Blueberry wine residues produced during the wine-brewing process contain abundant anthocyanins and other bioactive compounds. To extract anthocyanins from blueberry wine residues more efficiently, a novel procedure of ultrasound-assisted deep eutectic solvent extraction (UADESE) was proposed in this work. The extraction process was optimized by response surface methodology coupled with genetic algorithm. The optimum extraction parameters to achieve the highest yield of anthocyanins (9.32 ± 0.08 mg/g) from blueberry wine residues by UADESE were obtained at water content of 29%, ultrasonic power of 380 W, extraction temperature of 55 °C, and extraction time of 40 min. The AB-8 macroporous resin combined with Sephadex LH-20 techniques was used to purify the crude extract (CE) obtained under optimum extraction conditions and analyze the anthocyanins composition by HPLC-ESI-MS/MS. The cyanidin-3-rutinoside with purity of 92.81% was obtained. The HepG2 antitumor activity of CE was better than that of the purified anthocyanins component. Moreover, CE could increase the intracellular reactive oxygen species levels and the apoptosis, and arrest HepG2 cells in the S phases. These findings provided an effective and feasible method for anthocyanins extraction, and reduced the environmental burden of this waste. Vaccinium spp.), as a good source of bioactive compounds, includes polyphenols, anthocyanins, superoxide dismutases and flavanols +) corresponded to the loss of a glycoside on m/z 449.0. The mass spectra obtained were similar to those obtained by other authors in the case of cyanidin-3-rutinoside from litchi pericarp and tartary buckwheat + at m/z 331.0 corresponded to the loss of the glucoside from malvidin-3-glucoside. This anthocyanin was identified in grape skins [Rhodomyrtus tomentosa [Vitis vinifera red grape [The ESI/MS profile of peak 4 . However, the viability of HepG2 cells treated with CE at different concentrations was significantly lower than that of the cells treated with component Ⅰ (p < 0.05). Moreover, the viability of the HepG2 cells treated with CE at 48 h was lower than that at 24 h. Results indicated that the anti-tumor effect of CE on HepG2 cells was better than that of component Ⅰ, and this effect was observed in a time-dependent manner. Based on the above results, the 48 h exposure of CE was chosen for later studies. In addition, the normal human hepatocytes (HL-7702 cells) were treated by using different concentrations of CE and component Ⅰ at 24 h and 48 h. Results are described in p > 0.05). Results implied that CE and component Ⅰ had no toxic effect on HL-7702 cells at a range of 0.1–10.0 µg/mL. Subsequently, the cytotoxicity of the CE and the component Ⅰ to HL-7702 cells increased significantly with increasing concentrations at 24 and 48 h (p < 0.05). Consequently, 0.1–10.0 µg/mL of CE were used in subsequent experiments.First, the effects of the CE and component Ⅰ on cell viability were determined using the MTT assay. Experimental results are shown in p < 0.05). Results indicated that CE could inhibit the growth of HepG2 cells by improving the intracellular ROS levels. Similar experimental results were found in the case of purple rice and bilberry anthocyanins extracts [The production and the clearance of ROS in normal cells were in a dynamic equilibrium. The appropriate amount of ROS can promote macrophages to play their phagocytotic and enzymatic immunophysiological functions. However, the generation of excessive ROS can inhibit tumor cell activity and cause apoptosis. Thus, the fluorescent probe DCFH-DA was utilized to monitor the intracellular ROS levels and clarify whether the growth inhibition of CE on HepG2 cells was related to intracellular ROS levels. As illustrated in extracts ,31.The Annexin V/PI double staining and the flow cytometry analysis were carried out to elucidate the effect of CE on the apoptosis of HepG2 cells. As shown in p < 0.05). The CE treatment (0.1–10.0 μg/mL) notably enhanced the percentage of cells in the S phases in a dose-dependent manner compared with the vehicle-control treatment (p < 0.05). Compared with the vehicle treated group, 0.1–10.0 μg/mL CE treatment significantly increased the percentage of cells in the G2/M phases (p < 0.05). Nevertheless, no remarkable difference in the percentage of cells in the G2/M phases was observed between the 0.1 μg/mL and the 10.0 μg/mL CE treated groups (p > 0.05). These results revealed that CE could arrest the HepG2 cells in the S phases.The effect of different concentrations of CE on the cell cycle distribution was analyzed using the commercial cell cycle detection kit to clarify whether the growth inhibition of CE on HepG2 cells was related to cell cycle arrest. As shown in Blueberry wine residues were collected from Heilongjiang blueberry manor Biotechnology Co.; Ltd. . The squeezed blueberry wine residues weighing 50 kg were dried in the FD-1A-50 freezing-vacuum dryer  at −18 ℃ until the moisture content was less than 5%, and then the dehydrated blueberry wine residues were stored at −18 ℃ for 12 h before crushed. The frozen samples were thawed and milled into powdered particles smaller than 0.45 mm using an electric mill , sealed in a brown reagent bottle and stored at 4 ℃ for the follow-up experiments.Cyanidin-3-O-glucoside (C3G) was offered from Chengdu Gelip Biotechnology Co.; Ltd. . Choline chloride, glycerol, 1,3-butanediol, 1,4-butanediol, glycol, acetonitrile, and sodium acetate buffer of analytical purity were purchased from Shanghai McLean Biochemical Technology Co.; Ltd. . AB-8 macroporous resin and Sephadex LH-20 were offered from Tianjin Tianxin Fine Chemical Factory . Human hepatoma cells (HepG2 cells) and Human normal hepatic cell (HL-7702 cells) were afforded from Concorde Cell Repository . The fetal bovine serum (FBS) was from GIBCO-BRL . MTT was obtained from Beijing Baileibo Technology Co.; Ltd. . RMPI-1640 medium, penicillin, and streptomycin were provided from Beijing Shengmu Biotechnology Co.; Ltd. . Trypsin was obtained from Beijing Fubo Biotechnology Co.; Ltd. . Annexin V-FITC/PI cell apoptosis detection and ROS kits were from Shanghai Yisheng Biotechnology Co.; Ltd. . Formic acid, ethanol, and potassium chloride buffer were purchased from Shanghai Jinjinle Industrial Co.; Ltd. .DESs were prepared following the previous research with some modifications . DESs cog and 25 °C for 15 min by using the KH20R-Ⅱ type centrifuge  to obtain the anthocyanins extract. The extract was concentrated using the DZFY-2L type vacuum rotary evaporator  at 40 °C and freeze-dried using the FD-1A-50 dryer for 48 h. After drying, the crude anthocyanin powder was sealed in a brown reagent bottle and stored at −18 °C.Anthocyanins were extracted using UADESE in accordance with a previously described method with some modifications . The lyo3COONa-HCl buffer at pH 4.5). Each of these mixtures was stored away from light for 30 min at 25 °C. The absorbance of each sample was determined at 510 and 700 nm, respectively. The anthocyanins yield was calculated by Equation (2) [ωM is the molecular weight of C3G, 449.2 g/mol; DF is the dilution factor; ε is the molar extinction coefficient of C3G, 26,000 L/mol·cm; L is the path length, cm; V is the total volume of extraction solvent, mL; m is the weight of blueberry wine residues powder, g.The yield of anthocyanins in blueberry wine residues was measured by a pH differential method using a UV-3802S visible spectrophotometer . Briefly, 3 mL of anthocyanins extracts were diluted with 5 mL of two different buffers (0.025 M KCl-HCl buffer at pH 1.0 and 0.4 M CHtion (2) .