Musculoskeletal (MSK) conditions are common and the biggest global cause of physical disability. The objective of the current study was to estimate the population prevalence of MSK-related pain using a standardized global MSK survey module for the first time.A MSK survey module was constructed by the Global Alliance for Musculoskeletal Health Surveillance Taskforce and the Global Burden of Disease MSK Expert Group. The MSK module was included in the 2015 Solomon Islands Demographic and Health Survey. The sampling design was a two-stage stratified, nationally representative sample of households.A total of 9214 participants aged 15–49 years were included in the analysis. The age-standardized four-week prevalence of activity-limiting low back pain, neck pain, and hip and/or knee pain was 16.8, 8.9, and 10.8%, respectively. Prevalence tended to increase with age, and be higher in those with lower levels of education.Prevalence of activity-limited pain was high in all measured MSK sites. This indicates an important public health issue for the Solomon Islands that needs to be addressed. Efforts should be underpinned by integration with strategies for other non-communicable diseases, aging, disability, and rehabilitation, and with other sectors such as social services, education, industry, and agriculture. Primary prevention strategies and strategies aimed at self-management are likely to have the greatest and most cost-effective impact.The online version of this article (10.1186/s12891-018-2198-0) contains supplementary material, which is available to authorized users. Musculoskeletal (MSK) conditions are common and the biggest global cause of physical disability . A serieMany other health conditions causing a large global burden of disease have standard surveys and/or survey modules for estimating population-wide prevalence. For example, for mental health, there is the World Mental Health Survey , and theThe Solomon Islands is a nation that sits in the Pacific region. Like many areas of the world, there is very limited information on MSK pain in the Pacific . The objThe Solomon Islands is a low-income country and is part of the Melanesian group of islands. It consists of nearly 1000 islands and has a tropical climate. English is the official language, but Pidgin is also widely used. Most of the country’s labor force is engaged in subsistence crop and animal raising, hunting and fishing. In 2016, the population was estimated to be approximately 640,000 with approximately 80% living in rural areas. In 2009, life expectancy at birth was estimated to be 66 years for males and 73 years for females. While infectious diseases continue to be prominent in the Solomon Islands, non-communicable diseases (NCDs) are also rapidly increasing due largely to changing lifestyles .The GMUSC MSK survey module was included in the 2015 Solomon Islands Demographic and Health Survey (SIDHS). The Global Demographic and Health Survey (DHS) Program has conducted the DHS more than 300 times in over 90 countries. It selects nationally-representative samples to study fertility, family planning, maternal and child health, gender, HIV/AIDS, malaria, and nutrition . The SIDThe SIDHS was coordinated by the Solomon Islands National Statistics Office (SINSO) with assistance from the Pacific Community (SPC). Training for conducting the survey was conducted at three levels according to standard DHS training procedures: 1) Training of trainers; 2) Pilot training; and 3) Main training. Training of trainers included training of those who would lead subsequent trainings, as well as testing of the questionnaires for content, translation, skip procedures and filtering instructions. The pilot training of fieldworkers was provided to 70 field workers from five provinces and was also another opportunity to further test the questionnaires. The field workers consisted of SINSO staff, nurses, health technicians, and trained interviewers. All the field workers could read, speak and understand Pidgen, and most, but not all, were literate in English. The main training took 3 weeks and included 145 field workers. It included presentations, mock interviews, quizzes and role-playing. Data were collected by 14 teams, each of nine people. Data collection initially ran from April to September 2015, and a follow-up period ran from October to November 2015 to revisit those people who were not available to respond to the survey at their initial visit. This was limited to the capital, Honiara, as this was the site where the majority of non-responders lived.The sampling design was a two-stage stratified, nationally-representative sample of households. In the Solomon Islands, enumeration areas (EAs) are at the sub-village level and are considered by the SINSO to be the smallest geographical unit. The average size of an EA is 68 households. There are a total of 1342 EAs and 91,251 households in the Solomon Islands . A targeThe sampling frame was a list of all EAs and their respective number of households. From this list, 211 EAs were selected using sampling with probability proportional to the estimated number of households in the EA. In each of the selected EAs, 24 households were selected using systematic random sampling. Consistent with standard DHS protocol, which has a focus on women’s reproductive health, all women aged 15–49 in these households were eligible to be individually interviewed, while men aged 15 and over in every second household were eligible to be interviewed. For this reason, women aged 50 years and over were not sampled.Three questionnaires  were used . All conThe MSK survey module was constructed by the GMUSC Surveillance Taskforce and members of the GBD MSK Expert Group. The intention was to develop a one-page module that would not necessarily be used as a stand-alone tool, but rather as a component that could seamlessly integrate within other pre-existing and planned surveys such as national health surveys, or in this case, the DHS. Such purposive integration would likely increase its uptake, save resources, minimise survey burden from conducting multiple surveys on local communities, provide access to a larger range of covariates, and encourage responses that are integrated with other NCDs and other health issues such as healthy aging, and disability, rather than having ‘siloed’ MSK responses.The MSK module was based on literature reviews and previous consensus exercises for establishing a standard approach to collecting population-based data on the epidemiology of various MSK conditions. The measures in the MSK module were prevalence of low back pain, neck pain, and hip and/or knee pain. For low back pain, we used the minimal definition of low back pain for face-to-face interviews from an international modified Delphi consensus study . For necUsing standard DHS protocols, the survey questionnaires were translated into Pidgin and back-translated into English in order to check the accuracy of the translation. Survey content, skip procedures and filtering instructions were pre-tested by staff from the SINSO.To minimise risk of bias in the prevalence estimates of MSK pain we used a framework based upon a risk of bias tool for prevalence studies . SpecifiData were entered into the CSPro computer package two times with 100% verification . AnalysiProportions and confidence intervals (CIs) for each outcome variable of interest were calculated. An overall design effect  had been calculated for the SIDHS to account for the complex sampling design  – this vn = 9214 participants) were successfully interviewed. Among the households interviewed, 6657 eligible females 15–49 years were identified, of whom 6292 (95.0%) were successfully interviewed. For males, 3920 eligible males were identified, of whom 3628 (93.0%) were successfully interviewed. Of these, 2922 (80.6%) were aged 15–49 years   resided in rural areas, 3750 (41%) were educated to pre-school or primary level, 4032 (44%) to secondary level, and 721 (8%) to tertiary level. 8857 (96%) were Melanesian, 202 (2.2%) Polynesian, 131 (1.4%) Micronesian, and the remainder from some other ethnic group.The four-week prevalence of low back pain was 50.5% (95% CI: 49.3 to 51.7). The four-week prevalence of activity-limiting low back pain was 16.8%; the four-week age-standardized prevalence of activity-limiting low back pain was 16.7% (95% CI: 16.4 to 16.9). Prevalence was significantly higher in females compared with males, and rural areas compared with urban areas. Across both sexes, prevalence generally tended to increase with age and decrease by education level. Prevalence was highest in Micronesians, followed by Melanesians, and then Polynesians . The four-week prevalence of activity-limiting neck pain was 8.92%; the four-week age-standardized prevalence of activity-limiting neck pain was 8.9% (95% CI: 8.7 to 9.1). Prevalence was higher in females compared with males, although this was not significant at the 0.05 level. Prevalence was significantly higher in rural areas compared with urban areas. Again, prevalence generally tended to increase with age and decrease by education level across both sexes. Prevalence was highest in Melanesians, followed by Micronesians, and then Polynesians . The four-week prevalence of activity-limiting hip or knee pain was 10.8%; the four-week age-standardized prevalence of activity-limiting hip or knee pain was 10.8% (95% CI: 10.5 to 11.0). Prevalence was significantly higher in females compared with males, and rural areas compared with urban areas. Across both sexes, prevalence increased with age, and tended to decrease by education level. Prevalence was highest in Melanesians, followed by Micronesians, and then Polynesians ; the four-week age-standardized prevalence of any hip or knee pain that had lasted for 3 months or more was 9.9% (95% CI: 9.7 to 10.1). Prevalence was significantly higher in females  compared with males , and rural areas  compared with urban areas . Prevalence increased with age in both sexes, and decreased by education level in males; there was no clear relationship between prevalence and education level in females. Prevalence was highest in Melanesians, followed by Micronesians, and then Polynesians.The data collectors accidentally asked about any hip or knee pain that had lasted for 3 months or more, as opposed to the diagnosis related to activity-limiting hip or knee pain that had lasted for 3 months or more. Of the 3125 people who had experienced hip or knee pain over the past 4 weeks, 18.2% (n = 570) reported they had received a diagnosis from a medical doctor. The most common diagnoses given were pneumonia (n = 228), common cold (n = 161), and bone dislocation (n = 14).Similar to the previous question, the data collectors accidentally asked for the past-month diagnosis related to n = 2035) of people who had activity-limiting MSK pain at one or more of the three sites examined, 11.7% (n = 1093) had activity-limiting MSK pain at one site only, 6.0% (n = 556) at two sites, and 4.2% (n = 386) at all three sites.Of the 22.1% , and used a standardized tool, which integrated into an existing national survey instrument. A number of measures were taken to minimize study bias, and there was a very good response rate. The recall period of 4 weeks may have resulted in some recall bias. One minor error by data collectors occurred in that for question MSK 7 and MSK8, they used question MSK 5 as the entry