IMPORTANCE Diabetes prevention is imperative to slowworldwide growth of diabetes-related morbidity and mortality. Yet the long-term efficacy of prevention strategies remains unknown. OBJECTIVE To estimate aggregate long-term effects of different diabetes prevention strategies on diabetes incidence. DATA SOURCES Systematic searches of MEDLINE, EMBASE, Cochrane Library, andWeb of Science databases. The initial search was conducted on January 14, 2014, and was updated on February 20, 2015. Search terms included prediabetes, primary prevention, and risk reduction. STUDY SELECTION Eligible randomized clinical trials evaluated lifestyle modification (LSM) and medication interventions (>6 months) for diabetes prevention in adults (age ≥18 years) at risk for diabetes, reporting between-group differences in diabetes incidence, published between January 1, 1990, and January 1, 2015. Studies testing alternative therapies and bariatric surgery, as well as those involving participants with gestational diabetes, type 1 or 2 diabetes, and metabolic syndrome, were excluded. DATA EXTRACTION AND SYNTHESIS Reviewers extracted the number of diabetes cases at the end of active intervention in treatment and control groups. Random-effects meta-analyses were used to obtain pooled relative risks (RRs), and reported incidence rates were used to compute pooled risk differences (RDs). MAIN OUTCOMES AND MEASURES The main outcomewas aggregate RRs of diabetes in treatment vs control participants. Treatment subtypes (ie, LSM components, medication classes) were stratified. To estimate sustainability, post-washout and follow-up RRs for medications and LSM interventions, respectively, were examined. RESULTS Forty-three studies were included and pooled in meta-analysis (49 029 participants; mean [SD] age, 57.3 [8.7] years; 48.0% [n = 23 549] men): 19 tested medications; 19 evaluated LSM, and 5 tested combined medications and LSM. At the end of the active intervention (range, 0.5-6.3 years), LSM was associated with an RR reduction of 39% (RR, 0.61; 95% CI, 0.54-0.68), and medications were associated with an RR reduction of 36% (RR, 0.64; 95% CI, 0.54-0.76). The observed RD for LSM and medication studies was 4.0 (95% CI, 1.8-6.3) cases per 100 person-years or a number-needed-to-treat of 25. At the end of the washout or follow-up periods, LSM studies (mean follow-up, 7.2 years; range, 5.7-9.4 years) achieved an RR reduction of 28% (RR, 0.72; 95% CI, 0.60-0.86); medication studies (mean follow-up, 17 weeks; range, 2-52 weeks) showed no sustained RR reduction (RR, 0.95; 95% CI, 0.79-1.14). CONCLUSIONS AND RELEVANCE In adults at risk for diabetes, LSM and medications (weight loss and insulin-sensitizing agents) successfully reduced diabetes incidence. Medication effects were short lived. The LSM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed.

Systematic review (SR) is an essential process to identify, evaluate, and summarize the findings of all relevant individual studies concerning health-related questions. However, conducting a SR is labor-intensive, as identifying relevant studies is a daunting process that entails multiple researchers screening thousands of articles for relevance. In this paper, we propose MMiDaS-AE, a Multi-modal Missing Data aware Stacked Autoencoder, for semi-automating screening for SRs. We use a multi-modal view that exploits three representations, of: 1) documents, 2) topics, and 3) citation networks. Documents that contain similar words will be nearby in the document embedding space. Models can also exploit the relationship between documents and the associated SR MeSH terms to capture article relevancy. Finally, related works will likely share the same citations, and thus closely related articles would, intuitively, be trained to be close to each other in the embedding space. However, using all three learned representations as features directly result in an unwieldy number of parameters. Thus, motivated by recent work on multi-modal auto-encoders, we adopt a multi-modal stacked autoencoder that can learn a shared representation encoding all three representations in a compressed space. However, in practice one or more of these modalities may be missing for an article (e.g., if we cannot recover citation information). Therefore, we propose to learn to impute the shared representation even when specific inputs are missing. We find this new model significantly improves performance on a dataset consisting of 15 SRs compared to existing approaches.