(2)c=[.X1), ultrasonic power (X2), extraction temperature (X3), and extraction time (X4) are selected as independent variables, whereas the anthocyanins yield (Y) is regarded as the response. The level and code of these factors are shown in Y is the anthocyanins yield, mg/g; iX and jX are the coded variables (i and j range from 1 to k); β0, jβ, jjβ and ijβ are regression coefficients of intercept coefficient, linear, quadratic, and the second-order terms, respectively; k is the number of independent parameters (k = 4) and ie is the error.According to the single-factor experimental results, the Box–Behnken design (BBD) of 4-factor-3-level was conducted to investigate the influence of different variables and their interactions on the yield of anthocyanins from blueberry wine residues. The following four independent factors were considered: water content in DESs (R2) and the percentage absolute error of deviation (AED) between the experimental (Yexp) and the calculated (Ymod) results were used to assess the effectiveness of the model in this paper. R2 and AED were calculated using Equations (3) and (4), respectively.The regression coefficient  Determination of decision variablesX1), ultrasonic power (X2), extraction temperature (X3), and extraction time (X4). The process could be represented by Equation (5).According to the single-factor experimental results, four factors were selected as decision variables: Water content in DESs  Determination of objective functionidK is the design value of the i-th parameter; imK is the target value of the i-th parameter; iK is value of i-th parameter processing.Deviation method has the advantage of avoiding the influence of unit dimension on optimization model. The process could be described by Equation (6)iK is equal to 1, the function exactly satisfies the design aim of the objective parameter i. Euclidean distance is employed to express the deviation of each parameter from the target value, which is calculated by Equation (7).ik is the deviation of parameter i from the target value. Each design parameter has a big optimization objective. The following objective function is confirmed to achieve overall optimization.iw is the target weight of the i-th parameter, iw is larger, parameter i is more important, and the goal of parameter i is satisfied first in design.When (3) Determination of constraint functionConstraints of GA optimization: Select the upper and lower limits of each factor level, and the constraints of the highest anthocyanins yield are as follows:The optimization mathematical model of UADESE anthocyanins from blueberry wine residues is a mixed programming problem with inequality constraints. According to the required optimization objective function and related constraints, the GA toolbox of MATLAB version R2018b was employed for optimization studies. The objective function can be detected by Equation (8).v/v) of pH 3 at 2 BV/h. The eluent was collected, and ethanol was recovered using the rotary evaporator at 40 °C to obtain an anthocyanin-rich solution. The anthocyanin-rich solution was further separated using Sephadex LH-20 medium pressure column chromatography (2.9 × 25 cm) and washed with 70% ethanol  at 1.5 BV/h when anthocyanins were completely absorbed in the Sephadex LH-20. The eluent was collected 1 tube for pre 3 mL and freeze-dried via the FD-1A-50 dryer. Finally, the purified anthocyanin component (component Ⅰ) was obtained.The separation and the purification of anthocyanins were described in a previous report . CE (200v/v)) and filtered through a 0.45 μm filter membrane. The 1100 series liquid chromatography system equipped with a DAD and Zorbax Eclipse XDB-C18 column  was used to determine the anthocyanins contents. Two solvents, including 5% (v/v) formic acid (mobile phase A) and 1% (v/v) formic acid acetonitrile (mobile phase B), were used in the mobile phase. The gradient elution was as follows: 5%–20% B (0–5 min), 20%–25% B (5–15 min), 25%–30% B (15–20 min), 30%–33% B (20–35 min), and 33%–5% B (35–40 min). The mobile phase was pumped by the system at a rate of 0.8 mL/min. The injection amount of the sample was set to 20 µL. Moreover, the column temperature and the wavelength set 25 °C and 520 nm, respectively. The purity of the anthocyanins component can be calculated using Equation (10).iw and iA are purity and peak area of component i, respectively. if is the correction factor.The HPLC-DAD and HPLC-MS methods for the analysis of anthocyanins components in CE and component Ⅰ were consistent with our previous study . Before m/z in the positive mode. The voltages of the capillary, sampling cone, and extraction cone were 2.0 kV, 40 V, and 2.0 V, respectively. The temperatures of source and desolvation were set to 115 and 350 °C, respectively. The time of scan and interscan were 13 min and 0.28 s, respectively. The gas flow of the cone and the desolvation were 50 and 900 L/h, respectively. The collision energy was set 20.0–45.0 eV. The Mass-Lynx TM V 4.1 software was used to collect experimental data.The mass spectra were obtained at a range of 100–1000 2, and the media were replenished every two days. Logarithmic cells were used in this study. The RMPI-1640 medium was employed to prepare the sample solutions of CE and component Ⅰ. Samples were filtered through a 0.22 µm membrane for sterilization before the experiment.HepG2 and HL-7702 cells were cultured in the RMPI-1640 medium with 10% FBS and 1% penicillin-streptomycin and placed in an incubator maintained at 37 °C and 5% CO3 cells/mL) were grown in 96-well plates at 37 °C in a humidified 5% CO2 incubator for 24 h. Cells were treated with different concentrations of CE  and component Ⅰ for 24 h and 48 h. After the above treatment, the supernatant was removed, and each well was added with 20 µL MTT (5 mg/mL) and incubated for another 4 h. The culture medium was then replaced with 150 µL DMSO in each well to dissolve the formed blue formazan crystals. Subsequently, the absorption value of each well was determined at 490 nm by using the WD-2102b automatic enzyme labeling instrument . Cell viability was calculated using Equation (11). All experimental results were described as the mean ± SD of three experiments with six wells per treatment group.Cell viability was measured by using the MTT method in accordance with the previously described method . The Hep5 cells/mL) were seeded into 6-well plates and incubated overnight. Cells were treated with different concentrations of CE  for 48 h. Cells were then washed with PBS and subsequently incubated with 5 μM DCFH-DA in PBS at 37 °C for 30 min. HepG2 cells were washed with PBS, and collected by centrifugation, and re-suspended in PBS. Finally, the ZE5 multicolor flow cytometer  was used to determine the fluorescence intensity.In accordance with the results of MTT, CE was selected for subsequent experiments. The effect of CE on ROS generation in HepG2 cells was monitored by the ROS kit in accordance with its instructions. In short, HepG2 cells (1 × 10The apoptosis of HepG2 cells was determined using the Annexin V-FITC and propidium iodine (PI) dual staining, which was performed using the ZE5 multicolor flow cytometer . The tre5 cells/mL and incubated overnight. The cells were exposed to different concentrations of CE . After 48 h, HepG2 cells were harvested and fixed with cold 70% ethanol  at −20 °C for 24 h. Subsequently, the treated HepG2 cells were washed with PBS and incubated with RNase (50 μg/mL) at 37 °C for 20 min. Finally, the cells were stained with 50 μg/mL PI at 4 °C for 15 min in the dark and subjected to the ZE5 multicolor flow cytometer. The experimental data were analyzed using the Modfit LT software .The cell cycle analysis was conducted using a previously published method . Brieflyp < 0.05 represented the experimental data with statistical significance. Design-Expert software (version 8.0.6) for BBD analyses was employed to design combinatorial experiments. All analyses were performed with SPSS Statistics 19 (version 13.0). Origin software (version 9.0) was used for drawing in this study.All experimental data were represented as mean ± SD. The one-way analysis of variance was used to analyze statistical differences between groups. This study was performed to investigate the UADESE anthocyanins from blueberry wine residues and optimize the extraction conditions by GA based on RSM. The optimum extraction parameters to achieve the highest yield of anthocyanins of (9.32 ± 0.08 mg/g) from blueberry wine residues via UADESE were obtained at water content of 29%, ultrasonic power of 380 W, extraction temperature of 55 °C, and extraction time of 40 min. The cyanidin-3-rutinoside with purity of 92.81% was obtained. The HepG2 antitumor activity of CE was better than that of component Ⅰ. In addition, CE could increase the intracellular ROS levels and the apoptosis, and arrest the HepG2 cells in the S phases. Finally, findings confirmed that the UADESE was an efficient, reliable, and environmentally friendly extraction method. Further studies will focus on more detailed identification and quantification of other phenolic compounds available in the extract and to investigate their antitumor mechanism.