point, rather than question MSK 6, thus including The prevalence of pain was high at all the MSK sites that were evaluated. Low back pain had the highest prevalence, followed by hip or knee pain, and then neck pain. Our findings for the age-standardized prevalence of activity-limiting low back and neck pain in the Solomon Islands were substantially higher than those of GBD 2016 , which are based on models that extrapolate data from elsewhere . This isConsistent with previous research on MSK conditions, prevalence of MSK pain tended to increase with age in each of the sites that we evaluated , 23, 24.The diagnoses reported for hip and/or knee pain were most commonly pneumonia and the common cold. There are high rates of communicable diseases in the Solomon Islands and it is possible that these symptoms reflect manifestations of infection . While SThis study has established that MSK pain is common, and given existing data on the burden of disease associated with MSK conditions, a significant burden of disease is likely to be present in the Solomon Islands. This likely current and future burden needs to be better addressed in order to maximise function, productivity and livelihoods, and ensure that health systems in the Solomons are not overwhelmed as the country’s population ages. However, in upscaling efforts to address the burden of MSK in the Solomons, it is important that a vertical or ‘siloed’ approach to addressing MSKs is avoided.It is key that any approach addressing the burden of MSKs is underpinned by ‘integration’ , 33. MSKPrimary prevention strategies and strategies aimed at self-management are likely to have the greatest and most cost-effective impact in reducing the burden of MSK pain in the Solomon Islands. For example, Buchbinder et al. promote the concept of living well with low back pain through focusing on self-management and healthy lifestyles . Where fStaff reported the tool MSK module integrated well, was easy to use, and it was very affordable compared with the alternative of a stand-alone survey. Utilization of the module as part of existing surveys is therefore likely to be a relatively affordable way of improving data coverage across the globe, and thus improving the understanding of MSK pain, and informing ways of mitigating the growing global burden of MSK pain. While in-depth cognitive interviews and examination of inter-rater reliability of the tool was not possible in the current study due to resource constraints and heavy workloads of the data collection team, this is planned for the future.The other benefit of including the module within other more general surveys, and consistent with the Principles of Development Effectiveness –37, is thttp://bjdonline.org/msk-survey-module/.The Global Alliance for Musculoskeletal Health have already used the results of the pilot to further refine the module for use in other countries throughout the world. Questions on upper limb pain have been added, and the tool has recently been piloted in a South Australian health survey. The latest version of the tool can be found at The prevalence of activity-limited pain was high in all measured MSK sites in the Solomon Islands. This indicates an important public health issue for the Solomon Islands that needs to be addressed. Efforts should be underpinned by integration with strategies for other non-communicable diseases, aging, disability, and rehabilitation, and with other sectors such as social services, education, industry, and agriculture. Primary prevention strategies and strategies aimed at self-management are likely to have the greatest and most cost-effective impact.Additional file 1:Global Alliance for Musculoskeletal Health survey module: This is the survey module that is referred to in the manuscript. (PDF 462 kb)Additional file 2:Two-page summary of findings and key recommendations for the Solomon Islands government: This is a summary of findings and key recommendations for the Solomon Islands government. (PDF 440 kb)


Aspergillus species are highly toxic, carcinogenic, and cause severe contamination to food sources, leading to serious health consequences. Contaminations by aflatoxins have been reported in food and feed, such as groundnuts, millet, sesame seeds, maize, wheat, rice, fig, spices and cocoa due to fungal infection during pre- and post-harvest conditions. Besides these food products, commercial products like peanut butter, cooking oil and cosmetics have also been reported to be contaminated by aflatoxins. Even a low concentration of aflatoxins is hazardous for human and livestock. The identification and quantification of aflatoxins in food and feed is a major challenge to guarantee food safety. Therefore, developing feasible, sensitive and robust analytical methods is paramount for the identification and quantification of aflatoxins present in low concentrations in food and feed. There are various chromatographic and sensor-based methods used for the detection of aflatoxins. The current review provides insight into the sources of contamination, occurrence, detection techniques, and masked mycotoxin, in addition to management strategies of aflatoxins to ensure food safety and security.Aflatoxins produced by the  Food safety and security are among the major problems in the current climate of increasing population. These are mainly determined by three key aspects viz., (i) enough food availability, (ii) access to safe food and (iii) utilization of the food in terms of quality, nutritional and cultural purposes for a healthy life . The faiAspergillus, Fusarium, and Penicillium , one-fourth of the world’s crop is affected by mycotoxins . The thricillium . Among vicillium . AFs areasiticus , in additellatus . These ftellatus . Food prtellatus .The ingestion of AFs from contaminated food and feed has led to serious health complications in humans and animals . TherefoA. flavus while G-types are produced by A. parasiticus  or a lactone ring (in case of AFGs) . The fouasiticus . The bioasiticus .The occurrence of AFs is common in wide varieties of food and feed . Some of2 levels and rainfall patterns  in the environment which further influences the gene expression to produce AFs. The conditions of temperature and aw regulate the extent of fungal growth and AFs production  expression and production of AFB1 by A. flavus in maize. They observed the optimum growth of A. flavus at 30°C/0.99 aw with no growth at 20°C/0.90 aw. Both temperature and aw influenced the relative aflR gene expression and AFB1 production, however, the trends for the production of AFB1 were not in accordance with the gene expression. Further, the effect of temperature  and aw  on the growth of A. flavus and A. parasiticus along with the production of AFB1 were investigated on ground Nyjer seeds by w for both A. flavus and A. parasiticus. In addition to this, the fungi showed optimum growth on polished rice in the range of 28–37°C/0.92–0.96 aw. The maximum AFB1 was produced at 33°C/0.96 aw  official method in food and feed samples . Among tA. flavus from peanuts. Similarly, the avfA, omtA, and ver-1 genes encoding the major enzymes in AF-biosynthesis were used as target genes for detecting AFs using multiplex PCR  based on Au/Ag, carbon (CBNs), magnetic (MNPs), Quantum dots (QDs), up-conversion (UCNPs), metal-organic frameworks (MOFs) as well as hybrid nanostructures have been utilized . Rui et in vitro digestion and hydrolysis, as applied in case of masked fumonisins, can be carried out for masked AFs in food and feed followed by detection with LC/MS/MS and confirmation by other methods like ELISA to ensure the food and feed safety.Masked mycotoxins pose a major concern in food and feed as they are not identified and detected by the usually employed detection techniques . These aImplementation of advanced agricultural technologies, good agricultural practices (GAPs), good manufacturing practices (GMPs) and good storage practices (GSPs) can mitigate the mycotoxins contamination . The nov2S2O4) was enhanced with increased pressure for AFs reduction in black pepper  and pressure (8N) was effective in degrading AFs in extruded sorghum . On the k pepper . Furthermination . The appAflatoxins’ contamination of crops at pre- and post-harvest conditions can be controlled to some extent by the implementation of good agricultural practices (GAPs), good manufacturing practices (GMPs) and good storage practices (GSPs). Further, the novel processing technologies involving a microwave, UV, pulsed light, electrolyzed water, cold plasma, ozone, electron beam or gamma (γ) irradiation in combination with either biological, physical, chemical or genetic engineering methods have the potential to improve the efficiency of AFs decontamination as well as to overcome the limitations of any specific technology. However, it is vital to understand the mechanisms of AFs detoxification so that no AF-residues are left behind when these methods are applied in food and feed samples. Furthermore, as there is less information on the masked AFs present in food and feed, it requires in-depth research and understanding with regards to adequate hydrolysis, identification, detection and control strategies. Therefore, utilization of the novel technologies along with raising public awareness for implementing GAPs, GMPs and GSPs are crucial for controlling AFs contamination in food and feed to ensure food safety and security and to safeguard human and animal health.PK conceived and designed the manuscript. DM, PK, and MK wrote the manuscript. KL, KD, and SD helped in the editing of the manuscript. PK and SK critically reviewed the manuscript and did the required editing.SD employed by company SAB Miller India Ltd., Sonipat, India. