Christa L. Lilly

An examination of sex and racial/ethnic differences in the metabolic syndrome among adults: A confirmatory factor analysis and a resulting continuous severity score

OBJECTIVE The metabolic syndrome (MetS) is typically diagnosed based on abnormalities in specific clustered clinical measures that are associated with increased risk for coronary heart disease (CHD) and Type 2 diabetes mellitus (T2DM). However, current MetS criteria result in racial/ethnic discrepancies. Our goals were to use confirmatory factor analysis (CFA) to delineate differential contributions to MetS by sub-group, and if contributions were discovered, develop sex and racial/ethnic-specific equations to calculate MetS severity. RESEARCH DESIGN AND METHODS Using data on adults from the National Health and Nutrition Examination Survey 1999-2010, we performed a CFA of a single MetS factor that allowed differential loadings across groups, resulting in a sex and race/ethnicity-specific continuous MetS severity score. RESULTS Loadings to the single MetS factor differed by sub-group for each MetS component (p<0.001), with lower factor loadings among non-Hispanic-blacks for triglycerides and among Hispanics for waist circumference. Systolic blood pressure exhibited low factor loadings among all groups. MetS severity scores were correlated with biomarkers of future disease (high-sensitivity C-reactive-protein, uric acid, insulin resistance). Non-Hispanic-black-males with diabetics had a low prevalence of MetS but high MetS severity scores that were not significantly different from other racial/ethnic groups. CONCLUSIONS This analysis among adults uniquely demonstrated differences between sexes and racial/ethnic groups regarding contributions of traditional MetS components to an assumed single factor. The resulting equations provide a clinically-accessible and interpretable continuous measure of MetS for potential use in identifying adults at higher risk for MetS-related diseases and following changes within individuals over time. These equations hold potential to be a powerful new outcome for use in MetS-focused research and interventions.

Parental influences on 7–9 year olds' physical activity: A conceptual model

OBJECTIVE Models characterizing parental influence on child and adolescent physical activity (PA) over time are limited. Preschool and Adolescent Models (PM and AM) of PA are available leaving the need to focus on elementary-aged children. We tested current models (PM and AM) with a sample of 7-9 year-olds, and then developed a model appropriate to this specific target population. METHODS Parent-child dyads completed questionnaires in 2010-2011. All models were assessed using path analysis and model fit indices. RESULTS For adequate power, 90 families were needed, with 174 dyads participating. PM and AM exhibited poor fit when applied to the study population. A gender-specific model was developed and demonstrated acceptable fit. To develop an acceptable model for this population, constructs from both the PM (i.e. parental perception of child competency) and AM (i.e., child-reported self-efficacy) were used. For boys, self-efficacy was a strong predictor of PA, which was influenced by various parental variables. For girls, parental PA demonstrated the greatest strength of association with child PA. CONCLUSION This new model can be used to promote PA and guide future research/interventions. Future studies, particularly longitudinal designs, are needed to confirm the utility of this model as a bridge between currently available models.

Association between Birth Characteristics and Coronary Disease Risk Factors among Fifth Graders

OBJECTIVE To evaluate the associations between selected birth characteristics-prematurity and poor intrauterine growth-and risk factors for coronary artery disease detected among children enrolled in the fifth grade. STUDY DESIGN Children (n = 3054) with matched birth and fifth grade health screening data on body mass index (BMI), systolic blood pressure, and fasting lipid profiles were analyzed using MANOVA with the following independent variables of weight gain by the fifth grade: BMI percentile, normal or overweight/obese (BMI ≥ 85 th percentile), prematurity, and intrauterine growth (ie, small for gestational age [SGA], appropriate for gestational age [AGA], or large for gestational age [LGA]). RESULTS LGA status at birth was associated with overweight/obesity later in life. In fifth grade, overweight/obese children had elevated systolic blood pressure and abnormal levels of most fasting serum lipids compared with normal-weight children regardless of birth characteristics. Beyond the effects of BMI percentile, preterm infants had higher levels of triglycerides (TG) than term infants by the fifth grade (P < .05). SGA infants who become overweight/obese had higher levels of TGs and very low-density lipoproteins compared with AGA and LGA infants, whether overweight or normal weight (P < .05). CONCLUSION BMI ≥ 85 th percentile in the fifth grade is associated with abnormalities in most coronary artery risk factors regardless of birth characteristics. Beyond the effects of BMI percentile in the fifth grade, preterm infants had higher TG levels than term infants. SGA infants who were overweight/obese in the fifth grade had higher TG and very low-density lipoprotein levels compared with AGA and LGA infants who were overweight/obese or of normal weight in the fifth grade.