Aims: To develop and pilot test a taxonomy that empirically estimates health intervention effectiveness from efficacy data. Methods: We developed a taxonomy to score health interventions across 11 items on a scale from 0–100. The taxonomy was pilot-tested in efficacy and effectiveness diabetes prevention studies identified in two separate systematic reviews; here, the face validity, inter-rater reliability and factor structure of the taxonomy were established. Random effects meta-analyses were used to obtain weight loss and diabetes incidence pooled effects across studies. These effects and taxonomy scores were used to down calibrate efficacy estimates to effectiveness estimates as follows: Efficacy effect*[Efficacy score/highest possible score]. Results: We scored 82 effectiveness lifestyle modification studies (mean score 49.2), 32 efficacy lifestyle modification studies (mean score 69.8) and 20 efficacy studies testing medications (mean score 77.4). The taxonomy had face validity and good inter-rater reliability (ICC = 0.9 [0.87, 0.93]). The between-groups down calibrated weight loss estimate was similar to that observed in the effectiveness meta-analysis (1.7 and 1.8 kg, respectively). The down calibrated diabetes relative risk reduction was also similar to that observed in the effectiveness meta-analysis (30.6% over 2.7 years and 29% over 2 years, respectively). Conclusions: The taxonomy is a promising tool to estimate the real-world impact of health interventions.

Purpose and Objectives Low- and middle-income countries (LMICs) have a large burden of noncommunicable diseases and confront leadership capacity challenges and gaps in implementation of proven interventions. To address these issues, we designed the Public Health Leadership and Implementation Academy (PH-LEADER) for noncommunicable diseases. The objective of this program evaluation was to assess the quality and effectiveness of PH-LEADER. Intervention Approach PH-LEADER was directed at midcareer public health professionals, researchers, and government public health workers from LMICs who were involved in prevention and control of noncommunicable diseases. The 1-year program focused on building implementation research and leadership capacity to address noncommunicable diseases and included 3 complementary components: a 2-month online preparation period, a 2-week summer course in the United States, and a 9-month, in-country, mentored project. Evaluation Methods Four trainee groups participated from 2013 through 2016. We collected demographic information on all trainees and monitored project and program outputs. Among the 2015 and 2016 trainees, we assessed program satisfaction and pre-post program changes in leadership practices and the perceived competence of trainees for performing implementation research. Results Ninety professionals (mean age 38.8 years; 57% male) from 12 countries were trained over 4 years. Of these trainees, 50% were from India and 29% from Mexico. Trainees developed 53 projects and 9 publications. Among 2015 and 2016 trainees who completed evaluation surveys (n = 46 of 55), we saw pre-post training improvements in the frequency with which they acted as role models (Cohen's d = 0.62, P < .001), inspired a shared vision (d = 0.43, P =.005), challenged current processes (d = 0.60, P < .001), enabled others to act (d = 0.51, P =.001), and encouraged others by recognizing or celebrating their contributions and accomplishments (d = 0.49, P =.002). Through short on-site evaluation forms (scale of 1-10), trainees rated summer course sessions as useful (mean, 7.5; SD = 0.2), with very good content (mean, 8.5; SD = 0.6) and delivered by very good professors (mean, 8.6; SD = 0.6), though they highlighted areas for improvement. Implications for Public Health The PH-LEADER program is a promising strategy to build implementation research and leadership capacity to address noncommunicable diseases in LMICs.

Objective:To assess the performance of an adapted American Diabetes Association (ADA) risk score and the concise Finnish Diabetes Risk Score (FINRISC) for predicting type 2 diabetes development in women with and at risk of HIV infection.Design:Longitudinal analysis of the Women's Interagency HIV Study.Methods:The women's Interagency HIV Study is an ongoing prospective cohort study of women with and at risk for HIV infection. Women without prevalent diabetes and 3-year data on fasting blood glucose, hemoglobin A1c, self-reported diabetes medication use, and self-reported diabetes were included. ADA and FINRISC scores were computed at baseline and their ability to predict diabetes development within 3 years was assessed [sensitivity, specificity and area under the receiver operating characteristics (AUROC) curve].Results:A total of 1111 HIV-positive (median age 41, 60% African American) and 454 HIV-negative women (median age 38, 63% African-American) were included. ADA sensitivity did not differ between HIV-positive (77%) and HIV-negative women (81%), while specificity was better in HIV-negative women (42 vs. 49%, P = 0.006). Overall ADA discrimination was suboptimal in both HIV-positive [AUROC = 0.64 (95% CI: 0.58, 0.70)] and HIV-negative women [AUROC = 0.67 (95% CI: 0.57, 0.77)]. FINRISC sensitivity and specificity did not differ between HIV-positive (72 and 49%, respectively) and HIV-negative women (86 and 52%, respectively). Overall FINRISC discrimination was suboptimal in HIV-positive [AUROC = 0.68 (95% CI: 0.62, 0.75)] and HIV-negative women [AUROC = 0.78 (95% CI: 0.66, 0.90)].Conclusion:Model performance was suboptimal in women with and at risk of HIV, while greater misclassification was generally observed among HIV-positive women. HIV-specific risk factors known to contribute to diabetes risk should be explored in these models.