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hodgkin lymphoma (HL) is an uncommon B cell lymphoma. We assessed the global, regional, and national burden of HL from 1990 to 2017, by gender, age, and social-demographic index (SDI).Data on HL, including incidence, mortality, and disability adjusted life-years (DALY), from 1990 to 2017 were obtained from the 2017 Global Burden of Disease study. Estimated annual percentage changes (EAPCs) were calculated to assess incidence rate, mortality, and DALY trends.HL incidences increased by 38.66%, from 72,937 in 1990 to 101,133 in 2017, while the age-standardized incidence rate (ASIR) was relatively stable. ASIR decreased in the low SDI regions  and was stable in the other four SDI regions. Incidence showed a bimodal distribution with peak values in patients aged 20–39 years and patients aged 60 years or higher. The number of death cases and DALYs were stable. The age-standardized death rate decreased by 2.36%  per year. The annual age-standardized DALY rate decreased by 2.29% . The incidence and mortality in male subjects was higher than that in female subjects. The incidence in male and female subjects aged 15–30 years old was close, whereas the biggest difference existed in patients aged < 10 years old and 45–75 years old between genders.Globally, incidence of HL was stable, while mortality and DALY rate of HL had been decreasing from 1990 to 2017. Compared with lower and decreasing ASIR in the low SDI region, ASIR in the high SDI region was always high, indicating the need for HL treatment improvement and the establishment of more targeted and specific strategies in high SDI countries to reduce the incidence of HL. Hodgkin lymphoma (HL) is a rare B cell lymphoma with 79,990 new cases  and 26,167 deaths  worldwide in 2018 . SignifiThe Global Burden of Disease (GBD) study assessed the burden of 354 diseases and injuries in 194 countries and regions worldwide and provided an opportunity to comprehensively assess the distribution and development trends of HL in different countries. More detailed data on HL incidence, mortality, DALY, and the corresponding trends in different countries is necessary and could enable policymakers to allocate limited resources and formulate policies more rationally based on this information. Therefore, we conducted this study to reveal the incidence, mortality, disability adjusted life-years (DALY), and the corresponding trends of HL, according to sex, age, socio-demographic index (SDI), region, and country.http://ghdx.healthdata.org/gbd-results-tool). We also obtained information on gender and age to assess the impact of age and gender on the burden of Hodgkin lymphoma. To further analyze the global burden of Hodgkin lymphoma, we classified location information according to three criteria. We used the social-demographic index (SDI) to divide the countries and regions into five categories . SDI is the geometric average of total fertility, per capita income, and average years of education and ranges from zero to one [Information on the annual incidence rate, death rate, and DALY of Hodgkin lymphoma, from 1990 to 2017, was collected from the Global Health Data Exchange (GHDx) query tool  in age group i and the number (or weight) (wi) of the selected reference standard population group i divided by the sum of number (or weight) of the standard population, i.e., y = α + βx + ε, where y represents ln (ASR) and x refers to the calendar year. EAPC = 100 × (exp(β) − 1) and its 95% confidence interval (CI) can be obtained from the regression model [ρ represents Pearson’s correlation coefficient. All calculations were performed using R software (version 3.5.1).The annual age-standardized incidence rate (ASIR), age-standardized death rate (ASDR), age-standardized DALY rate, and the corresponding estimated annual percentage changes (EAPCs) were calculated to assess trends of Hodgkin lymphoma incidence and mortality. DALY was estimated by adding the years lived with disability (YLDs) and the years of life lost (YLLs) . Age-sta×100,000 . EAPCs wmentclasspt{minimaAt the global level, the annual incidence increased gradually and there were 101,133  incidences in 2017 and 72,937  incidences in 1990 , a stable trend in 180 countries, and a downward trend in 10 countries . Among female subjects, ASIR showed an upward trend in 10 countries , a stable trend in 181 countries, and a downward trend in three countries . Among male subjects, ASIR showed an upward trend in four countries , a stable trend in 188 countries, and a downward trend in two countries (South Korea and Lebanon). The three countries with the highest ASIR were Lebanon, Greece, and Montenegro; the three countries with the lowest ASIR were Sao Tome and Principe, Cape Verde and Ghana; the three countries with the highest EAPC were Cuba, South Korea, and Lebanon; the three countries with the lowest ASIR were Equatorial Guinea, Bangladesh, and Iraq, and the details were listed in Additional file At the global level, the number of annual deaths was stable with 35,946  deaths in 1990 and 32,560  deaths in 2017. The number of deaths was stable over the past 28 years, while the ASDR decreased significantly with an EAPC of − 2.36 , dropping from 0.75/100,000 persons  in 1990 to 0.41/100,000 persons  in 2017  DALYs in 1990 and 1,378,170  DALYs in 2017. The number of DALYs was stable over the past 28 years, and the age-standardized DALY rate decreased significantly with an EAPC of − 2.29 , dropping from 31.51/100,000 persons  in 1990 to 17.77/100,000 persons  in 2017 . In GCO, we found that the incidence of HL in Australia, North America, and Europe was the highest and the mortality in Africa and Asia was the lowest. The mortality of HL was higher in Africa and lower in Eastern Asia, Europe, and Australia. For the high mortality rate of HL in Africa, African countries should pay more attention to the treatment of HL. Previous study has shown a significant increase in the incidence of HL in some populations, such as those with infectious mononucleosis or direct relatives with HD cases. For these high-risk people in high SDI countries, we believe that it is necessary to strengthen their screening for HL [To our knowledge, this study presents the latest trends and patterns of global incidence, mortality, and DALY of HL from 1990 to 2017, based on GBD 2017 results. Previous epidemiological studies of HL were conducted before the twenty-first century or focused on individual or several countries [g for HL . Althougg for HL : for insg for HL ; over tig for HL , 16; andIncidence showed a bimodal distribution and increased in people aged 20–39 years and 60 years or higher. Incidence in most countries had a bimodal distribution of age. However, some countries like the Russian Federation and Canada showed a unimodal distribution in the recent years, peaking in young people, due to the increased incidence of nodular sclerosis subtypes in HL. Similar distribution was described in previous studies –20. The The proportion of annual young incidences and deaths in all HL cases decreased year by year, while the proportion of elderly incidences and deaths cases increased. This could be attributed to population growth and population aging. It is well known that aging and fewer births in developed countries has a serious concern in the recent years. We also observed a phenomenon that the higher the SDI, the lower the proportion of children and higher the proportion of the elderly, which confirmed this conjecture. Even different SDI regions in the same continent showed this difference. For instance, the incident and death HL population in high-income Asia Pacific tended to be aging, compared with other regions in Asia. Moreover, in recent years, new treatment schedule and the improvement in supportive nursing measures had led to an unprecedented long-term cure rate of HL treatment, which further promoted this trend , 30.In addition, we found a significant negative correlation between the variation of ASDR between 1990 and 2017 and the baseline ASDR in 1990. For the countries with higher ASDR in 1990, the change in ASDR is more significant. The results could be explained as countries with higher ASDR were more likely to consider HL as a top priority in prevention plans, due to the public health factor. A similar trend of age-standardized DALY rate was also found. We also found a significant negative correlation between the variation of ASDR and SDI. For countries with higher SDI, the downward trend in ASDR was more obvious possibly due to better health care in countries with high SDI.Some limitations were unavoidable in this study. First, the accuracy of the results depended on the quality and the quantity of data in GBD. Second, data quality in some underdeveloped areas, like Africa and Latin America, was not guaranteed which may cause data on some underdeveloped regions inaccuracy because many countries did not have reliable mortality information systems and population-based cancer registries are rare. Third, the GBD study took the country as its basic unit and neglected the influence of race. Last, due to the lack of relevant data, no further study was conducted on the etiology and risk information related to HL, which might better explain the changing trend and age distribution of HL and help local governments formulate more detailed policies to reduce the incidence of HL.In summary, developed areas had higher incidence, lower mortality rates, whereas underdeveloped areas had lower incidence rate and higher mortality rates. Globally, incidence of HL was stable, while mortality and DALY rate of HL had been decreasing from 1990 to 2017. Compared with lower and decreasing ASIR in the low SDI region, ASIR in the high SDI region was always high, signifying the need for larger investment in research to reduce the incidence of HL in developed countries. And the low SDI country should attach importance to improve HL treatment and prolong patient life. It was noteworthy that the change pattern was heterogeneous across sex, age, SDI, region, and country. The incidence was the lowest in childhood and the highest in youth and old ages, which highlighted the need to strengthen HL screening in these two age groups. The incidence and mortality in male subjects was always higher than that in female subjects. These differences have to be taken into account for policymakers to allocate limited resources and formulate relevant policies more rationally.Additional file 1. Supplementary tables and figures.


Nonalcoholic steatohepatitis (NASH) is a form of chronic liver disease (CLD): patients have an increased risk of developing cirrhosis, liver failure, and complications (e.g. hepatocellular carcinoma). NASH has a high clinical burden, and likely impairs patients’ health-related quality of life (HRQoL), but there are currently no licensed therapies. The objective of this robust pragmatic literature review was to identify and describe recent studies on the HRQoL burden of NASH from the patient perspective.English-language primary research studies were identified that measured HRQoL in adults with NASH . Searches were conducted in the following bibliographical databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA). Abstracts from selected congresses (2015/2016) were hand searched. Articles were assessed for relevance by two independent reviewers, and HRQoL data were extracted.A total of 567 de-duplicated abstracts were identified, and 20 full-text articles were reviewed. Eight studies were included: five quantitative, two interventional, and one qualitative. The quantitative and interventional studies measured HRQoL using the Short-Form 36 (SF-36) and the Chronic Liver Disease Questionnaire (CLDQ), and the qualitative study involved focus groups and individual interviews. Overall, the studies showed that NASH affects HRQoL, especially physical functioning, with many patients reporting being fatigued. In quantitative studies, overall, patients with NASH had a reduced HRQoL versus normative populations and nonalcoholic fatty liver disease (NAFLD) patients, but not versus chronic liver diseases. A longitudinal study showed that when weight loss was achieved, HRQoL improvement over 6 months was greater in patients with NASH versus NAFLD. Qualitative research suggested that, in addition to fatigue, other symptoms are also burdensome, having a broad negative impact on patients’ lives. The impact of pharmacological treatment on HRQoL was explored in only two included studies.HRQoL is impaired in patients with NASH. Patients experience a range of symptoms, especially fatigue, and the impact on their lives is broad. Further research is needed to understand the HRQoL burden of NASH (e.g. assessing NASH-specific impacts not captured by SF-36 and CLDQ) and the impact of future NASH therapies on HRQoL. Nonalcoholic steatohepatitis (NASH) is a form of chronic liver disease (CLD) in adults and children. Histologically, NASH is characterized by hepatic steatosis (fatty infiltration of the liver) and inflammation, with hepatocyte injury  with or without fibrosis . PatientDespite its clinical burden, there are currently no evidence-based licensed therapies for NASH. The World Gastroenterology Organisation (WGO) suggests that, in patients who fail to achieve a 5–10% weight reduction over 6 months to 1 year of lifestyle changes, experimental therapies may be added  . If thesIn addition to its clinical burden, NASH likely results in a high patient burden and a negative impact on patients’ health-related quality of life (HRQoL) . UnderstThe objective of this literature review was to identify and describe studies on the HRQoL burden of NASH from the patient perspective. Studies of interest were: (1) population-based studies  assessing HRQoL in patients with NASH; and (2) clinical trials assessing the HRQoL impact of (unlicensed) pharmacological therapies for NASH.A search protocol was developed to guide the development and completion of the literature review. It outlined information on the proposed approach, the objective, the search strategy, study selection criteria, data extraction method, and data synthesis methods. The development of a search protocol reduces the impact of review authors’ biases, ensures transparency and accountability, and maximizes the chances of correct data extraction.Included in the review were English-language primary research studies that measured HRQoL in adults with NASH. Studies could be population-based studies  or clinical trials of pharmacological therapy. The quantitative measurement of HRQoL could include the use of generic and/or disease-specific HRQoL instruments. Journal articles were included if they were published from 2006 to June 2016, and congress abstracts if they were disclosed at the most recent meetings (2015/2016).Studies were excluded if they were not specifically in patients with NASH; if they reported an outcome such as disability, depression, or physical functioning as opposed to the multi-dimensional construct of HRQoL; or if they were clinical trials on nondrug treatment . Reviews, discussion papers, letters, and editorials were also excluded.Searches were conducted in in the following bibliographic databases for this review: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA). In addition, the reference lists of identified studies were checked.The abstracts presented at the most recent meetings of various congresses were searched for relevant studies: International Society for Pharmacoeconomics and Outcomes Research (ISPOR) – both European and international meetings ; International Society for Quality of Life Research (ISOQOL) (2015); International Liver Congress, organized by the European Association for the Study of the Liver (EASL) (2016); The Liver Meeting, organized by the American Association for the Study of Liver Diseases (AASLD) (2015); and the Asian Pacific Association for the Study of the Liver (APASL) (2016).The literature review is considered to be a robust pragmatic review rather than a systematic review. The approach is robust in that a research plan was developed, a range of bibliographic sources were interrogated, and there was a double abstract review and quality control. However, not all elements were defined a priori, and the review allowed the scope to evolve in terms of focus.The base search strategy was developed for PubMed, and this syntax was then adapted for the other databases. The search strategies are provided in the Supplement. To remove duplicates, the titles and abstracts of bibliographic records were downloaded and imported into EndNote bibliographic software. The titles and abstracts of the search results were assessed for relevance by two independent reviewers. Studies that met (or could meet) the eligibility criteria were selected for more detailed assessment using the full text. Exclusion codes were assigned at the full text review stage only. In cases of disagreement, both reviewers discussed the record to reach consensus.Data extraction tables were designed and then populated for all included studies by one reviewer with quality checking undertaken for 10% of records. Information  were included in the data extraction tables.The literature search yielded a total of 567 de-duplicated abstracts, and 20 full-text articles were reviewed for relevance. Three additional records were identified: two from manual checking of reference lists, and one relevant conference abstract. A total of eight studies were suitable for inclusion in the final literature review Fig. . There wTable Two validated HRQoL questionnaires—the generic Short-Form 36 (SF-36) instrument , 19 and n = 80), vitamin E 800 IU (n = 84), or placebo (n = 83) for 96 weeks. The trial by Chande et al. (2006) ). Although only reported for the total nonviral CLD population, fatigue was the domain that was most affected . The main focus of the study by Alt et al. (2016) [p = 0.048) as well in the CLDQ domains Worry  and Fatigue . Levels of CK18 were the highest in patients with NASH versus all other CLD etiologies (p < 0.001).The study by Alt et al. (2016)  compared. (2016)  was to eIn the longitudinal study of weight reduction , total CThe two interventional trials of patients with NASH did not detect any changes in HRQoL from baseline , 16. In p > 0.05). For PCS, in the placebo, vitamin E, and pioglitazone groups, respectively, mean (SD) scores at baseline were 47 (11), 49 (10), and 49 (9), and the changes from baseline to 96 weeks were − 0.3, 0.4, and − 0.9. For MCS, corresponding mean (SD) scores at baseline were 47 (12), 49 (10), and 49 (8), and the changes from baseline to 96 weeks were 0.4, − 0.5, and − 1.9.In the phase 3, 96-week trial , PCS andIn the small pilot, 8-week trial , the effIn the qualitative research study, the development of the conceptual framework provided useful insight on the symptoms that patients with NASH experience, and how these symptoms impact their lives . In the NASH was associated with a wide-ranging impact on patients, including effects on diet, work, family life, sleep, and usual activities. The most commonly reported impacts were: limits to and frustration with diet (52.3% of patients), reduced or impacted sleep (37.9%), impacts on social/family activities (31.1%), and medication/healthcare frustration (29.5%). An additional theme was ‘fear for the future’, with 26.5% of patients worrying that their condition would get worse .The concepts discussed by patients as either symptoms or impact on activities of daily living were placed in six hypothesized domains: Fatigue, Pain/discomfort, Abdominal issues, Sleep, Social/Emotional issues, and Unclassified concepts Table . From thThis literature review identified a limited evidence base documenting HRQoL in patients with NASH. Eight studies were found to assess HRQoL in patients with NASH and overall, they demonstrate that NASH is associated with impaired HRQoL.Importantly, most of the patients enrolled in the included studies had not progressed to cirrhosis, and none had progressed to liver failure. As discussed by Chawla et al. 2016) , this ma , this mIn general, the cross-sectional quantitative studies showed that presence of NASH was associated with a reduced HRQoL versus normative populations , 13 and n = 713) and within this with biopsy-proven NASH (n = 436). The authors stated that the multicenter design of the NASH CRN and the recruitment of patients from a variety of settings mean that data can be generalized to adults with NAFLD in the USA [Regarding the comparisons to patients with NAFLD, significant impairments in HRQoL were seen in patients with definite NASH as compared to NAFLD but definitely not NASH in most or all of the SF-36 domains: this included the PCS but not the MCS score , 13. A m the USA . It is iBoth the SF-36 and CLDQ have been shown to be reliable and validated in populations with NASH , and theAlthough existing NASH data have limitations, the HRQoL burden of severe liver outcomes, such as cirrhosis, HCC, and LT, has been explored in literature reviews. For example, the multifaceted ways in which a person is impacted by cirrhosis including physical, emotional, social, functioning and economic is detailed in a narrative paper by Loria et al. (2013)  and compClinicalTrials.gov identifier, NCT02704403) is comparing the efficacy and safety of elafibranor versus placebo in patients with NASH and fibrosis. The change in HRQoL (SF-36) is a secondary outcome that will be reported at Week 72 and at the end of long-term treatment (estimated to be 4 years). Primary outcomes include histological improvement, all-cause mortality, and liver-related clinical outcomes. The trial is estimated to complete in December 2021.Despite the clinical and HRQoL burden associated with NASH, there are currently no licensed therapies for NASH . It is iA number of limitations of the present review should be noted. The review highlighted that there appears to be a limited amount of published literature on the HRQoL burden of NASH, and the HRQoL impact of treatment of NASH. The search strategy excluded clinical trials on nondrug treatment  as well as non-English papers, and journal articles published before 2006, and it cannot be ruled out that other relevant studies may have been published. It is also possible that some clinical trials of treatments for NASH that included an assessment of HRQoL did not make mention of this in the abstract (or title) or were not indexed and were therefore not identified. In addition, a more recent search may reveal further relevant studies.Another limitation of this review is the difficulties defining and diagnosing NAFLD and NASH. For example, in the included study by Sayiner et al. (2016) , patientIn addition, it should be noted that in the quantitative studies it is possible that the HRQoL impairment associated with NASH could be due to factors other than the condition itself, for example the presence of comorbidities. Although some of the studies did consider sex-matched populations, and multiple regression analysis was undertaken in two of the studies, there is certainly scope for further in-depth analysis. Depending on the study design, there is a possibility for comorbidity to confound the HRQoL results. As such, it is recommended that future studies consider comorbidity as an important factor, and employ designs and methods to better control for potential confounding due to comorbidities.Further research is needed to understand the HRQoL burden of NASH and the impact of treatments on patients’ HRQoL. Longitudinal studies are needed to better understand HRQoL burden over time . Four of the five quantitative studies in the present review had a cross-sectional design. As discussed by David et al. (2009) , cause aIn summary, this literature review shows that, although there is a limited amount of published literature on the HRQoL burden of NASH, the available studies do offer some very useful insights. The instruments that have been used to measure HRQoL in studies are the SF-36 and the CLDQ. Although few in number, the quantitative studies consistently showed that HRQoL is impaired in patients with NASH, especially in terms of physical functioning, with many patients reporting being fatigued. The qualitative research suggests that a range of other symptoms are also burdensome, having a broad negative impact on different aspects of patients’ lives. In this review, the impact of pharmacological treatment on HRQoL was explored in only two included studies.