Individual-, Family-, Community-, and Policy-Level Impact of a School-Based Cardiovascular Risk Detection Screening Program for Children in Underserved, Rural Areas: The CARDIAC Project

The Coronary Artery Risk Detection In Appalachian Communities (CARDIAC) Project has screened more than 80,000 children (10–12 years) for cardiovascular and diabetes risk factors over the past 15 years. Simultaneous referral and intervention efforts have also contributed to the overall program impact. In this study, we examined evidence of programmatic impact in the past decade at the individual, family, community, and policy levels from child screening outcomes, referral rates, participation in subsequent services, and policies that embed the activities of the project as a significant element. Within this period of time, fifth-grade overweight and obesity rates were maintained at a time when rates elsewhere increased. 107 children were referred for additional screening and treatment for probable familial hypercholesterolemia (FH); 82 family members were subsequently screened in family-based screening efforts. 58 grants were distributed throughout the state for community-appropriate obesity intervention. A state wellness policy embedded CARDIAC as the method of assessment and national child cholesterol screening guidelines were impacted by CARDIAC findings. The sustainability and successful impact of this school-based program within a largely underserved, rural Appalachian state are also discussed.

Discerning suicide in drug intoxication deaths: paucity and primacy of suicide notes and psychiatric history

Objective A paucity of corroborative psychological and psychiatric evidence may be inhibiting detection of drug intoxication suicides in the United States. We evaluated the relative importance of suicide notes and psychiatric history in the classification of suicide by drug intoxication versus firearm (gunshot wound) plus hanging/suffocation—the other two major, but overtly violent methods. Methods This observational multilevel (individual/county), multivariable study employed a generalized linear mixed model (GLMM) to analyze pooled suicides and undetermined intent deaths, as possible suicides, among the population aged 15 years and older in the 17 states participating in the National Violent Death Reporting System throughout 2011–2013. The outcome measure was relative odds of suicide versus undetermined classification, adjusted for demographics, precipitating circumstances, and investigation characteristics. Results A suicide note, prior suicide attempt, or affective disorder was documented in less than one-third of suicides and one-quarter of undetermined deaths. The prevalence gaps were larger among drug intoxication cases than gunshot/hanging cases. The latter were more likely than intoxication cases to be classified as suicide versus undetermined manner of death (adjusted odds ratio [OR], 41.14; 95% CI, 34.43–49.15), as were cases documenting a suicide note (OR, 33.90; 95% CI, 26.11–44.05), prior suicide attempt (OR, 2.42; 95% CI, 2.11–2.77), or depression (OR, 1.61; 95% CI, 1.38 to 1.88), or bipolar disorder (OR, 1.41; 95% CI, 1.10–1.81). Stratification by mechanism/cause intensified the association between a note and suicide classification for intoxication cases (OR, 45.43; 95% CI, 31.06–66.58). Prior suicide attempt (OR, 2.64; 95% CI, 2.19–3.18) and depression (OR, 1.48; 95% CI, 1.17–1.87) were associated with suicide classification in intoxication but not gunshot/hanging cases. Conclusions Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the US is likely profoundly under-reported. Findings harbor adverse implications for surveillance, etiologic understanding, and prevention of suicides and drug deaths.

Evaluation of the effectiveness of a problem-solving intervention addressing barriers to cardiovascular disease prevention behaviors in 3 underserved populations: Colorado, North Carolina, West Virginia, 2009.

Introduction In low-income and underserved populations, financial hardship and multiple competing roles and responsibilities lead to difficulties in lifestyle change for cardiovascular disease (CVD) prevention. To improve CVD prevention behaviors, we adapted, pilot-tested, and evaluated a problem-solving intervention designed to address barriers to lifestyle change. Methods The sample consisted of 81 participants from 3 underserved populations, including 28 Hispanic or non-Hispanic white women in a western community (site 1), 31 African-American women in a semirural southern community (site 2), and 22 adults in an Appalachian community (site 3). Incorporating focus group findings, we assessed a standardized intervention involving 6-to-8 week group sessions devoted to problem-solving in the fall of 2009. Results Most sessions were attended by 76.5% of participants, demonstrating participant adoption and engagement. The intervention resulted in significant improvement in problem-solving skills (P < .001) and perceived stress (P < .05). Diet, physical activity, and weight remained stable, although 72% of individuals reported maintenance or increase in daily fruit and vegetable intake, and 67% reported maintenance or increase in daily physical activity. Conclusion Study results suggest the intervention was acceptable to rural, underserved populations and effective in training them in problem-solving skills and stress management for CVD risk reduction.

