the day of discharge from the medical facility as it was the maximum allowable duration. The study has addressed the possibility of secondary effects in its objectives. However, depending on the available resources, a long-term study to follow up on the subjects should be conducted. | ||||||||||
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Table 2 Case Control: Association between depression and diabetes amongst adults in Bangladesh: Hospital–based case–control study | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Did the study address a clearly focused issue? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study’s objective was to carry out an assessment of the effects of the two main non-communicable diseases that are depression and diabetes which in contemporary times have caused significant morbidity and mortality and have become major epidemics. Currently, around 382 million people are diagnosed with diabetes and the number is projected to grow in the next two decades to 592 million as today’s younger population grows older. In 2013, it was estimated by the IDF (international diseases foundation) that the global healthcare spending on diabetes accumulated to 548 billion U.S. dollars and the mortality rate was 5.1 million deaths. Globally, diabetes has been a significant contributor to reduced life quality, imposed enormous economic and social impact on international healthcare systems, and been one of the main causes of premature mortality. By 2030, depression was predicted to become the leading the leading disease and diabetes was predicted to occupy 10th place with 6.3 % and 2.3% respectively of the entire disease burden as a percentage of the whole disability adjusted life years. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the cohort recruited in an acceptable way? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution A team comprising three research assistants, one research officer, and one project research physician who had vast experience in hospital data collection was used to collect the data. The team underwent training for 4 weeks on blood and anthropometric pressure measurements, research ethics, interview skills, study objective and aims, study design, and diabetes epidemiology. A section of the IDF known as the Health Economic Group developed the required research instruments and tools and as per the back-translating and translating WHO standards, translated the required material into Bengali. The pre-testing of the questionnaires was conducted in a similar setting using 25 control subjects and 25 cases in BIRDEM hospital OPD. The field-testing feedback played an essential role in improving the contents and language of the tools and questionnaires. Information that pertained to socio-demographic factors like smoking history, diabetes history of the family, diabetes and depression history, income levels, occupation, education levels, marital status, sex, age, and self-reported complications such as kidney diseases, cardiovascular diseases, hypertension, eye complications and so forth was contained in the questionnaire. In addition, the standard protocol was used in measuring the individual’s waist and hip circumference, height, and weight. Furthermore, the SEM-1 digital blood pressure monitors from the Omron Corporation located in Japan were used to measure the individual’s blood pressure. After every 5 minutes, the researchers recorded two repeated measurements alternating between the left and right hands with the two readings average being considered as the individual’s blood pressure level. As per the JNC 7 guideline, hypertension was defined using a (DBP) ³90 mm Hg diastolic blood pressure and/or a (SBP) ³140 mm Hg systolic blood pressure. Additionally, the BIHS research laboratory was used by the research team tom measure the blood tests on HbA1c. The (PHQ-9) patient health questionnaire that comprised of nine items that utilized a Likert-type 4-point scale that was equipped with scores that ranged from 0-27 and corresponded to the statistical and diagnostic mental disorder manual (DSM-IV) used as a diagnostic criterion in measuring major depressive disorder was used by the research team to measure the individual’s depression levels. In addition, the different depression levels were each assigned a score by the researchers of ³10, 5-9, and 0-4 to correlate to severe, moderate, and mild depression respectively. In primary healthcare, one of the most prevalent depression screening tools is the PHQ-9 and a ³10 cut-off score on its scale points to a 88% specificity and 88% sensitivity to diagnose major depression. A previously evaluated and developed PHQ-9 Bengali depression screening tool version was used by researchers in this study. In the Bangladeshi population, the PHQ-9 cut-off points and the PHQ-9 have been validated and the medical experts consider it to be reliable in diagnosing depression. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the exposure accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution This study reveals how common it is for depression and diabetes to develop together in a single patient and the clinical challenge it poses to medical workers as the outcome of one condition is worsened by the presence of the other. Using the SPSS version 20, a univariate analysis was carried out with the dichotomous outcome being diabetes.