Complying with individual privacy perceptions is essential when processing personal information for research. Our specific research area is performance development of elite athletes, wherein nutritional aspects are important. Before adopting new automated tools that capture such data, it is crucial to understand and address the privacy concerns of the research subjects that are to be studied. Privacy as contextual integrity emphasizes understanding contextual sensitivity in an information flow. In this study, we explore privacy perceptions in image-based dietary assessments. This research field lacks empirical evidence on what will be considered as privacy violations when exploring trends in long-running studies. Prior studies have only classified images as either private or public depending on their basic content. An assessment and analysis are thus needed to prevent unwanted consequences of privacy breach and other issues perceived as sensitive when designing systems for dietary assessment by using food images.The aim of this study was to investigate common perceptions of computer systems using food images for dietary assessment. The study delves into perceived risks and data-sharing behaviors.We investigated the privacy perceptions of 105 individuals by using a web-based survey. We analyzed these perceptions along with perceived risks in sharing dietary information with third parties.We found that understanding the motive behind the use of data increases its chances of sharing with a social group.In this study, we highlight various privacy concerns that can be addressed during the design phase. A system design that is compliant with general data protection regulations will increase participants’ and stakeholders’ trust in an image-based dietary assessment system. Innovative solutions are needed to reduce the intrusiveness of a continuous assessment. Individuals show varying behaviors for sharing metadata, as knowing what the data is being used for, increases the chance of it being shared. Food images are highly relevant for use in medical research and sport science. They can capture continuous and accurate measurement of diets, and therefore are imperative in understanding the relationship between food intake and athletic development  or betweAlthough research on human subjects is already strictly regulated by local, national, and international boards and procedures, the increased usage of personal information recorded automatically through new technology comes with new concerns for the security and privacy of the subjects. Little attention has been given to the specific individual privacy requirements related to the design of IBDA systems ,18, and survey wherein subjects were asked about their perceptions of privacy with regard to capturing food images by using a smartphone camera. Taking food pictures is already a trend on many social networks, where people typically post images of their meals during vacations and special events [To improve our understanding of the privacy requirements in population-based research data, we conducted a web-based l events , and thel events ,24; our Another important lesson from previous epidemiological-related work is that the data capturing should not be intrusive. We have previously attempted to use, for instance, 24-hour dietary recall–inspired methods with pictures taken during meals, but this showed to be too intrusive and too time-consuming for elite athletes. Moreover, the dropout rates of these elite athletes were very steep with these methods. Hence, we developed this survey by using alternative schemes for data assessment, wherein pictures of meals were captured similar to that captured in social media engagement.From a more general perspective on privacy, food images offer an interesting case to study, as few food images might not carry much sensitive information. However, a large individual data set of images that is continuously recorded over long periods (>2 weeks) and linked to an individual’s identity might disclose information that many find too sensitive to share. Such disclosure is a growing public concern ,26 and tSystematic reviews of dietary assessment methods ,27 have Zerr et al  exploredThe work on IBDA methods by Boushey et al ,11 and OTo improve our understanding of the privacy perception related to the capture and use of food images, we conducted a study by using a web-based questionnaire  hosted bThe survey was designed to record participants’ perceptions in the following scenarios: (1) Scenario A, the participant having to record and share dietary data as an athlete; (2) Scenario B, the possibility and severity of privacy leak from one’s dietary data; and (3) Scenario C, sharing dietary data and reports among different social groups.The scenarios were designed to be familiar to our participants and to cover various angles on data sharing. For Scenario A, sharing is both internally and externally motivated and controlled by the subject; however, the subject is not in control of the processing. For Scenario B, the subject is not in control of the data processing but has concerns about the processing outcomes, and for C, the sharing is consensual but is based on external motivation from different social groups, for example, receiving feedback from a doctor or sharing with family/friends as part of social behavior/interaction.We used these scenarios to record our participants’ perceptions and attitudes toward sharing data. Note that we considered the perceptions on a scenario valid even for participants who never encountered that scenario in real life beforehand. One’s perceptions can affect one’s participation in a study if the concerns are not addressed at the beginning of a study.Likert item, ranging from strongly disagree to strongly agree. These include perceptions toward responsibility for privacy, intrusiveness, and general attitude toward dietary practices [Our questionnaire starts by familiarizing participants with food pictures on social networks (Scenario A). It then asks about the use of social networks and experience with taking food pictures. Additionally, participants are asked about their preference of IBDA methods over other similarly used techniques for dietary assessment. Attitudes toward privacy and personal control over data were collected on a 5-level ractices .Next, the participants are asked to consider Scenario A—an athlete who records his/her diet by taking pictures. We specify that every meal is recorded by taking a picture, including drinks, and even at events outside training by using a mobile app. We specify that the app allows the team owner, manager, coach, and doctor to monitor his/her diet and recommend diet plans. Continuing with questions from Scenario A, we further obtain responses toward the privacy and usability of metadata collected through such a system. tag the location of a restaurant when posting a food picture. Further, we presented the hypothetical situation of a third party that gains control of a participant’s diet data of 1 year. Based on that data, a few aspects of the individual might be inferred. We presented Scenario B and collected responses on what the participants thought can be inferred. The inferred information examples were hypothetical, and to our knowledge, no such work exists. It was designed to evaluate perceptions toward what is possible and how sensitive particular information is to the participant. The responses were collected on a 3-item likelihood and sensitivity Likert scale.Regarding metadata collected through an IBDA system, we presented existing social network jargon that many are familiar with. For example, some users Family, Friends, Doctor, Team, and Fans. Participants indicated their binary responses by checking corresponding blocks in the questionnaire. Additionally, we provided an option if they thought the information is sensitive and they do not wish to share with anyone. At the end of the questionnaire, the participants were asked a series of demographic questions, including some additional ones about their diet and allergy. The collected data from Nettskjema were downloaded and analyzed after the end of the study. The results are presented in the Results section.In addition to perceived threats with sharing food pictures and subsequently data set, we collected responses about which social groups an individual was voluntarily willing to share information about their diet with. The information as food images and attached metadata typically associated with an image was considered for sharing. In addition to food images, we added additional parameters such as medications and diet plans. The groups provided were P>.05 supporting the hypotheses that the responses are uniform across the participants. The actual P values that we obtained were P=.14, P=.15, P=.56, P=.18, and P=.78. We performed another set of Kruskal-Wallis tests to determine whether the responses among European and non-European participants had statistically significant differences. For E1-E5, the observed P values, that is, P=.20, P=.14, P=.28, P=.92, and P=.50 indicated that they were not different. Therefore, we proceeded with reporting ordinal variables in our results by using compound bar charts.We performed the Kruskal-Wallis test  to deterlikelihood did not indicate a strong correlation with the concern. The maximum correlation coefficient we observed was between the likelihood and severity of concern for “financial status” with r=0.41 (P<.001). However, it was still a low correlation. We report our observed ordinal values later in the Results section. We did not use a prediction model in our analysis as we did not find any predictor variables to be significantly related to the outcome in our analysis (P>.05).Additionally, we measured consensus among the reported ordinal values by using the Tastle and Wierman’s consensus measure . We reposnowball sampling methodology [Chung at al  showed thodology  to recruOf the 105 participants, 99 (94.2%) indicated having an account on a social network. Of the 99 participants, 95 (96%) reported seeing food pictures at least once over social networks. In this section, we discuss the perception of privacy and related attitudes based on the findings in our study. We divided our results into expectations and concerns. The expectations cover general perception toward privacy, IBDA methods, and data use. The concerns cover information that can be inferred from their dietary data. Additionally, we discuss the concerns toward exposing such information to a third party from their mobile Food Records (mFRs). Finally, we present our findings regarding the sharing of collected dietary information with different social groups.We present the general expectations that participants have indicated toward IBDA methods. We also explored their attitudes toward data collection and use.Approximately 80.9% (85/105) of the participants agreed that capturing diet records by using a phone camera is easier than writing down their dietary intake see E1, . Individterms of use.” While Europeans have a legal right to demand such explanations, we excluded data from them to see what the participants from outside Europe prefer. Even among non-Europeans , we observed a similar interest in the participants in knowing what their data are being used for.Individuals tend to have very little or no information about how their data are being used. Many individuals feel that they have no control . In 2018Trust is important for participation in epidemiological research . The earWith regard to food allergies, only a fraction of the participants  were very concerned about it being exposed to a third party . About oAbout the possibility of deriving allergies from their mFRs, more than two-thirds  thought that allergies