Objective: The aim of this systematic review was to explore the relationship between coeliac disease (CD) and headache. The objectives were to establish the prevalence of each entity amongst the other, to explore the role of gluten free diet (GFD), and to describe the imaging findings in those affected by headaches associated with CD. Methodology: A systematic computer-based literature search was conducted on the PubMed database. Information regarding study type, population size, the age group included, prevalence of CD amongst those with headache and vice versa, imaging results, the nature of headache, and response to GFD. Results: In total, 40 articles published between 1987 and 2017 qualified for inclusion in this review. The mean pooled prevalence of headache amongst those with CD was 26% (95% CI 19.5–33.9%) in adult populations and 18.3% (95% CI 10.4–30.2%) in paediatric populations. The headaches are most often migraine-like. In children with idiopathic headache, the prevalence of CD is 2.4% (95% CI 1.5–3.7%), whereas data for adult populations is presently unavailable. Brain imaging can be normal, although, cerebral calcifications on CT, white matter abnormalities on MRI and deranged regional cerebral blood flow on SPECT can be present. GFD appears to be an effective management for headache in the context of CD, leading to total resolution of headaches in up to 75% of patients. Conclusions: There is an increased prevalence of CD amongst idiopathic headache and vice versa. Therefore, patients with headache of unknown origin should be screened for CD, as such patients may symptomatically benefit from a GFD. Gluten-related disorders (GRDs) represent a diverse spectrum of clinical entities for which the ingestion of gluten is a common trigger.Coeliac disease (CD) is the best-recognised GRD and it is characterized by a small bowel enteropathy occurring in genetically susceptible individuals whilst exposed to the protein gliadin . Non-coeAlthough the gastrointestinal manifestations of GRDs are the most prevalent, a range of debilitating neurological manifestations are increasingly being recognised in clinical practice, often preceding or in the absence of GI symptoms. The most well-known neurological GRDs are cerebellar ataxia  and periThe aim of this paper is to systematically review the current literature in order to establish the relationship between headache and CD.This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines . A systeThe study subjects were diagnosed with idiopathic headache and gluten sensitivity or coeliac disease.The study subjects were human.The study contained original data.The study was available as a full-text, English language article, or contained utilisable information in an English language abstract.For randomised control trials, a JADAD score  of aboveArticles to be included in the review were required to meet the following criteria:Details of the inclusion process are detailed in the PRISMA chart, A database was developed using IBM SPSS Statistics . Data were extracted from each study and included: study type; population size; the age group included; prevalence of GRD/headache; imaging results; the nature of headache; and, response to GFD. Frequencies and descriptive statistics were examined for each variable. The outcomes of interest were the proportion of patients with CD or GS suffering from headache and the proportion of patients suffering from idiopathic headache that had CD or GS.Meta-analysis of the pooled proportions was conducted in R language  while usp < 0.05 was considered to be statistically significant.A value of This article is based upon previously published studies. The article is in compliance with the journal’s ethical guidelines.The search strategy identified 96 articles. A total of 57 articles were excluded during the eligibility assessment. After perusing the reference lists of included studies, one additional article meeting our inclusion criteria was identified, which had not already been discovered in the aforementioned search strategy. Therefore, in total 40 articles published between 1987 and 2017 qualified for inclusion in this review, studying a total of 42,388 individuals with either headache or GRD (mean number of patients per citation 1059.7 ± 4626.5). The characteristics of the included papers are summarised in p < 0.0001). However, in this study, there was no information provided regarding the criteria for headache diagnosis used and if diagnosed, its exact type.Only one population based epidemiological study, inclusive of all ages, has been conducted to date . In thisp < 0.0001).Information about prevalence of headache in adults was available through five cohort ,15,16,17p < 0.0001).Information about prevalence of headache in children and adolescents, was available through five cohort ,23,24,25Headache, usually migraine, has been reported as the first manifestation of CD in several case reports ,34,35,36p < 0.05).In a case-controlled study, Gabrielli et al.  investigInformation about prevalence of CD in children with headache was available through two case-control ,39 and tSixteen papers provided information regarding imaging findings ,41,42,43Although brain CT scans in patients with CD and headache are usually normal, there have been cases described of migraine-like headaches with occipital ,30 or paMRI findings have been reported in isolated case reports and small case series. In a consecutive cohort of 33 adult patients with CD who were referred for a neurological opinion, Currie et al. reported that 12 patients (36%) had white matter abnormalities (WMA) on MRI . When loHadjivassiliou et al. has presented the largest series of patients with CD or GS and WMA on MRI to date . Among 499mTc hexemethyl-propylene-amineoxime using a brain-dedicated tomograph -fluoro-2-deoxy-malities . This coThe effect of a gluten-free diet (GFD) has been reported in numerous cohort studies ,28,37,40As well as direct clinical improvement, it has been demonstrated that a GFD can normalize the cortical hypoperfusion abnormalities that are seen in SPECT . AlthougIn a survey of pediatric patients with CD that was conducted by Rashid et al., it was reported that up to 13% of patients experience headache after accidental gluten ingestion . In a siSome case reports describe patients who presented with headache secondary to increased intracranial pressure and CD. Dotan et al. reported two cases of boys (three and four years old) who presented with idiopathic intracranial hypertension (IIH). Diagnostic work-up revealed low serum vitamin A titres and further diagnostic work-up led to a diagnosis of CD . A theraGluten encephalopathy is a term that is used to describe a combination of frequent, often intractable, headaches, and cognitive complaints (which patients sometimes describe as a “foggy brain”). Crosato et al. were the first to describe a case of a nine-year-old boy with a history of seizures, headaches, episodes of drowsiness and cerebral calcification on CT who, because of his very low folate levels, was eventually diagnosed with CD . KakoraçA link between headache and NCGS or GS has been also demonstrated in a smaller number of studies.p = 0.06).Information about prevalence of GS in children with headache , was available through three case-controlled studies ,47,48. AInformation about the prevalence of headache in patients with NCGS was available through two studies ,50. In aThere is an increased prevalence of headache amongst patients with CD and an increased prevalence of CD amongst those with idiopathic headache. Such an increased prevalence is evident in both child and adult populations; however, the figures are higher in the latter.Headaches that are associated with CD are predominantly migraines. However, many studies that were used in this report tended to report headaches without specifying the exact type  making the interpretation of the findings more difficult.CT calcifications and WMA are frequent in patients with headaches that are related to CD, and therefore patients with such imaging findings in in the context of idiopathic headache require further testing for CD.GFD is a very effective treatment for headaches associated with CD and should therefore be offered as soon as possible. This is highly consistent with other neurological GRD, such as the observation that GFD is associated with a significant reduction of pain in patients with gluten neuropathy and an improvement of their quality of life ,52. SpecFurther studies of the prevalence of GS in patients with idiopathic headache are needed. Currently, to our knowledge, no such studies in adults exist.Although there is some evidence that brain hypoperfusion and perivascular inflammation might play a role in the pathogenesis of GS-related headaches more studies on the likely pathogenetic mechanisms are needed.Serum positivity for TG6 antibodies has been identified as a sensitive measure of neurological involvement in GS ,54 ThereThis systematic review, highlights the following key points:


Prevotella, particularly Prevotella copri, were more abundant in the RA than in the OA group, although these differences were not statistically significant. The relative abundance of Bacteroides and Bifidobacterium was lower in the RA group. At the species level, the abundance of certain bacterial species was significantly lower in the RA group, such as Fusicatenibacter saccharivorans, Dialister invisus, Clostridium leptum, Ruthenibacterium lactatiformans, Anaerotruncus colihominis, Bacteroides faecichinchillae, Harryflintia acetispora, Bacteroides acidifaciens, and Christensenella minuta. The microbial properties of the gut differed between RA and OA patients, and the RA dysbiosis revealed results similar to those of other autoimmune diseases, suggesting that a specific gut microbiota pattern is related to autoimmunity.The aim of this study was to investigate differences between the gut microbiota composition in patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA). Stool samples from nine RA patients and nine OA patients were collected, and DNA was extracted. The gut microbiome was assessed using 16S rRNA gene amplicon sequencing. The structures and differences in the gut microbiome between RA and OA were analyzed. The analysis of diversity revealed no differences in the complexity of samples. The RA group had a lower Bacteroidetes: Firmicutes ratio than did the OA group. Lactobacilli and  The human gut is one of the richest microbial ecosystems, containing more than 5000 different species with wide variation in their genetics and biochemistry. The gut microbiota start building up at birth and several environmental and host-related factors are involved in shaping the established microbial composition ,2,3. GutRheumatoid arthritis (RA) is a very common systemic autoimmune disease that leads to progressive joint destruction . So far,Osteoarthritis (OA), the most common type of arthritis, is a degenerative disease, and the role of inflammatory factors, such as those from microbiota, has been considered minor . The exaThere have been reports of several mechanisms by which changes in the intestinal microbiota can cause joint disease. First, nutritional absorption in the intestine is regulated to some extent by the intestinal microbiome . The intWhile there is a considerable amount of research on RA links to gut microbiome, the gut microbiome in patients with RA in comparison with that in OA patients requires further studies. In this study, we attempted to distinguish RA and OA by comparing the fecal microbiome and describing its potential association with both diseases using a non-invasive strategy.n = 9) and OA (n = 9), based on the diagnostic criteria. RA patients were confirmed according to the classification criteria in the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2010; the patients were also naïve to biological drugs. The disease duration, activity markers, and medication use among the RA patients are shown in This study was approved by the Institutional Review Board of Kosin University Gospel Hospital (2017-08-15). A total of 18 Korean patients were recruited at the outpatient Division of Rheumatology and were divided into two groups, RA , following the manufacturer’s protocol. The obtained DNA were checked for concentration and quality using the NanoDrop2000 spectrophotometer  and by agarose gel electrophoresis (0.8% agarose in Tris-borate-EDTA). The qualitatively assessed samples of intact metagenomics DNA with appropriate A260/A280 and A260/A230 ratios were stored at −20 °C in TE buffer until they were used in sample preparation, 16S rRNA amplification, sequencing, and sequence analyses.Fresh fecal samples from study participants were collected in sterile containers and immediately stored at −80 °C until further processing. Total metagenomic DNA in 250 mg (fresh weight) of the homogenized fecal samples was extracted using PowerSoilThe V3 and V4 variables of the 16S rRNA region were amplified and the sequence library was generated by Polymerase chain reaction (PCR) using the following primer pair:(F), 5’-TCGTCGGCAGCGTCAGATGTGTATAAGAGACAGCCTACGGGNGGCWGCAG(R), 5’-GTCTCGTGGGCTCGGAGATGTGTATAAGAGACAGGACTACHVGGGTATCTAATCC.