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| Critical appraisal questions | Underline your answer | |||||||||
| Was the outcome accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The research illustrates that depression and Diabetes tend to present together and signify a significant clinical challenge, which is because each condition outcome can be negatively affected by the other. The SPSS version 20 was responsible for the Univariate analysis that was performed with diabetes as the dichotomous outcome variable. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have the authors identified all important confounding factors? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution Confounding factors like ethnicity, sex, and age in the population have all been identified reducing the confounding bias. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have they take account of the confounding factors in the design and/or analysis? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution In the SPSS version 20 univariate analysis, exclusion has been used to control the confounding factors. The matched case-control design is this study’s strength as during the recruitment stage, it controls for the area of residence, sex, and age of the study’s participants. However, one possible confounding factor that was not taken into account by the author was the treatment effect since the author did not carry out an analysis of the treatment of depression and diabetes. Hence, additional research is needed in this vital area. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects complete enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The article does not mention any follow-up | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects long enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution Furthermore, the follow-up subject is not sufficiently addressed. | ||||||||||
| Table 3 RCTs: Relationship between obesity and depression in Korean adults Korea National Health and Nutrition Examination Survey 2014
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| Critical appraisal questions | Underline your answer | |||||||||
| Did the study address a clearly focused issue? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study significance is due to the increase in obesity rates in the country. The increase is leading to a rise in medical complications such as dyslipidemia and hypertension, which are affecting quality of life. The other medical complications resulting from the obesity challenges include depression, which is a common psychiatric disorder. The impact of depression and obesity combined is affecting delivery outcomes, which is due to the high costs involved in the treatment. Besides, the effects also include the rising morbidities and moralities, which are also affecting the young. Other implications of obesity include causing diabetes mellitus and cardiovascular diseases, resulting in reduced quality of life and poorer mental health outcomes. Furthermore, it is crucial that the medical complication is addressed quickly, as it can also lead to death. Hence, all these effects imply that the medical complication has disastrous effects on people’s health outcomes and the general quality of care, which is complicated by the costs involved in treating the disease and the lost economic opportunities of the patients and their families in taking care of the patients | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the cohort recruited in an acceptable way? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The research is critical in contributing to knowledge involving the understanding of obesity effects on health outcomes of individuals, communities and the health care system. The research was essential in investigating the relationship between depression and obesity in south Korean adults, where the data was obtained from a population-based sample of the Korea Health and Nutritional survey (KNHANES) of 2014, which was based through a cross-sectional study. Besides, the researchers utilized the KNHANES is a national based population survey that is conducted to determine Koreans nutritional and health status, which is essential for government planning as it is conducted by the Korea Centers for Disease Control and Prevention. The information is also critical in offering information on emerging trends in the healthcare sector, which is crucial in offering information on how the government and healthcare providers should deal with evolving threats. The researchers utilized the stratified multistage clustered probability approach in sampling, which comprised of the medical examination of the population. It also comprised of the nutritional and behavioral surveys plus a health interview. The study participants were over 19 years, who underwent the medical and health surveys examination. Moreover, the researchers selected 4026 participants out of 7550, with women being represented more at 2334 and men at 1692. Furthermore, the exclusion criteria for the study included those over 70 years and people who did not have their weights and heights measured. The study also excluded those who did not partake in the PHQ-9 survey, with those undergoing treatment for depression and pregnant women also excluded from the study. The inclusion criteria for the study comprised of participants giving their consent for data, with the KCDC Bioethics Committee approving the survey process. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the exposure accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The research notes that the obesity problem is also affecting the younger population, especially those below 40 years. The study also notes that the impact of the disease is that the disease is affecting people in their prime economic years, leading to them being a burden to their country, families and community. The research notes that the problem is most prevalent in urban areas compared to rural areas, which is due to the diets containing more fats. Another contributing factor is the less physical activity involvement of those in the urban areas in comparison to the rural areas. The study notes urban dwellers are more exposed to varying stress inducing environmental factors, which leads to the urban dwellers having more chances of contracting the medical complications. Furthermore, the study findings are crucial in improving the sample representation got from the KNHANES data of persons between 18 and 69 years of age | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the outcome accurately measured to minimize bias? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The researchers investigated the connection between Korea’s depression and obesity through the use of a cross sectional study. The study notes that underweight people tend to have higher risk rates of depression, which is higher than the normal weight group in both women and men. The researchers noted that in their findings that the underweight group is those who have a BMI 30. The study observes that the normal weight group is those with a (BMI 18.5–25), where the overweight group comprises of those with a (BMI 25– 30). Th study results are similar to a trend illustrated by a research by Noh et al 2015 which indicated a U-shaped distribution. Besides, the researchers utilized data by the Korean labor institute in their findings from the Korean Longitudinal Study of Aging done in 2010. The results indicated a noteworthy relationship between Depression symptoms and BMI in 7920 adults of the ages of 50 to 102 years old. The study notes that the groups’ classification utilizing the WHO Asia-Pacific requirements in the underweight group, normal weight group plus and obese group consecutively. The researchers noted that those in the overweight group had the lowest incidence rates of depression, and they also had the lowest CES-D scores. The researchers also note in their study that the underweight participants had in the underweight group tend to display higher depression incidences rates. The study findings indicate that the multivariate analyses shows that the underweight group has a noteworthy positive link with depression due to the OR of 3.34. Besides, the results indicate that the Underweight men had higher chances of depression when compared to underweight women, as they had (OR=5.71) to women’s (OR=2.65). The findings remained so after the adjustment for covariates such as household income, residential area, age, smoking, stress perception, education level, marital status, comorbidities, and alcohol drinking habits. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have the authors identified all important confounding factors? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution Several factors can affect the relationship between obesity and depression such as age, ethic differences and sex. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Have they take account of the confounding factors in the design and/or analysis? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The study used the SAS system, where the confounding factors were controlled for through the exclusion of Multivariate analyses, which also included the Statistical analyses. Furthermore, the researchers established that the impacts of sex among the Baseline features or characteristics. The observations were made in 4026 cases, with women 2334 (58.0%) and men 1692 (42.0%). The typical age for the study was 46.21±13.96, which also included an average BMI of 23.63±3.44. Besides, the study average PHQ-9 score was 2.70±3.60, where the ratio of overweight participants was 26.3%. furthermore, the entire number of cases with PHQ-9 scores >10 was 5.7%, where 7.0% were women and men were 3.9% men and 7.0% women, indicating that women had higher rates of depression | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects complete enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The research did not have long follow-up, as an alternative they have utilized the cross-sectional study as the study design. | ||||||||||
| Critical appraisal questions | Underline your answer | |||||||||
| Was the follow up of subjects long enough? | Yes/No/Unclear | |||||||||
| Evidence: justification, compare and contrasting or/and providing solution The research did not have long follow-up, in its place they utilized cross-sectional research as the study design. | ||||||||||
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