can be inferred. A little more than a quarter  thought that it was not very likely to be derived from the mFR of an individual. This trend was very similar among participants with allergies. Approximately 30% (12/39) of the participants with allergies thought that it was not likely that it can be inferred from their mFRs.Religious belief is often considered sensitive information in regional laws . It can very concerned about a third party learning about their religion. Participants following religious diets (n=17) were slightly more concerned about a third party learning about their religion. Approximately 65% (11/17) of the participants following religious diets indicated that they were concerned about a third party learning about their religion from the mFRs.With regard to a third party learning about their religion, a little more than half  of the participants were not concerned. Only 17.1% (18/105) were As personalized dietary interventions are more effective , IBDA syInformation collected by an IBDA system about an athlete’s diet provides insights into dietary habits and can guide toward a proper diet. There might be additional metadata collection through an IBDA system. The information collected in the form of food images along with metadata can be mined for other purposes as well. For example, the time of dietary intake can be useful for maximizing performance on the field or predicting burnout. Similar to trends on social networks , an athlfamily, the participants were more willing to share food images with their doctors . Only a quarter  of the participants showed willingness to share food pictures with their sports team while nearly half  showed willingness to share food pictures with friends. In terms of the metadata associated with dietary data, such as the time of the meal, the willingness to share further drops. Only 68.6% (72/105) of the participants agreed to share the time of the meal with their families in comparison to 82.9% (87/105) sharing the time of the meal with their doctors. Time of food intake is in fact an important consideration for elite athletes and coaches with respect to restitution and training planning.About three-fourths  of the participants showed willingness to share food pictures continuously with family. In comparison to the social group family and also with doctor. Unsurprisingly, participants were not very keen on sharing location with their fans . About 16.2% (17/105) of the participants did not want to share their location of places they eat with anyone.Individuals are more cautious about sharing their location. Only 70.5% (74/105) expressed willingness to share the location associated with diet records with doctor. There was a weak correlation between willingness to share location along with the food image with a doctor. Within the family group, there was a strong correlation in sharing diet plan and time. In terms of sharing metadata with one’s team, we observed a strong correlation between diet plan and food image. The willingness to share time and location with one’s team was also strongly correlated.In this paper, we present our findings on the perception of privacy for an IBDA system. Our findings provide a coarse view of privacy attitudes toward conducting dietary assessments with food images. Expanding upon prior works ,18, thesPersonalized dietary interventions are more effective than universal recommendations . HoweverOur initial assumption from the study by Chung et al  was thatSharing an athlete’s data with fans can be an interesting opportunity to engage with followers, such as for crowd support using HeartLink . HoweverElite sport clubs, particularly in our elite soccer domain, have nutritional experts hired as part of their management and support team. Such experts are involved in providing detailed dietary plans for their athletes, and they know in detail about most of the common meals provided on-premise for the athletes. For instance, our main elite soccer clubs involved in our cooperation, as a rule, have breakfast and lunch together in their training facilities. Involving such experts using our proposed scheme means that they receive the needed data from their athletes when outside the training facilities to complete the picture.We investigated the privacy perceptions and concerns for conducting long-running studies using IBDA methods. For epidemiological studies, it is important for users to continuously record diets without any biases. In this study, individuals preferred recording diets using a digital camera over other methods. However, taking a picture of every meal is still perceived as intrusive for some users. For long-running studies, prediction models can be employed to reduce the labor of taking pictures . In summOur study has the following limitation. A questionnaire-based study fails to identify the causation of behavior. For privacy reasons, we did not collect the contact information from the participants. Hence, any further study with the same set of participants is not possible.In conclusion, we conducted a questionnaire-based study to understand the privacy perceptions and concerns for building IBDA systems. The privacy concerns can be addressed during the design phase to mitigate risks and strengthen participants’ and stakeholders’ trust in a system. We find a growing interest to know what the collected data are being used for. While IBDA methods are preferred for ease of use, continuous assessment is still seen as intrusive. GDPR compliance is an attractive feature for individuals worldwide. While uncertain about the inferences from mFRs, identity remains a top concern with regard to privacy for individuals. Knowing what the data is being used for, increases the chances of it being shared. Individuals are concerned about metadata sharing with third parties. We recently started a large interdisciplinary study involving computer scientists, sports scientists, psychologists, mathematicians, and medical experts . Our select cohort includes over 400 female elite soccer athletes, from Norway to Portugal, and we intend to conduct our next study in this cohort.


Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to “social influences” (40 studies) and “social/professional role and identity” (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians’ paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients’ trust in the effectiveness of the medication and/or the doctor’s advice, or preferences for alternative therapies.Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level. The global burden of diabetes has been continuously increasing in the past decades and this trend is expected to continue in the coming years , 2. As gIn Latin America and the Caribbean (LAC), the lower consumption of fruit and vegetables, as well as the higher intake of saturated fats, sugar and salt in comparison with other regions in the world, is leading to a remarkable problem of obesity and, consequently diabetes . ImportaMany countries in LAC have developed a universal health insurance program. However, the programs tend to be more focused on patient’s rehabilitation and treatment, rather than on the prevention or diagnosis phases of disease . Like moThe reviews that have so far described barriers to T2DM management also come from high-income countries and have mainly focused on individual behaviours rather than considering the patients’ environment –19. The In this systematic review, we evaluate observational studies with qualitative and/or quantitative methodology to identify the barriers or facilitators to the management of T2DM in LAC countries, from the perspectives of patients, their relatives or caregivers, healthcare professionals, and/or any other stakeholders.We conducted a systematic review to identify barriers and/or facilitators in the management of the T2DM disease in LAC countries. We considered T2DM management to include strategies or care protocols for the control of the disease and its risk factors, as well as prevention of complications such as diabetic retinopathy, kidney or heart disease, and diabetic foot. How successful management of the disease was defined depended on the focus of the different studies included. For qualitative studies, it depended on the perceptions of the participants, and how they defined good or poor control of the disease. In quantitative reports the issue was more complex because it was highly influenced by the researcher who designed the data collection tools. In this case, successful care was considered according to measurements such as adherence to care protocols using predefined tools, questionnaires assessing quality of life, or indicators of health care access. We defined facilitator as any factor that supports the management of T2DM and barrier as any factor that limits the disease management. These factors may be socioeconomic, educational, cultural, behavioural, cognitive, structural, or logistical. The source of the data can be patients, patients’ families or caregivers, healthcare professionals or any other stakeholder. We recorded the information related to barriers and facilitators as they were reported in the studies. Depending on the perception of the study participants, the same factor may be perceived as a barrier by some stakeholders and a facilitator by others, e.g. religion.Paired reviewers independently assessed each stage of the review process, from study selection to data synthesis and analysis, and a third reviewer resolved discrepancies. Identification of barriers and facilitators related to disease management was not always explicitly stated as the objective of the research, and the use of different terminology was common. During the abstract review, if it was apparent that barriers or facilitators to diabetes management were reported, we assessed the full text for inclusion.https://www.crd.york.ac.uk/PROSPERO/, protocol number CRD42019134938 on 22 July 2019  AND . We included the condition that the research was carried out at least in one country in the LAC region, according to the World Bank . TherefoWe selected studies that: (1) included individuals with laboratory confirmed or self-reported T2DM who lived in LAC countries (2) described facilitators or barriers related to successful management of the disease; (3) reported original data; (4) were written in English, Spanish, French or Portuguese. Studies that included numerous pathologies were included provided that some participants had T2DM and they their results were reported separately. We excluded studies that included solely patients with other diagnoses, or with healthy individuals focussing on primary prevention of T2DM.We extracted the information of interest using an ad-hoc checklist that included the following variables:Study characteristics: first author, year of publication, study location, study focus , study methods , and whether or not the study was carried out in an urban or rural setting.Participants characteristics: medical issue ; participant type , number of participants, number of people with diabetes by sex, age of people with diabetes, socioeconomic status of people with diabetes, ethnicity of people with diabetes.The facilitators and/or barriers related to the management of T2DM described in the study to improve diabetes care.To evaluate the external validity and risk of bias of the selected studies, we developed a seven-item checklist using the Newcastle-Ottawa Scale  and the We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management and described their relative frequencies. We conducted a qualitative analysis of the identified barriers and facilitators according to the Systematic Text Condensation method developed by Malterud . This foWe initially identified 1,595 records, of which 168 full-text articles were assessed for inclusion and 60 studies were finally included –86 Fig . A detaiThe studies involved participants from 16 different countries from the LAC region. Nearly half of the studies included participants from Brazil (46.7%), followed by Mexico (20%). Thirty-six studies (55%) used qualitative methods, 17 (28.3%) quantitative methods and 10 (16.7%) mixed methods. Most of the studies were carried out in urban settings . Forty-five (75%) studies targeted diabetes alone, and 15 (25%) studies included diabetes with hypertension or other non-communicable diseases. Forty-nine (81.7%) studies analysed barriers and facilitators from the patients’ perspective, 19 (31.7%) included the health professionals’ perspective, while some studies included other stakeholders, such as family members, caregivers or health managers.The results of the quality assessment are summarised in The barriers and facilitators described in the studies were classified according to 13 different theoretical domains, which contained a further 29 themes .