Importance: Antihypertension medications have been associated with prevention of cardiovascular events, although less is known about the comparative effectiveness of different medication classes. Objective: To compare contemporary aggregated first-in-trial cardiovascular events among patients with hypertension and no substantial comorbidities. Data Sources: The PubMed, Embase, and Cochrane Library databases were systematically searched for articles published between January 1, 1990, and October 24, 2017. Study Selection: Randomized clinical trials that tested commonly used antihypertension medications (angiotensin-converting enzyme inhibitors, dihydropyridine calcium channel blockers, nondihydropyridine calcium channel blockers, β-blockers, angiotensin receptor blockers, and diuretics) and that reported selected cardiovascular outcomes for at least 6 months of follow-up. Data Extraction and Synthesis: The analysis was conducted from October 2017 to December 2019. Two reviewers extracted the number of cardiovascular events at the end of treatment for all study groups. For each outcome, a frequentist network meta-analysis was used to compare risk reductions between medication classes (random-effects models weighted by the inverse variance). The dose-response association between a 10-mm Hg reduction of systolic blood pressure and a 5-mm Hg reduction of diastolic blood pressure and the risk of first-in-trial cardiovascular events was estimated. Main Outcomes and Measures: First-in-trial cardiovascular events, including cardiovascular death, myocardial infarction, stroke, and revascularization. Results: In this systematic review and network meta-analysis, data were pooled from 46 eligible clinical trials (248 887 total participants with a mean [SD] age of 65.6 [5.8] years; 52.8% men). In the network meta-analysis, compared with placebo, angiotensin-converting enzyme inhibitors, dihydropyridine calcium channel blockers, and thiazide diuretics were reported to be similarly effective in reducing overall cardiovascular events (25%), cardiovascular death (20%), and stroke (35%); angiotensin-converting enzyme inhibitors were reported to be the most effective in reducing the risk of myocardial infarction (28%); and diuretics were reported to be the most effective in reducing revascularization (33%). In the metaregression analyses, each 10-mm Hg reduction in systolic blood pressure and 5-mm Hg reduction in diastolic blood pressure was significantly associated with a lower risk of cardiovascular death, stroke, and overall cardiovascular events. Conclusions and Relevance: In this network meta-analysis of clinical trials of patients with hypertension and no substantial comorbidities, different classes of antihypertension medications were associated with similar benefits in reducing cardiovascular events. Future studies should compare the effectiveness of combinations of antihypertension medications in reducing cardiovascular events.

Objectives. Mexico’s 2018 Report Card evaluates the opportunities available for Mexican children and youth to reach healthy levels of physical activity, sleep, and sedentary behavior. Methods. The Report Card is a surveillance system that gathers data from national surveys, censuses, government documents, websites, grey literature, and published studies to evaluate 16 indicators in four categories: Daily Behaviors; Physical Fitness; Settings and Sources of Influence; and Strategies and Investments. Data were compared to established benchmarks. Each indicator was assigned a grade from 1 – 10 (< 6 is a failing grade) or “incomplete” if data was insufficient/unavailable. Results. Daily Behavior grades were: Overall Physical Activity, 4; Organized Sport Participation, 5; Active Play, 3; Active Transportation, 5; Sleep, 7; and Sedentary Behavior, 3. Physical Fitness, received a 7. Settings and Sources of Influence grades were: Family and Peers, incomplete; School, 3; and Community and Environment, 4. Strategies and Investments were: Government Strategies, 6; and Non-Government Organizations, 2. Conclusion. Low grades in 11 of the 16 indicators indicate that schools, families, communities, and government need to work together to improve physical activity opportunities for children and youth in Mexico.