® MiSeq® platform at Macrogen  yielding paired-end reads. Paired-end reads were merged using Fast Length Adjustment of Short reads  [The amplification, sequencing, and library preparation workflow were conducted using Herculase II fusion DNA polymerase Nextera XT Index Kit V2, following the 16S metagenomic sequencing library preparation Part # 15044223 Rev. B protocol in Illumina/FLASH/) . The tax/FLASH/) . The obtt-test, where a p-value < 0.05 was considered to be statistically significant.Statistical analysis and data plotting for alpha- and beta-diversity were performed using QIIME scripts and R (version 3.1.3). The stacked bar graphs were used to show the relative abundance of different bacterial taxa for each individual. The means ± standard deviations of the differentially existed taxa between the RA and OA groups were statistically analyzed using two-tailed, independent samples The study participants of both groups, RA and OA, were similar in their age, body weight, and body mass index. However, RA patients had significantly higher levels of the ESR and hsCRP . RheumatThere was no significant difference in the number of qualified reads between RA  and OA  patients. The rarefaction curves of the number of reads plotted against the number of OTUs indicated that the number of qualified reads from the used samples were adequate for the final analysis, as a further increase in the reads would have a minor effect on the obtained OTUs .The diversity analysis revealed that there were no apparent differences in the complexity within samples represented as OTU numbers and the alpha-diversity, Chao1 richness, and Shannon and Simpson indices between the two groups . HoweverThe relative abundance of the OTUs, classified as phylum, class, family, and species levels, for each individual sample in the RA and OA groups are shown in the stacked bars in Prevotella copri (shown in red color) was the dominant species in most samples from both groups. In the RA and OA groups, seven out of nine samples and four out of nine samples were dominated by P. copri, respectively  in the RA group, with an average of 4.51% relative to 1.13% for the OA group.At the order level, Bacteroidales were significantly higher in the OA group, while Selenomonadales and Methanobacteriales were only present in the RA group. The relative abundance of Lactobacillales was also higher, although not statistically significant , Streptococcus , Lactobacillus , and Prevotella . Bacteroides  and Bifidobacterium  were higher in the OA group.At the genus level, Fusicatenibacter saccharivorans, Dialister invisus, Clostridium leptum, Ruthenibacterium lactatiformans, Anaerotruncus colihominis, Bacteroides faecichinchillae, Harryflintia acetispora, Bacteroides acidifaciens, and Christensenella minuta were significantly higher in the OA group. Megamonas funiformis, Clostridium xylanolyticum, Prevotellamassilia timonensis, Catenibacterium mitsuokai, Acidaminococcus fermentans, and Bacteroides clarus were significantly higher in the RA group (Prevotella copri was higher in the RA group (30.77%) than in the OA group (22.33%), although the difference was not statistically significant.At the species level, RA group . The avePrevotella abundance from another cluster with low Prevotella abundance. The Prevotella high abundance cluster contained seven RA samples and four OA samples. Samples in this cluster also had a higher relative abundance of other genera such as Megamonas, Megashaera, Lactobacillus, and Streptococcus. The Prevotella low abundance cluster included samples with a high abundance of Bacteroides and other genera, such as Faecalibacter, Barseniella, and Parabacteroidetes  activity and depressed regulatory T cell (Treg) activity [In our study, Bacilli were predominant in RA patients rather than in OA patients. Although it was not significant, activity . A 2018 activity . Liu et activity  also sugPrevotella, especially P. copri, were more predominant in the RA group than in the OA group, although this was not a statistically significant result. A previous study by Scher et al. [P. copri and Prevotella-like taxa in patients with new onset RA when compared with a healthy control group. Bacteroides and Bifidobacterium were decreased in the RA group than in the OA group in this study. Previous studies also showed a decrease in families Bifidobacterium and Bacteroides, with the addition of genus Prevotella, in an early RA group than in the control group [Bifidobacterium when compared with a healthy control group [In this study, r et al.  reportedol group ,31. Typeol group . Fusicatenibacter saccharivorans, Dialister invisus, and Clostridium leptum were decreased in the RA group rather than in the OA group in this study. These bacteria were also decreased in other autoimmune diseases, including Crohn’s disease (CD) and ulcerative colitis (UC) [Ruthenibacterium lactatiformans and Anaerotruncus colihominis were also decreased in the gut microbiota of RA patients when compared with healthy patients. Another bacterium, Bacteroides faecichinichillae, which decreased in RA patients, was also found to decrease in obese people relative to non-obese people. Bacteroides acidifaciens was related to insulin sensitivity and thought to be related to T1DM [Christensenella minuta showed significantly lower abundance in the RA group in this study and has been previously linked with Parkinson’s disease, the latter being investigated as a possible autoimmune disease [At the species level, tis (UC) ,34,35. R to T1DM . Christe disease .Bacteroides and Bifidobacterium, and predominance of lactobacilli and Prevotella in RA are supported by previous research. At the species level, the gut microbiota  in RA was decreased when compared with OA. To date, however, there has been no other study that supports the results revealed in this study regarding the RA group. Other researchers have reported that the microbiota mentioned above are linked to other autoimmune diseases.In this study, the lower Bacteroidetes:Firmicutes ratio, reduction in Lactobacillus casei and Streptococcus pyogenes, resulted in polyarthritis [Several mechanisms have been proposed for the association between gut microbiota and arthritis, including the activation of antigen-presenting cells by affecting Toll-like receptors (TLRs) and Nod-like receptors (NLRs), antigenic mimicry, affecting the intestinal permeability, modulating the host immune system through T cell differentiation, and increase T helper 17 (Th17)-related inflammation . In earlrthritis ,40. Studrthritis . The considerable body of evidence on the association between dysbiosis and the action of certain gut microbes with the onset and progress of RA has triggered research on novel therapeutic targets and strategies to enrich and restore healthy gut microbiome as an adjunctive therapy. Previous studies on RA patients have shown that supplementation with probiotics was associated with functional improvement and enhancement of the wellbeing of patients; although there were no significant differences in the clinical characteristics of RA ,42. MoreLimitations of this study include the small sample size and absence of healthy controls. Additionally, factors that could affect gut microbiota, such as sex, age, and BMI, were not investigated. Nonetheless, this is the first study to compare the gut microbiota of RA and OA patients. In this study, we found a difference in the gut microbiota of the RA and OA groups. The tendency of RA dysbiosis compared with that of OA was similar to results seen in other autoimmune diseases, indicating that the specific gut microbiome pattern may be linked with autoimmunity. Although the impact of microbiota on OA pathogenesis may be present in conjunction with individual-specific risk factors, as reported recently, effects of gut microbiota on RA pathogenesis, specifically autoimmunity and T cell immunity, were more significant. Furthermore, a more accurate analysis of the microbiome’s effect on RA and OA progression may be possible by comparing RA and OA patients with a healthy control group. In addition, it may be helpful to elucidate the pathogenesis and treatment of RA by investigating the linkage between the dysbiosis of gut microbiome and the presence of anti-cyclic citrullinated peptide (CCP) as a biomarker for RA, Th 17, Treg activity, and pro-inflammatory cytokines.


Background: Health-related lifestyle behaviors such as smoking, alcohol consumption, physical inactivity and obesity are major cardiovascular risk factors. Previous studies have mostly demonstrated a favorable association between religiosity and these cardiovascular risk factors; however, no studies have investigated this relationship in Polish immigrants. The aim of this cross-sectional study was to examine the association between health-related lifestyle behaviors and religiosity in Polish immigrants in Germany. Methods: The smoking patterns, frequency of alcohol consumption, physical activity, and presence of overweight/obesity were assessed in 257 first-generation immigrants of Polish origin living in Germany. Religiosity was measured with the Centrality of Religiosity Scale  consisting of 15 items that categorized the respondents into intrinsically, extrinsically, and not/marginally religious. Results: After adjusting for various sociodemographic, migration, and health-related characteristics, intrinsic religiosity was significantly associated with a lower risk of being a smoker (odds ratios (OR) = 0.34, confidence intervals (CI) = 0.15–0.76) and was also associated with a lower risk of alcohol consumption , but a higher risk of being overweight/obese  in comparison with extrinsic/marginal religiosity. No significant relationship was found between religiosity and physical activity. Conclusions: In Polish immigrants, intrinsic religiosity acts as a protective factor against some cardiovascular risk factors . There has been increasing interest in examining the relationships between religious, spiritual, and health variables in medical and psychological research during the last decades. Despite scientific progress, the role of religion/religiosity is still substantial for a large proportion of humankind. According to the Global Index of Religion and Atheism from 2012 [Religion plays an essential role in the lives of Poles. In Poland, 96% of the population declare their affiliation with the Roman Catholic Church , whereasThe statistics indicate not only the formal declaration of being Catholic of most Poles but also the high proportion of religious people in this nation. Eighty-one percent of Poles and 51% of the Germans describe themselves as religious .In Germany, no statistics are available for the mass attendance of Polish immigrants. Many immigrants of Polish origin participate in Polish-speaking religious services in the “Polish Catholic Missions” in almost every large city in Germany. In these Polish pastoral centers, it is not only church services that take place but also religious education in Polish, Polish classes, and activities of various religious and cultural groups . TherefoIn Germany, more than every fifth person (22%) has a migration background, either having personally moved there or having at least one parent who moved . There aAlthough religion/religiosity is a universal human phenomenon, there is no consensus among researchers regarding a definition for this concept. Religion is a complex and multidimensional construct that is generally associated with specific beliefs, practices, and rituals that are related to a sacred or transcendent  and take place within a community but can also be practiced in private . ReligioThe terms religiosity and spirituality are often used interchangeably in the literature; however, despite some similarities between them, they do not mean the same thing. Spirituality is more difficult to define than religiosity. It is a broader concept than religiosity and is not restricted to religious traditions. Spirituality can be regarded as the individual experience characterized by a quest for meaning in life and the relationship with the sacred or transcendent that can, but does not have to be, connected to formal religious communities and institutions . AnotherA wide variety of operationalizations of religion/religiosity exist. More than 125 measurement instruments were identified by Hill and Hood . SeveralTwo classical