“environmental context and resources”, where 54 studies (90%) identified at least one barrier or facilitator Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: PartlyReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: NoReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Thank you for the opportunity to review this interesting systematic review. The authors studied barriers and facilitators for diabetes care in LAC. The topic is relevant, and certainly the evidence is much needed in this region. The results are very well organised and easy to follow. I have a few suggestions that hopefully will improve this work.Introduction1. In the second paragraph, gender, socio-economic, and ethnic inequalities are pinpointed. Although relevant, and much related to the topic, the references used to support these statements are from Europe and US. I will encourage the authors to replace or complement these references with other studies conducted in Latin-America.Methods1. In the study selection subheading, it reads that studies were excluded if these did not focus “on patients with an established T2DM diagnosis”. This needs further clarification. Does this mean that only patients with a history of diabetes (self-reported diagnosis) were included? In other words, reports that studied patients with diabetes (self-reported) and people newly diagnosed (blood tests as part of the study) were not included? In this line, how was diabetes history defined? Was this based on self-reported diagnosis only, a combination of self-reported or taking drugs for diabetes, or other means?Discussion1. The discussion begins signalling that diabetes is a complex issue and that contextual factors seem to be more relevant than individual profiles. These ideas would benefit from strong references. The findings of this work, although interesting, do not provide evidence to conclude that contextual factors are more important. If there were not any relevant references, these statements should be toned down. This concern would also apply to the first lines of the conclusions; statements appear to be too strong and not fully backed-up by the findings.2. The limitations of the study argued briefly that qualitative original reports rarely study representative samples. Further discussion on this matter -representative and extrapolation of the results- is warranted. Can the findings of the review really apply to all patients in LAC? Should there be any considerations when interpreting the results across countries ?3. The conclusion includes arguments about “key determinants for successful care”. This seems quite a strong idea that has not been fully defined nor explored in the results. What is successful care? How is this defined? Does this relate to any care metric  or only to the patient’s perspective?Reviewer #2: This is a well written manuscript that aims to fill an important gap in the literature regarding barriers and facilitators in the management of T2DM in Latin American region. As stated by the authors, this region is experiencing a very large burden of T2DM and it is important to understand the challenges and opportunities uniques to the region.The study design, a systematic review is a great choice.Below are concrete comments for authors to consider that I think would improve the paper.Intro: the study is really about understanding barriers and facilitators of diabetes secondary and tertiary prevention; the authors should consider using these commonly used public health terms.Per PRISMA guidelines for the reporting of systematic reviews, introduction should include information about the study designs. Were these mostly qualitative studies or also quantitative studies.Methods:Study selection: include information about the type of study.With respect to 2) The objective of the study was to identify or describe facilitators orbarriers related to the management of the disease.Did the authors rely on the presence of these terms in the stated objectives? If so, please elaborate on the justification for this decision.Data extraction:With respect to 3) The facilitators and/or barriers related to the management of T2DM described in the study to improve diabetes care.This is key given the objective of the study and the statement is vague in light of the types of studies included. Specifically: 1) it is unclear to me whether for quantitative studies, the authors used the results of the studies to identify barriers and facilitators, in other words and for example, did the authors examined results to identify factors associated with a controlled A1c, vs. uncontrolled A1c, first ones were considered facilitators, others barriers. I suspect the authors encountered that type of studies (e.g. registries) and it is important to clarify how they handled/used these results under their own conceptual framework. In fact, some of the characteristics listed in number 2 of the data extraction can fall in the category of barriers (e.g. socioeconomic status). 2) Did they rely on the use of the terms “barriers and facilitators” in the article text. If so, please elaborate on the justification for this decision and consider doing a validation study, examining a random 1-2% of the 65 studies excluded because not focused on “barriers/facilitators”Did the authors obtain information about the setting: urban, rural, clinic in the hospital, pharmacies, etc.. I think this information would be very valuable to understand the context.It is recommended to avoid using “diabetic” to refer to patients with diabetes.Results:In addition to having table 3 as is, I’d recommend to have 2 similar tables subdivided by type of stakeholder with 2 main groups:1- Individual patient, caregiver, relative2- Health care professionals, health managers and other stakeholders.Figure 1.For the 890 studies removed in early phase, please include the reasons for these exclusions. (as you do for the other exclusions).**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  20 Jul 2020Journal Requirements:When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found athttps://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf andhttps://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdfWe have checked the manuscript according to the style requirements.2. We note that your search was completed in February 2019.Please update your search to include studies published in the last 12 months.We have updated the search to the 16th June 2020, as requested. 12 new studies have been added to the review. The results section and figure 1 have been updated accordingly. Responses to reviewers’ comments1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.Reviewer #1: PartlyReviewer #2: YesWe have modified the paper in light of the different comments made and strongly believe that the manuscript has improved.2. Has the statistical analysis been performed appropriately and rigorously?Reviewer #1: YesReviewer #2: Yes 3. Have the authors made all data underlying the findings in their manuscript fully available?The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.Reviewer #1: YesReviewer #2: Yes 4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: NoReviewer #2: Yes We have reviewed the language. The final manuscript has been proofread by an experienced native English researcher.5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Thank you for the opportunity to review this interesting systematic review. The authors studied barriers and facilitators for diabetes care in LAC. The topic is relevant, and certainly the evidence is much needed in this region. The results are very well organised and easy to follow. I have a few suggestions that hopefully will improve this work.Introduction1. In the second paragraph, gender, socio-economic, and ethnic inequalities are pinpointed. Although relevant, and much related to the topic, the references used to support these statements are from Europe and US. I will encourage the authors to replace or complement these references with other studies conducted in Latin-America.Thank you for your comments. We appreciate your suggestions for improving this manuscript. We have replaced the previous references 7 to 9 with studies conducted entirely or partially in LAC region. We have included the following papers: ● Emmerick ICM, Luiza VL, Camacho LAB, Vialle-Valentin C, Ross-Degnan D. Barriers in household access to medicines for chronic conditions in three Latin American countries. International journal for equity in health. 2015;14(1):115.● Rivera-Andrade A, Luna MA. Trends and heterogeneity of cardiovascular disease and risk factors across Latin American and Caribbean countries. Progress in cardiovascular diseases. 2014;57(3):276-85.● Nieblas-Bedolla E, Bream KD, Rollins A, Barg FK. Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala. International journal for equity in health. 2019;18(1):1-10.Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes research and clinical practice. 2014;103(2):150-160.Methods1. In the study selection subheading, it reads that studies were excluded if these did not focus “on patients with an established T2DM diagnosis”. This needs further clarification. Does this mean that only patients with a history of diabetes (self-reported diagnosis) were included? In other words, reports that studied patients with diabetes (self-reported) and people newly diagnosed (blood tests as part of the study) were not included? In this line, how was diabetes history defined? Was this based on self-reported diagnosis only, a combination of self-reported or taking drugs for diabetes, or other means?We agree that the way it was originally worded left this issue unclear. We included studies that were carried out with patients with self-reported type 2 diabetes and/or those with laboratory tests that confirmed their diagnosis. We only excluded studies that included solely patients with other diagnoses, or with healthy individuals focussing on primary prevention of type 2 diabetes. Studies including a mixture of pathologies were included provided that some of the participants had type 2 diabetes, and the results provided the information on type 2 diabetes separately. We have modified the manuscript to make this clearer. This section now reads: “We selected studies that: (1) included individuals with laboratory confirmed or self-reported T2DM who lived in LAC countries (2) described facilitators or barriers related to successful management of the disease; (3) reported original data; (4) were written in English, Spanish, French or Portuguese. Studies that included numerous pathologies were included provided that some participants had T2DM and they their results were reported separately. We excluded studies that included solely patients with other diagnoses, or with healthy individuals focussing on primary prevention of T2DM.”Discussion1. The discussion begins signalling that diabetes is a complex issue and that contextual factors seem to be more relevant than individual profiles. These ideas would benefit from strong references. The findings of this work, although interesting, do not provide evidence to conclude that contextual factors are more important. If there were not any relevant references, these statements should be toned down. This concern would also apply to the first lines of the conclusions; statements appear to be too strong and not fully backed-up by the findings.In light of the comments of the reviewer we have toned down out statement in the conclusions section. Furthermore, we have added 2 references to support the observations made. Please see revised text: “We show here that diabetes management in LAC region is a complex issue. Contextual factors appeared to be highly relevant and in some cases individual factors appeared to be on a more secondary plane. The relative importance of contextual factors in diabetes self-management and in diabetic retinopathy screening has been identified in other studies .” The references that were added are: ● Schmidt-Busby J, Wiles J, Exeter D, Kenealy T. Understanding ‘context’ in the self-management of type 2 diabetes with comorbidities: A systematic review and realist evaluation. Diabetes research and clinical practice. 