Background: Gains in life expectancy through optimal control of HIV infection with antiretroviral therapy (ART) may be threatened if other comorbidities, such as diabetes, are not optimally managed. Methods: We analyzed cross-sectional data of the Women's Interagency HIV Study (WIHS) from 2001, 2006, and 2015. We estimated the proportions of HIV-positive and HIV-negative women with diabetes who were engaged in care and achieved treatment goals (hemoglobin A1c [A1c] <7.0%, blood pressure [BP] <140/90 mmHg, low-density lipoprotein [LDL] cholesterol <100 mg/dL, not smoking) and viral suppression. Repeated-measures models were used to estimate the adjusted prevalence of achieving each diabetes treatment goal at each time point, by HIV status. Results: We included 486 HIV-positive and 258 HIV-negative women with diabetes. In 2001, 91.8% visited a health care provider, 60.7% achieved the A1c target, 70.5% achieved the BP target, 38.5% achieved the LDL cholesterol target, 49.2% were nonsmokers, 23.3% achieved combined ABC targets (A1c, BP, and cholesterol), and 10.9% met combined ABC targets and did not smoke. There were no differences by HIV status, and patterns were similar in 2006 and 2015. Among HIV-positive women, viral suppression increased from 41% in 2001 to 87% in 2015 compared with 8% and 13% achieving the ABC goals and not smoking. Viral suppression was not associated with achievement of diabetes care goals. Conclusions: Successful management of HIV is outpacing that of diabetes. Future studies are needed to identify factors associated with gaps in the HIV-diabetes care continuum and design interventions to better integrate effective diabetes management into HIV care.

Objective: To estimate the pooled effects of community-based, recreational-level group sports on cardiometabolic risk factors and fitness parameters among adults. Participants and Methods: We systematically searched PubMed, EMBASE, PsychINFO, CINAHL, and Web of Science electronic databases for English-language articles reporting the effectiveness of recreational-level group sports published between January 1, 1965, and January 17, 2017. We extracted baseline and end of intervention means for cardiometabolic and fitness parameters. Random- or fixed-effects meta-analyses were used to obtain pooled before and after change in outcome means within intervention participants and between groups. Results: From 2491 screened titles, 23 publications were included (902 participants; mean ± SD age, 46.6±11.7 years), comprising 21 soccer and 2 rugby interventions. Intervention participants achieved larger improvements (mean [95% CI]) compared with control subjects in weight (−1.44 kg [−1.79 to −1.08 kg]), body mass index (−0.88 kg/m2 [−1.73 to −0.03 kg/m2]), waist circumference (−0.77 cm [−1.21 to −0.33 cm]), body fat (−1.8% [−3.12% to −0.49%]), total cholesterol level (−0.33 mmol/L [−0.53 to −0.13 mmol/L]), low-density lipoprotein cholesterol level (−0.35 mmol/L [−0.54 to −0.15 mmol/L]), systolic blood pressure (−5.71 mm Hg [−7.98 to −3.44 mm Hg]), diastolic blood pressure (−3.36 mm Hg [−4.93 to −1.78 mm Hg]), maximum oxygen consumption (3.93 mL/min per kg [2.96-4.91 mL/min]), and resting heart rate (−5.51 beats/min [−7.37 to −3.66 beats/min]). Most studies (16) were classified as high quality, and we found no evidence of publication bias. Conclusion: We found significant cardiometabolic and fitness improvements following group sport participation, primarily recreational soccer. These findings suggest that group sport interventions are promising strategies for reducing cardiometabolic risk in adults.

Introduction Exercise is Medicine (EIM) is an initiative that seeks to integrate physical activity assessment, prescription, and patient referral as a standard in patient care. Methods to assess this integration have lagged behind its implementation. Purpose and Objectives The purpose of this work is to provide a pragmatic framework to guide health care systems in assessing the implementation and impact of EIM. Evaluation Methods A working group of experts from health care, public health, and implementation science convened to develop an evaluation model based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The working group aimed to provide pragmatic guidance on operationalizing EIM across the different RE-AIM dimensions based on data typically available in health care settings. Results The Reach of EIM can be determined by the number and proportion of patients that were screened for physical inactivity, received brief counseling and/or a physical activity prescription, and were referred to physical activity resources. Effectiveness can be assessed through self-reported changes in physical activity, cardiometabolic biometric factors, incidence/burden of chronic disease, as well as health care utilization and costs. Adoption includes assessing the number and representativeness of health care settings that adopt any component of EIM, and Implementation involves assessing the extent to which health care teams implement EIM in their clinic. Finally, Maintenance involves assessing the long-term effectiveness (patient level) and sustained implementation (clinic level) of EIM in a given health care setting. Implications for Public Health The availability of a standardized, pragmatic, evaluation framework is critical in determining the impact of implementing EIM as a standard of care across health care systems.