theoretical approaches to religion are worth mentioning: the conceptualizations of Allport  and GlocThe questionnaire applied in the present study to measure religiosity  is a syScientific evidence for the association between religion and mental health is largely based on the Handbook of Religion and Health  which isAlthough most of the research on religiosity and health has been conducted in the USA in Christian samples, in recent years, studies from other countries and religions have mostly supported the protective function of religiosity observed in U.S. surveys ,22.Despite the growing research interest in the examination of the health status of immigrants as well as the association between religiosity and various indicators of health, the literature on the relationship between religiosity and health-related lifestyle behaviors among immigrants is very scarce, and no investigation has been conducted on the population of Polish immigrants. Most of the studies on this topic have been conducted in the USA in Latino and Asian Indian immigrants. In sum, the scarce literature on the association between religiosity and health-related behaviors in immigrants has consistently shown an inverse relationship between religiosity and tobacco ,24,25 asIn a recently published systematic review on religion and body weight  includinSeveral mechanisms have been proposed as explanations for the impact of religion/religiosity on human health, namely, healthy behaviors and lifestyle, cognitive framework, social support, religious practices, spiritual direction, coping, alternative values, and positive emotions ,31,32. RThe relationship between religiosity and health has also aroused scientific interest in the field of neuroscience, for example, brain activity during prayer and meditation has been investigated . Also, sAlthough a large body of studies has generally demonstrated a positive effect of religiosity on various parameters of health, it is important to mention that religion/religiosity  may also have negative effects on human health in some cases, e.g., if a religious group forbids blood transfusions or medications, or leads to social isolation, etc. .Since religion/religiosity is a multidimensional phenomenon, it can be postulated that not the single mechanisms but rather their combination contributes to the favorable effects of religion/religiosity on health.The homogenous structure of the religious affiliation among the Polish immigrants provides a favorable basis to analyze the impact of  religiosity on health-related lifestyle behaviors.To examine the frequency of health-related lifestyle behaviors  and categories of religiosity  in immigrants of Polish origin in Germany.To investigate the association between religiosity and the four health-related lifestyle behaviors, with adjustment for various important sociodemographic, migration, and health-related characteristics in immigrants of Polish origin.The aims of the study were:Based on previous research, we postulated high religiosity to be associated with a lower risk of being a smoker and for alcohol consumption but hypothesized that there is no relationship between religiosity and physical activity or being overweight/obese.The recruitment took place in Germany (immigrants of Polish origin) and in Poland (autochthone Poles). The present study focuses only on Polish immigrants. The data obtained have already been used for other publications ,35,36,37In Germany, participants were recruited in centers in the Ruhr area  where Polish communities had been established, e.g., after Polish language mass, in religious and cultural groups in Polish churches, in non-religious places promoting Polish culture as well as among students from Polish migration backgrounds at the Ruhr University Bochum in Germany. In addition, probands were also recruited by the “snowball” method. This method can be regarded as an alternative sampling strategy if the examined target population is difficult to reach or identify , which iThe inclusion criteria for the study were age of consent (minimum of 18 years), agreement to participate in the study, adequate knowledge of the Polish language due to the fact that the questionnaire was applied only in Polish, residence in the Ruhr area or in neighboring cities, and the status of a Polish immigrant according to the definition applied in epidemiological research in Germany , i.e., hn = 257 first-generation immigrants were included in the present study.Four hundred and nine questionnaires were distributed, and 264 were returned (response rate: 56.3%). Two participants were excluded based on the exclusion criteria (residence not in the Ruhr area). Because only five people belonged to the second generation of immigrants (born in Germany), they were excluded from the analyses, so a total sample of Data were collected between August 2009 and October 2010 in the abovementioned recruitment centers. Participants completed the self-report questionnaire in Polish language at home.The present study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the Medical Faculty of the University of Duisburg-Essen (Project identification code: 11-4723). Written informed consent was obtained from all participants.The following sociodemographic and migration-specific items were assessed: gender, age, marital status, education level, employment status, subjectively perceived income, citizenship, length of residence in Germany, and German language proficiency.The smoking status: current smoker or non-smoker and the number of smoked cigarettes per day: <5, 5–10, 11–20, 21–40, >40.Alcohol consumption: never, seldom, once a month, several times a month, once a week, several times a week, every day.Physical activity per week (sport): never, <1 h, 1–2 h, 2–4 h, >4 h.2): <18.5 (underweight), 18.5–24.9 , 25.0–29.9 (overweight), ≥30 (obese). Obesity was defined according to the World Health Organization (WHO) as BMI ≥ 30 kg/m2 [Body mass index (BMI) category   which coAnxiety symptoms were assessed by the Beck Anxiety Inventory (BAI)  which coThe brief form of the Giessen Subjective Complaints List (GBB-24) , which cSubjectively perceived discrimination was assessed by means of four self-constructed items on a 1–5 Likert scale (higher scores indicating higher perceived discrimination) concerning the categories “neighborhood”, “shopping”, “administrative office”, and “working life” (see ). A totaThe Sense of Coherence Scale (SOC-29) is a self-report questionnaire consisting of 29 items on a seven-point Likert scale designed to assess the extent of coherence  which reThe Centrality of Religiosity Scale (CRS)  was applχ2-tests or Fisher’s exact test) were performed and for continuous data, t-tests for independent samples were computed. Pearson’s correlation analyses among the main psychological variables were calculated prior to estimating regressions to test multicollinearity (by inspection of a pairwise correlation matrix). If the correlation coefficients were higher than 0.70 [p < 0.05 was predetermined.Data analyses were conducted with SPSS V. 21 . Missing values in the questionnaires were replaced with the expectation-maximization algorithm . The following descriptive statistics were computed to profile the sociodemographic and migration-specific sample characteristics and the lifestyle behaviors: means, standard deviations, ranges, and frequencies. To test for differences between women and men for categorical data, parametric tests , were more likely to be unemployed (p = 0.001), to have a (very) low income (p = 0.001) but a higher education (p < 0.001), to have lived for a shorter period of time in Germany than the men (p = 0.027), and they more frequently had Polish citizenship (p = 0.001).In p = 0.022) but more frequently were overweight/obese (p < 0.001) than immigrant women. Regarding the number of smoked cigarettes per day, the frequency of alcohol consumption, and the physical activity level as well as the level of religiosity, no significant gender-specific differences were found.To avoid multicollinearity, bivariate correlations were computed among the main psychological variables. The correlation coefficients are presented in p = 0.009) and also a lower risk of alcohol consumption  in comparison with extrinsic/marginal/non-religiosity. No relationship was found between religiosity and physical activity. Highly religious immigrants were more likely to be overweight/obese than extrinsically, marginally, and non-religious immigrants .The odds ratios for the total sample are depicted in p = 0.089) and age (p = 0.09): older individuals and women were more likely to be physically inactive. In the full model for overweight/obesity, gender, depression, and age were also significant predictors: masculine gender, older age and a higher depression level were risk factors for being overweight/obese. The explanation of variance for the full model was 13.7% for smoking, 22.2% for alcohol consumption, 15.0% for physical activity, and 44.0% for overweight/obesity, respectively.Other significant predictors for smoking were gender and depression: women and more depressed individuals had a higher risk of being a smoker. Concerning alcohol consumption, younger age, masculine gender, lower discrimination levels, and higher anxiety were further significant predictors. For physical activity, significant tendencies were only detected for gender  [n = 16,557)   and the 16,557)    healthy lifestyle behaviors is not realized.Highly religious people showed an increased risk of being overweight/obese. This result was also demonstrated in a study with immigrants from the USA . One expAn important finding of our study is the high smoking rate (35.5%) in women. Also, the regression model provided support for the conclusion that immigrant women of Polish origin are a risk group for cigarette smoking. This gender difference found in our study does not match trends, as (immigrant) men are more likely to smoke than (immigrant) women ,54,55. AAnother important gender-related difference in this study was the significantly higher proportion of overweight/obese men than women. The male gender was also found to be a risk factor for being overweight/obese in the regression analysis. The higher probability of being overweight/obese among immigrant men is in line with the results of some prior studies ,59, whilIt is notable that a large proportion of our sample are physically inactive and are also overweight/obese. Almost two-thirds of the immigrants do not participate in any sport activity or participate for less than 1 h per week. According to the WHO, at least 150 min of moderate intensity physical activity per week is recommended to receive benefits on health . HoweverIn the present study, high levels of depressive or anxiety symptoms were associated with a higher risk of smoking, alcohol consumption, and being overweight/obese. This finding is in line with empirical evidence supporting the association between worse lifestyles and depressive and anxiety symptoms . It can The primary strength of the present study is that we applied a multidimensional, well conceptualized, reliable, and valid measurement of religiosity in a relatively large, religiously homogenous population of immigrants of Polish origin. Furthermore, we were able to include individuals who are difficult to identify for surveys (immigrants of Polish origin with German citizenship) and people who are often excluded from participation in studies in Germany because of insufficient language competencies (immigrants of Polish origin with insufficient German language proficiency). In addition, we included many potential moderator factors of religiosity in the regression models; thus, we were able to control for several confounding variables when examining the impact of religiosity on the indicators of health-related lifestyle behaviors.The results of our study should be interpreted in light of some limitations. The cross-sectional design of the study did not allow causal conclusions regarding the influence of the variables examined on the health-related behavior to be drawn. Prospective studies are therefore needed to investigate the associations found in the study and to detect underlying mechanisms. Another limitation was the low response rate (56.3%), which may have led to a selection bias, possibly with healthier immigrants being included in the sample. The “snowball method” could also have biased the results. Thus, the findings should be viewed as exploratory and cannot be generalized to the population of all immigrants of Polish origin living in Germany or to other ethnic minorities. Moreover, the non-objective, self-reported estimates of the four health-related lifestyle behaviors may also have been a source of bias because (some) respondents may not have reported the real data due to social desirability or shame . Studies indicate that women may underestimate their body weight, while men may overestimate their height . FinallyDue to the limitations in the study design  and the low response rate, the findings should be interpreted with caution. Several conclusions can be drawn from the results that provide important implications for public health. First, our findings indicate that high religiosity can be regarded as a protective factor against tobacco and alcohol consumption in immigrants of Polish origin. This should be considered in prevention programs. Secondly, immigrant Polish women present a risk group for smoking and should be targeted in preventive gender and immigration-specific anti-smoking programs. Thirdly, highly religious people and men are at a higher risk of being overweight/obese. Religious leaders and local religious communities should therefore be involved in preventive programs to promote not only abstinence from smoking and drinking but also a healthy lifestyle with physical activity and a healthy diet. Fourth, depressive and anxiety symptoms were shown to increase the likelihood for smoking, drinking, and being overweight/obese. Psychological support should be offered to immigrants with mental health problems to avoid dysfunctional coping with cigarettes or alcohol. Finally, religiosity can still be regarded as the “forgotten factor” in the research of  health , so it r