2018;142:321-34.● Piyasena MMPN, Murthy GVS, Yip JL, Gilbert C, Zuurmond M, Peto T, et al. Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings. PloS one. 2019;14(4). 2. The limitations of the study argued briefly that qualitative original reports rarely study representative samples. Further discussion on this matter -representative and extrapolation of the results- is warranted. Can the findings of the review really apply to all patients in LAC? Should there be any considerations when interpreting the results across countries ?The reviewer has made a valid point here. We have added the following text into the discussion/limitations section: “However, we can suppose that the barriers and/or facilitators identified are potentially generalizable to similar sociocultural contexts with limited income and similar health coverage. By synthesising the results of 60 studies from the LAC region, this synthesis of the different types of issues affecting diabetes management can help broaden our understanding of the challenge ahead. The studies were mostly qualitative, and although this type of methodology rarely uses representative samples [100] it is clear that qualitatively synthesised information from the purposively selected participants in a specific setting can generate rich and useful information locally, but it may not be generalisable to the entire LAC region. For example, qualitative studies describing views and beliefs of specific indigenous groups. Despite this limitation, the review and synthesis of such studies can help shed light on the complexity of the issue in this region, and generate new lines of query for practitioners and researchers in similar contexts.” We also included some text to acknowledge the bias towards research from certain countries being included: “Furthermore, many of the studies included were from Brazil and Mexico, and other countries were under-represented. This is likely due differences with academic culture and publication of research findings in the different countries in the region.” 3. The conclusion includes arguments about “key determinants for successful care”. This seems quite a strong idea that has not been fully defined nor explored in the results. What is successful care? How is this defined? Does this relate to any care metric  or only to the patient’s perspective?We agree that this concept is perhaps not well described in the initial version of the manuscript. Our definition of “successful care” depended highly on how it was considered in the manuscripts that were included in the systematic review. Given that many of the included studies were qualitative, the definition of successful care followed what was reported or considered to be successful care according to the perspective of the study participants, ie patient or health care providers etc. In the quantitative studies the idea of what is successful care, would be influenced by choice of outcome measurement and the barriers/facilitators highly dependent on which factors and/or characteristics the researchers who conducted each study chose to measure. In some cases the studies were focussed on a specific issue of diabetes care, such as adherence to medication, in which case care was considered to be successful when individuals were adherent . Similarly, some studies used indicators of glycemic/metabolic control, indicators of health service access, or questionnaires to determine whether the living and health conditions of the patients were good (indicated they were successfully managed) or poor (poorly managed). We have modified the description provided in the methods section to make this more clear. Please see the new description in the methods section: “How successful management of the disease was defined depended on the focus of the different studies included. For qualitative studies, it depended on the perceptions of the participants, and how they defined good or poor control of the disease. In quantitative reports the issue was more complex because it was highly influenced by the researcher who designed the data collection tools. In this case, successful care was considered according to measurements such as adherence to care protocols using predefined tools, questionnaires assessing quality of life, or indicators of health care access.” Reviewer #2: This is a well written manuscript that aims to fill an important gap in the literature regarding barriers and facilitators in the management of T2DM in Latin American region. As stated by the authors, this region is experiencing a very large burden of T2DM and it is important to understand the challenges and opportunities uniques to the region.The study design, a systematic review is a great choice.Below are concrete comments for authors to consider that I think would improve the paper.Intro: the study is really about understanding barriers and facilitators of diabetes secondary and tertiary prevention; the authors should consider using these commonly used public health terms.Firstly, we would like to thank the reviewer for her keen observations. We have used the terms suggested to make the focus of our review clearer. Please see the modification in the introduction section. Inserted text: “Like most regions in the world strengthening the primary care system for improved secondary and tertiary prevention of diabetes, by ensuring the disease and its complications are promptly detected and correctly treated, could reduce the consequences of diabetes in the population.” Per PRISMA guidelines for the reporting of systematic reviews, introduction should include information about the study designs. Were these mostly qualitative studies or also quantitative studies.The reviewer makes a valid point here. This point has now been addressed. Please see the new text: “In this systematic review, we evaluate observational studies with qualitative and/or quantitative methodology to identify the barriers or facilitators to the management of T2DM in LAC countries, from the perspectives of patients, their relatives or caregivers, healthcare professionals, and/or any other stakeholders.”Methods:Study selection: include information about the type of study.With respect to 2) The objective of the study was to identify or describe facilitators orbarriers related to the management of the disease.Did the authors rely on the presence of these terms in the stated objectives? If so, please elaborate on the justification for this decision.We included studies where the stated objective clearly indicated that they sought to identify barriers and/or facilitators of diabetes care. However, given that these terms are not always used, during the abstract review if it appeared that determinants of diabetes care were reported in the results section, two researchers independently reviewed the full text and assessed each paper for inclusion according to our inclusion and exclusion criteria. We have modified the text in the methods section to make this more clear. Please see text: “Identification of barriers and facilitators related to disease management was not always explicitly stated as the objective of the research, and the use of different terminology was common. During the abstract review, if it was apparent that barriers or facilitators to diabetes management were reported, we assessed the full text for inclusion.”Data extraction:With respect to 3) The facilitators and/or barriers related to the management of T2DM described in the study to improve diabetes care.This is key given the objective of the study and the statement is vague in light of the types of studies included. Specifically: 1) it is unclear to me whether for quantitative studies, the authors used the results of the studies to identify barriers and facilitators, in other words and for example, did the authors examined results to identify factors associated with a controlled A1c, vs. uncontrolled A1c, first ones were considered facilitators, others barriers. I suspect the authors encountered that type of studies (e.g. registries) and it is important to clarify how they handled/used these results under their own conceptual framework. In fact, some of the characteristics listed in number 2 of the data extraction can fall in the category of barriers (e.g. socioeconomic status). 2) Did they rely on the use of the terms “barriers and facilitators” in the article text. If so, please elaborate on the justification for this decision and consider doing a validation study, examining a random 1-2% of the 65 studies excluded because not focused on “barriers/facilitators”This point was also raised by reviewer 1. In some cases the studies were focussed on a specific issue of diabetes care, such as adherence to medication, in which case care was considered to be successful when individuals were adherent . Similarly, some studies used indicators of glycemic/metabolic control, indicators of health service access, or questionnaires regarding the living and health conditions of the patients. In light of these comments, we have made significant changes in the wording of the methods section to clarify the definitions used and how information was managed. Please see text on lines 90-102: “We considered T2DM management to include strategies or care protocols for the control of the disease and its risk factors, as well as prevention of complications such as diabetic retinopathy, kidney or heart disease, and diabetic foot. How successful management of the disease was defined depended on the focus of the different studies included. For qualitative studies, it depended on the perceptions of the participants, and how they defined good or poor control of the disease. In quantitative reports the issue was more complex because it was highly influenced by the researcher who designed the data collection tools. In this case, successful care was considered according to measurements such as adherence to care protocols using predefined tools, questionnaires assessing quality of life, or indicators of health care access. We defined facilitator as any factor that supports the management of T2DM and barrier as any factor that limits the disease management. These factors may be socioeconomic, educational, cultural, behavioural, cognitive, structural, or logistical. The source of the data can be patients, patients’ families or caregivers, healthcare professionals or any other stakeholder.” Furthermore, we have added a clarification about how barriers and facilitators were defined: “Identification of barriers and facilitators related to disease management was not always explicitly stated as the objective of the research, and the use of different terminology was common. During the abstract review, if it was apparent that barriers or facilitators to diabetes management were reported, we assessed the full text for inclusion.”Did the authors obtain information about the setting: urban, rural, clinic in the hospital, pharmacies, etc.. I think this information would be very valuable to understand the context.We agree that this point would be very interesting to include. We have integrated this question into the manuscript. Please see table 1, and the comments in the results section lines 205-207: “Most of the studies were carried out in urban settings ” . Furthermore we have added this as a limitation in the discussion. See text on lines 606-608: “The majority of the studies were carried out urban setting so the challenges faced by individuals living in rural areas are likely to be underrepresented.”It is recommended to avoid using “diabetic” to refer to patients with diabetes.Given. We have changed this term to “people with diabetes” throughout the manuscript.Results:In addition to having table 3 as is, I’d recommend to have 2 similar tables subdivided by type of stakeholder with 2 main groups:1- Individual patient, caregiver, relative2- Health care professionals, health managers and other stakeholders.We agree with the reviewer that this would be a very interesting way to review the results. We have considered at length how to make these changes but concluded that with the study, the way it was originally designed, it is not possible to split the table into 2. The main reason is related to the inclusion of quantitative studies. It is difficult to identify who is really identifying the barrier or facilitator because the questionnaires used or the observations made is highly influenced by the researchers and what they consider may be a barrier etc. For example, if we present a table reflecting barriers identified by patients and their family members and include those identified in this manner (because the patients are the ones answering the questionnaire), we would not be properly the views of the patients, but rather the barriers identified by the observation. For this reason, we feel that only the qualitative reports truly reflect the perceptions of the participants. As suggested by the reviewer, we have prepared 2 tables according to the perspectives using the qualitative studies. At the moment they are included in the supplement but if the editor wishes we can move them to the main body of the article. Figure 1.For the 890 studies removed in early phase, please include the reasons for these exclusions. (as you do for the other exclusions). As it is suggested, we have included in Figure 1 the reasons for exclusion of the studies after screening title and/or abstract.6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.Reviewer #1: NoReviewer #2: Yes: MARIANA LAZOhttps://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, Thank you for the suggestion. We have used it. 29 Jul 2020Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic reviewPONE-D-20-13651R1Dear Dr. Parker,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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For more information, please contact Kind regards,Cesar Ugarte-Gil, MD MSc PhDAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 18 Aug 2020PONE-D-20-13651R1 Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review Dear Dr. Parker:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. 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ATP channels in the vasculature composed of Kir6.1 regulate vascular tone and may contribute to the pathogenesis of endotoxemia. We used mice with cell-specific deletion of Kir6.1 in smooth muscle (smKO) and endothelium (eKO) to investigate this question. We found that smKO mice had a significant survival disadvantage compared with their littermate controls when treated with a sub-lethal dose of lipopolysaccharide (LPS). All cohorts of mice became hypotensive following bacterial LPS administration; however, mean arterial pressure in WT mice recovered to normal levels, whereas smKO struggled to overcome LPS-induced hypotension. In vivo and ex vivo investigations revealed pronounced cardiac dysfunction in LPS-treated smKO, but not in eKO mice. Similar results were observed in a cecal slurry injection model. Metabolomic profiling of hearts revealed significantly reduced levels of metabolites involved in redox/energetics, TCA cycle, lipid/fatty acid and amino acid metabolism. Vascular smooth muscle-localised KATP channels have a critical role in the response to systemic infection by normalising cardiac function and haemodynamics through metabolic homeostasis.KATP channels are more susceptible to death from infection.• Mice lacking vascular KATP channels depresses cardiac function during infection.• Absence of smooth muscle K• Cardiac dysfunction is accompanied by profound changes in cellular metabolites.ATP channels in response to systemic infection.• Findings from this study suggest a protective role for vascular KThe online version of this article (10.1007/s00109-020-01946-3) contains supplementary material, which is available to authorized users. ATP channels in endotoxemia is unclear. Initially, KATP channel hyperactivity was thought to contribute to the profound hypotension seen in patients with endotoxemia. KATP channels are K+ selective ion channels that respond to and are regulated by changes in the metabolic status (changes in the ATP/ADP ratio) of the cell. They are expressed in many tissues and play a critical role in coupling cellular metabolism to membrane excitability. Functional KATP channels are composed of a hetero-octomeric complex of 4 pore-forming subunits (Kir6.1 or Kir6.2) and 4 SURs  [ATP channels regulate vessel tone and therefore blood pressure by opening or closing in response to vasoactive substances such as adenosine or noradrenaline and/or metabolic stress such as ischaemia. Opening of the channel leads to membrane hyperpolarisation, closure of voltage-dependent Ca2+ channels (VDCC) and subsequent relaxation [Endotoxemia is a component of the pathophysiology of gram-negative sepsis though the relative clinical importance is contentious . The admr SUR2B) , 4. In Vlaxation , 5.ATP blocker glibenclamide reversed an LPS-induced drop in arterial blood pressure, support the hypothesis that hypotension may be due to increased KATP channel activity [ATP may in fact be protective during infection. For example, global deletion of Kir6.1 in mice results in a poor survival outcome following LPS exposure [ATP [ATP channels against infection is preserved across species, for example in insects where suppression and activation of KATP is detrimental and protective, respectively [ATP channels in endotoxemia-induced myocardial metabolic changes are lacking.Studies in animal models of endotoxic shock, where the Kactivity –8. Furthactivity , 9. Howeexposure . Furtherure [ATP , 11. Intectively . Endotoxectively . StudiesATP channels can modulate immune cell function [ATP channel in endotoxemia is scarce. In this study, we have investigated the role of vascular  KATP channels in response to endotoxic shock using cell-specific and global Kir6.1 KO mice. We delineate the role of VSM KATP channels in preserving cardiac metabolism during endotoxin-induced shock.Though the studies in the global knockout mice are revealing, their interpretation is complicated by a number of factors. Kir6.1 is known to be ubiquitously expressed in many cells and tissues in addition to VSM. Evidence from mice with conditional deletion of Kir6.1, in endothelium and cardiac tissues, reveals important physiological functions complicating the understanding of pathophysiological data from the global knockout mouse , 15. In function . In geneAll experiments were conducted in accordance with the Guide for the Care and Use of Laboratory Animals published by the British Home Office regulations, in accordance with the EU Directive 2010/63/EU, and by the US National Institutes of Health .We used 2 models of endotoxemia/sepsis—administration of lipopolysaccharide  , 18 and In vivo cardiac function and morphology were assessed by M-mode echocardiography conducted under anaesthesia . Echocardiography was performed using a VisualSonics Vevo 770 or 3100 imaging system . Short-axis M-mode images were acquired for analysis to provide heart chamber dimensions and calculate percentage fractional shortening.1H-NMR metabolomics and data analysis can be found in the Details of the methods for BP telemetry, mouse generation and genotyping, quantification of renal dysfunction and liver damage, isolated heart experiments, TUNEL assay, P < 0.05 compared WT) and, globally, gKO  were more predisposed to LPS-induced mortality . Global KO mice started to die within 3 h of LPS administration with 60% of deaths occurring by 18 h and less than 10% surviving at 48 h. In the smKO cohort, mice had an improved long-term survival outcome compared with gKO but worse than WT mice with the majority of deaths occurring after 24 h. These data suggest an important role for vascular KATP channels in the response to endotoxic shock. There were no deaths of untreated mice over the same time period (data not shown).In response to a sub-lethal dose of LPS, all genotypes of mice showed signs of endotoxemia including decreased activity, piloerection and periocular discharge. WT mice were more tolerant to LPS than Kir6.1 KO mice Fig. . The majATP channels in the recovery from hypotension during endotoxemia. There was also a significant drop in heart rate (HR) in all 3 cohorts . Left ventricular end-diastolic volume (LVEDV) and left ventricular internal dimensions (LVID) were also significantly increased . In addition, fractional shortening (FS) and fractional area change (FAC) were also compromised suggesting progression towards LV failure in smKO mice . To ascertain if cardiac dysfunction was as a result of cell apoptosis, we used the TUNEL assay on heart sections from WT and smKO LPS-treated mice  in smKO mouse hearts . Furthermore, LV developed potential (peak systolic pressure–end-diastolic pressure) (LVDP) was significantly reduced in smKO hearts (P < 0.001). These data show a significantly reduced LV compliance in LPS-treated smKO hearts. Furthermore, in smKO hearts, the pressure-volume relationships were uncoupled with increasing pre-load of the LV. The LV of smKO hearts had reduced compliance with increased volumes as reflected in the significantly enhanced LVEDP and this occurred together with a minimal change in LVDP (P < 0.001). Overall, these data indicate increased LV stiffness leading to reduced compliance and impaired developed pressure at a given LV volume.We investigated LV function further using the Langendorff isolated heart method Fig. . IsolateP < 0.01, Fig. If left untreated, endotoxic shock can lead to multi-organ dysfunction. We investigated possible multi-organ dysfunction by analysing blood markers of kidney dysfunction and liver damage 18 h post-LPS. There was no difference in the levels of the kidney damage markers, urea and creatinine in smKO mice and their littermates Fig. . Liver fATP channels are also expressed in vascular endothelium [P = 0.35, Fig. ATP channels in endothelium make little or no contribution to the cardiac dysfunction in endotoxemia.The phenotype of gKO mice following LPS treatment was comparatively more severe than in smKO mice. Kir6.1-containing Kothelium . To inve1H NMR spectroscopy .