N = 888). Osteoporosis was present in 20% of this population. Participants with, as compared to without, osteoporosis reported that their physical health limited moderate activities , stair climbing , and shopping . More than half of the participants consumed less than the recommended servings of dairy, meat, grains, and fruits/vegetables regardless of osteoporosis status. Participants with osteoporosis had lower self-rated health and more physical limitations than people without osteoporosis. Although congregate meals are a way to improve nutritional intake, additional methods to improve nutrition (including education) may be of benefit, since undernutrition is a concern in this population.Osteoporosis, a chronic disease that results in low bone mass with an increased risk of fragility fractures, is prevalent in older adults. Diet can prevent or lessen the severity of osteoporosis. The purpose of this cross-sectional study was to assess differences in diet, quality of life, self-rated health, and physical function between congregate meal participants with and without osteoporosis. Data were from telephone survey, 10th Annual National Survey of Older American Act Participants, a representative sample of congregate meal attendees across the United States. ( Older adults are the fastest growing segment of the population and they have the highest medical cost of all age groups in the United States . PrimaryOsteoporosis is a degenerative disease of the skeletal mineral content resulting in low bone mass with increased risk of fragility fractures. Bone mineral density for persons with osteopenia (low bone density) is between 1 and 2.5 standard deviations below, and for persons with osteoporosis is ≥2.5 standard deviations below the mean density of young, non-Hispanic White adults; osteoporosis affects 24.8% of women and 5.6% of men aged 65 and older . Diet is a critical and modifiable risk factor for osteoporosis; calcium and vitamin D and an overall healthy diet including adequate protein from meat, eggs, beans, nuts, tofu, and sufficient vitamins, and minerals from fruits and vegetables are essential for adequate bone mass ,9,10. AnOther lifestyle factors associated with reduced risk of osteoporosis are tobacco and second-hand smoke cessation, reduced alcohol intake, and increased weight-bearing exercise . OsteopoThis study is a cross-sectional analysis of data from the 2015 Tenth Annual National Survey of Older American Act Participants (NSOAAP). The data are available to the public. The research protocol was approved by the Office of Management and Budget (OMB); the OMB Control Number for the 2015 Tenth NSOAAP is: 0985-0023. All participants signed an informed consent form for public use of their de-identified data. A two-staged stratified selection of 312 out of 628 area agencies on aging (AAoA) method was conducted and described in the Agency for Community Living website . BrieflyN = 888 which had data available for osteoporosis diagnosis (absent/present).The data for this study were extracted from Congregate Meals, which was one of the six services; other services included Home Delivered Meals, Homemaker Services, Transportation, the Family Caregiver Support Program, and Case Management. The 2015 NSOAAP Congregate Meals survey was conducted by telephone. Participants were asked, by trained interviewers, about their socio-demographics, foods consumed at the site and throughout the day, degree of satisfaction with meals and services that were received, medical health, emotional health, functionality, and social life. Sample weights and variance estimation were applied to account for non-response and to achieve a representative sample of congregate meal attendees across the United States. The population included 901 adults ages 60 years and older who completed the 2015 NSOAAP Congregate Meals survey. The final sample size was Level of dietary adequacy was considered as servings per day: under, at, or over the dietary guidelines’ recommendations for older adults for meat/protein-group , grains, dairy, total fruit and vegetable intake, and dessert. Dessert is not considered a major food group; albeit, it is considered as discretionary calories along with added sugars, solid fats, and alcohol. For persons eating from 1000 to 1600 calories, only 100 to 170 calories per day remain for discretionary calories . This woDietary recommendations for adults >50 years of age from each food group are as follows: 3.5 and 4.0 servings of fruits and vegetables; eight and nine servings of grain; five and 5.5 servings from the protein group; for women and men, respectively; and, three servings of dairy for both sexes .Dietary information was collected by interviewers who were trained in interpreting participants’ responses to type and amount of food consumed by probing interview questions sufficient to collect these details. They were asked to consider the foods they usually eat in a day. They could answer independently or with the help of their caretaker. The specific food group was presented. The following is an example of the script: “Considering all the food {you eat/s/he eats} in a day, how many servings of fruit {do you/does NAME OF PARTICIPANT} usually eat? One serving of fruit is one piece of fruit; one-half cup chopped, cooked, or canned fruit; or three-fourths cup of juice”. Difficulty with activities of daily living (ADL) skills were assessed by an affirmative response to questions concerning dressing, shopping, cooking, cleaning, and other physical activities.Physical health interfering with physical function was assessed by the question: “during the past four weeks, how much of the time have you accomplished less than you would like as a result of your physical health?”. The categories were collapsed into: all or most of the time, some of the time, and little or none of the time. This question is part of the Medical Outcome Study, RAND 36-item Short Form Survey Instrument .Self-rated health (SRH) was assessed based on the question: “in the past 12 months how would you rate your health?” Responses were collapsed from five categories  to three . SRH has been validated against actual health in older adults, and it is an independent predictor of mortality ,18,19. TRace/ethnicity was constructed by coding the responses for Hispanic and subtracting Hispanics from other categories to create non-Hispanic Whites, non-Hispanic Blacks, Hispanics, and Others .Other variables included activities at the site ; self-reported diabetes; education level; sex; marital status; food security (having or not having enough money to buy food), and low income .The dependent variable, osteoporosis, was determined by the participants recalling and furnishing an affirmative response to ‘having a medical doctor tell you that you had osteoporosis.’ The independent variables were activities of daily living skills, dietary adequacy , quality of life, and race/ethnicity.Characteristics of the study population were determined by frequency analysis with the test of equal cell proportions and presented as percentages with 95th confidence intervals. Diet and ADL were cross-tabulated by osteoporosis status and the Pearson chi-square test was used for testing differences between groups. Dietary adequacy was compared by sex. Separate reduced and full logistic regression models were created for SRH and dietary adequacy as major independent variables with osteoporosis as the dependent variable. Full models included major sociodemographics  and the rest of the study variables. The reduced model was the most parsimonious model  that retained the hypothesized predicting independent variable and the major sociodemographics. Analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 24 , with the module for complex sample analysis. Sample weights applied to achieve a representative sample of the United States population attending congregate meals. The results were presented with and without the Bonferroni correction for multiple comparisons. The general characteristics of the study population are shown in p < 0.008) was considered. Medical conditions, such as joint pain and arthritis, and comorbidities, such as diabetes and anemia, were also associated with physical function (data not shown) and may be confounders for physical function and osteoporosis. p < 0.007) was applied.p = 0.235), nor could a model by race and sex . The dietary recommendation for total fruits and vegetables does not include potatoes, which accounted for some calories. Total consumption of vegetables, including potatoes, for men and women was as follows: 9.5%, one serving; 45.9%, two servings; 27.0, three servings; 10.7%, four servings; and 4.5%, five servings, with 2.4% misclassified or missing . Persons surveyed in this study had below the recommended servings from the meat and dairy groups placing them at risk for osteoporosis or the disease progression. The International Osteoporosis Foundation  recommenSociodemographic differences in diet adequacy were present in Florida congregate meal attendees. Thirty-one percent of older adults in six congregate meal sites in Northern Florida were at high nutrition risk with the majority being African-American and female . In the Vitamin and mineral supplementation and exercise, associated with bone mass, were not measured in the current study. Vitamin D supplementation in bread improved physical function (locomotion and daily activities) over time in older adults living in a nursing home . Another2) [Bone mineral density was positively associated with greater total fruit and vegetable intake and lower rates of osteoporosis for Chinese adults aged 40–75 years with low body mass indices <24 kg/m kg/m2 [22) . AccordiInadequate nutrition affects community-dwelling elders in the United States ,26, as wIn the present study, participants with osteoporosis were more-likely to have difficulty performing active daily living skills, a poorer quality of life, and a lower self-rated health as compared to participants without osteoporosis. Our results agreed with a study of community-dwelling adults aged 75 and older in Germany where osteoporosis negatively affected active daily living skills ; albeit,Finally, in the present study, several sex differences were found for osteoporosis and diet. Osteoporosis was more common in females as compared to males. Males consumed more servings of desserts and grains as compared to females; however, there were no differences in daily servings of meat, dairy, and fruits and vegetables. Our study agrees, in part, with Powers et al. , who repThis study has several limitations that should be mentioned. Causality cannot be assumed due cross-sectional design. Bone mass is determined largely by genetic factors; albeit, 10–50% of bone mass and structure is attributed to lifestyle factors such as diet, smoking, alcohol consumption, and physical activity . GeneticPeople with osteoporosis had lower self-rated health and poorer physical health than people without osteoporosis. Even though congregate meal sites offer nutritious meals, the people surveyed were likely to have undernutrition. In particular they were found to have inadequate consumption of protein, dairy, and produce  essential for bone health despite. Strategies to increase participation in nutrition education may benefit health in this population.