Characterizing the future risks of climate change is a key goal of climate impacts analysis. Temperature binning provides a framework for analyzing sector-specific impacts by degree of warming as an alternative or complement to traditional scenario-based approaches in order to improve communication of results, comparability between studies, and flexibility to facilitate scenario analysis. In this study, we estimate damages for nine climate impact sectors within the contiguous United States (US) using downscaled climate projections from six global climate models, at integer degrees of US national warming. Each sector is analyzed based on socioeconomic conditions for both the beginning and the end of the century. The potential for adaptive measures to decrease damages is also demonstrated for select sectors; differences in damages across adaptation response scenarios within some sectors can be as much as an order of magnitude. Estimated national damages from these sectors based on a reactive adaptation assumption and 2010 socioeconomic conditions range from $600 million annually per degree of national warming for winter recreation to $8 billion annually per degree of national warming for labor impacts. Results are also estimated per degree of global temperature change and for 2090 socioeconomic conditions. Emissions or concentrations from these scenarios are used as inputs to climate models with the goal of producing comparable results. However, when using climate model output to drive impacts analyses, the differences in climate sensitivity between different models can have a dominant effect, obscuring the role of other structural differences between the models  . An addi2-equivalent concentrations to warming.” In the case of Arctic sea ice, the NRC assessment showed that in some cases, there is value to presenting hazards and impacts on an absolute temperature scale, rather than a degree-change scale. The IPCC 1.5 degrees assessment presented a comparison of impacts at 2° and 1.5° in order to inform global temperature targets  “Climate Stabilization Targets” assessment  presente targets . The IPC targets . Pattern targets . Wobus e targets . Hsiang Temperature binning aids comparability of independent analyses by producing an estimate of damages for a given amount of warming, without consideration of when that warming occurred or which scenario or climate model was used to develop the estimate. This approach generally reduces the spread of results when showing uncertainty ranges by eliminating the contributions of global climate sensitivities or transient climate responses to variations in estimates of sectoral impact . In a waIn this study, we apply a temperature binning approach to nine US sectors. This approach combines several key features of previous studies: providing quantified, monetized damages in a consistent fashion for a number of different impact sectors as in 2Monetized damages resulting from warming in the US at integer national temperatures from 0 to 6 °C relative to 1986–2005 were calculated for nine sectors  and six downscaled GCMs —see the “Those climate impact sectors where damages are most closely related to national annual average temperatures will generally have the least dispersion between GCMs, as the bins are defined based on that metric (such as winter recreation and electricity demand and supply). GCMs can vary in terms of temporal and regional variability of temperature even for the same national annual average temperature. While precipitation patterns can differ more between models, these changes are often still proportional to large-scale temperature changes. This variation among GCMs can drive differences between the resulting relationship between temperature and damages. The agreement across GCMs in climate damages for a given temperature varies by sector—for winter recreation, there is little difference from one GCM to the next (the standard error is less than 2% of the slope of the temperature/damage relationship) . With thThe results presented focus on the final, monetized outputs for each sector: however, for a number of these sectors, impacts can also be reported in their native physical impact units, such as deaths for the health-related sectors, percent change in hours worked for labor, or number of skiing visits for winter recreation. For some purposes, these native units may facilitate better communication of the results.To illustrate some of the differences between temperature binning and the traditional scenario-based representations of damages, Another option for producing damage functions for climate impact sectors is to use an ensemble of opportunity e.g., . However3The results shown in the previous section can serve as the backbone for several objectives. The first is communication. The graphs can stand alone in order to communicate the relationship between US national temperatures and climate damages expected in various sectors. Alternatively, collating results at each degree point can inform a “risk by degrees” communication effort: for example, looking at the difference between 2 and 3° of warming  in terms of damages on the US, which can also be related to temperature targets. The second objective is to develop damage functions for generating reduced form models. The linear fits from Timing is an important part of climate impacts analysis. The temperature binning approach develops functions by initially removing the time element. This time element can then be reintroduced in at least two ways. The first is to provide a mapping function showing the probability of temperature exceedance for key time periods for each scenario of interest . These more complex approaches would be useful for reduced complexity modeling and benefits analysis, but might not be as amenable for general communication purposes.Sectors where the impacts are a function of cumulative exposure will be more challenging to represent in a temperature binning context. For example, sea level rise is a function of the integration of heat absorption by the ocean and melting of land ice and so is a more complex function of temperature over time than impacts such as heat mortality. Similarly, carbon storage in managed forests would be a difficult sector to model in this fashion, both because of the integrative nature of storage and the dependence of the rate on CO2 fertilization, or ozone resulting from methane oxidation in the atmosphere. Impacts that are sensitive to non-GHG factors, such as aerosol emissions or land-use changes, will also be challenging to emulate. Inter-sectoral interactions (such as the land-water-energy nexus) and cascading risks would also be difficult to capture in this framework. Some of these challenges are surmountable—for example, 2 concentration as a complement to the temperature-based reasons for concern—but require more complexity in approach.This approach does not capture impacts that are a function of rate of change rather than absolute change , nor does it capture impacts that are a direct function of greenhouse gas concentrations, such as ocean acidification, COSix GCMs are used in this study . For tho4The framework described in this manuscript builds on approaches demonstrated in numerous previous studies in order to produce quantified, monetized damage estimates for nine different impact sectors across a range of temperatures for two different socioeconomic conditions. The temperature binning approach has several advantages over scenario-driven approaches: improved comparability due to standardizing results by temperature; more accessible communication by moving away from the ever-changing alphabet soup of climate models and scenarios; and increased flexibility of scenario analysis through the development of reduced-form tools. The strong relationship between increased temperatures in the US and monetized damages is also demonstrated by the analyses of the nine sectors analyzed here. While the authors of this manuscript will continue to add new sectors and improve the analysis of existing sectors, this approach would be greatly strengthened by more consistent adoption of similar approaches by the wider impacts modeling community. If future impacts papers were to consider presenting their damage estimates as a function of temperature, whether as the central thrust of the paper or in the 5At its core, temperature binning relies on calculating sectoral impacts for multiple future temperatures while using constant socioeconomic parameters. In this manuscript, we maximize consistency by using a standard set of six climate models , one downscaling approach applied to the contiguous US , this analysis used climate projections from the Geophysical Fluid Dynamics Laboratory coupled General Circulation model (GFDL_CM3) in addition to the five GCMs used in CIRA2.0 . The original five GCMs were chosen based on criteria described in All but one of the sectoral impact analyses required downscaled climate data. The temperature binning approach presented here relies primarily on the LOCA  approach to produce daily temperature (maximum and minimum) and precipitation data at a 1/16 degree scale (approximately 6.25 km). The one exception is the sectoral analysis from the coastal property model which requires sea level rise projections produced by a separate method, described in the method for that sector below.For this manuscript, the decision was made to select time slices based on average warming in the continental US compared to the baseline (1986–2005) by integer degrees, where the first 11-year period to have an average temperature equal to that of the warming degree was chosen. A subset of nine of the sectoral impact models from CIRA2.0 were used for the temperature binning analysis. These sectors were chosen based on large magnitudes of the monetized damages, high visibility or common interest, and/or amenability to the temperature binning analysis method. The nine sectors chosen were extreme temperature mortality, labor impacts, road infrastructure, electricity demand and supply, rail infrastructure, coastal property impacts, electricity infrastructure, Southwest dust health effects, and winter recreation.Climate projections from each of the temperature bins  realized after a delay. In these cases, it is possible that the trajectory of estimated adaptation costs may not align temporally with an 11-year temperature bin. To improve the alignment, we perform a “financial smoothing” of capital costs, essentially annualizing capital costs over the useful life of the adaptation investment, using a discount rate of 3%. Details of the financial smoothing are provided in the To estimate global mean temperature from the six sea level rise projections  used in Five of the sectoral models have the capability of modelling future impacts with and without adaptation . ProjectBecause damages in the temperature binning approach are not time dependent, two methods are used to isolate damages from socioeconomic drivers. Five sectors were run with static socioeconomic inputs, relying on 2010 and 2090 population and GDP projections. The other four sectors were run with a static assumption—that is, constant socioeconomic inputs for the entire time series—as well as a dynamic assumption, where socioeconomic inputs change across the century in a continuous fashion. The difference in damage outputs between the two runs can be used as an indicator of the impact of socioeconomic drivers. These two methods allow for exploration of the potential effect of socioeconomic changes for any given temperature. Socioeconomic projections are drawn from EPA’s Integrated Climate and Land Use (ICLUSv2.0) model for population, and MIT’s Emissions Prediction and Policy Analysis (EPPAv5) model for GDP, as described in more detail in 1As noted above, impact damages are scaled to average national temperatures rather than average global temperatures. This relationship can be used to build a direct computational framework. Such a framework might use reduced complexity models, such as FaIR, MAGICC, or Hector , to prodFor any impact model that resolves the US into smaller sub-national regions , the temBinningSI