Trends in serum lipids among 5th grade CARDIAC participants, 2002–2012

Background Studies have shown that serum low-density lipoprotein (LDL-C) and non-high-density lipoprotein (non-HDL-C) have recently declined in the USA among adult and child populations despite high obesity prevalence rates. The purpose of this study was to assess whether there was a significant linear decrease in LDL-C and non-HDL-C, but not Body Mass Index (BMI) percentile among a cross-sectional, large, homogenous cohort with consistent methodology over the past decade. Methods A total of 47 198 children, mostly between 10 and 11 years old, participating between 2002 and 2012 were examined to assess trends in serum lipid concentration and BMI percentile. Results For LDL-C, year of screening was significant (p<0.0001) even with the inclusion of gender, age and BMI (all p<0.0001). For non-HDL-C, year of screening was also significant (p<0.0001), even with the inclusion of gender (p=0.0445), age (p<0.0001), BMI (p<0.0001) and systolic blood pressure (p=0.0021). Although some non-linear trends were also significant (eg, a quartic trend, p<0.001), the linear trend provided the best fit for both cholesterol models. By comparison, we noted general maintenance of BMI percentile over time. Conclusions Between 2002 and 2012, among 5th grade Appalachian children, there was a consistent linear decrease in LDL-C and non-HDL-C despite continued high prevalence rates of obesity, diabetes and hypertension. The improvement in LDL-C and non-HDL-C could be due to multifactorial causes.

Nonvitamin, Nonmineral Dietary Supplement Use among Adults with Fibromyalgia: United States, 2007–2012

Background Fibromyalgia (FMS) is a pain condition affecting 2–6% of US adults; effective treatment remains limited. Determinants of nonvitamin, nonmineral dietary supplement (NVNM) use among adults with FMS are not well-studied. We investigated the relation of NVNM use to FMS, and trends, in two nationally representative samples of US adults ≥18 years. Methods Data were drawn from 2007 and 2012 National Health Interview Surveys (Ns = 20127 and 30672, resp.). Logistic regression was used to examine associations of FMS to NVNM use (past 12 months) and evaluate potential modifying influences of gender and comorbidities. Multivariate models adjusted for sampling design, demographic, lifestyle, and health-related factors. Results FMS was significantly higher in 2012 than in 2007 (1.7% versus 1.3%), whereas NVNM use decreased (57% versus 41%; p < 0.0001). Adults reporting diagnosis were more likely to use NVNMs within 12 months, 30 days, or ever relative to adults without; positive associations remained significant after controlling for demographics, lifestyle characteristics, medical history, and other confounders (ranges: 2007 and 2012 AORs = 2.3–2.7; 1.5–1.6, resp.; ps < 0.0001). Conclusion In this cross-sectional study of two national samples, NVNM use was strongly and positively associated with FMS, highlighting the need for further study.

Method overtness, forensic autopsy, and the evidentiary suicide note: A multilevel National Violent Death Reporting System analysis

Objective Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note. Methods This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011–2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note. Results An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy. Conclusions Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.

Maternal smoking during pregnancy and scholastic achievement in childhood: evidence from the LIFECOURSE cohort study

Abstract Background Research on the impact of maternal smoking during pregnancy (MSDP) on scholastic achievement in the offspring has shown conflicting findings. The objective of this study was to assess the impact of MSDP on scholastic achievement in a birth cohort of children in 4th, 7th and 10th grades. Methods We analysed data from the LIFECOURSE study, a cohort study of risk and protective factors in all children born in Reykjavik, Iceland, in the year 2000 (N = 1151, girls = 49.3%). Retrospective registry data for 2014–2015 were merged with prospective survey data that were collected in April 2016. Data on MSDP were assessed during regular antenatal visits at the end of the first trimester. Standardized academic achievement scores were obtained from official school transcripts. Data were analysed using OLS regressions that were entered in three hierarchical blocks. Results Children of mothers who smoked tobacco during the first trimester consistently revealed between 5% and 7% lower scores on standardized academic achievement in 4th, 7th and 10th grade (∼6–8 points on a normally distributed 120 point scale) than those of mothers who had not smoked tobacco during this period (P < 0.05). These findings held after controlling for several factors associated with the time of birth (e.g. birth weight, maternal age at birth, birth order, parental cohabitation and household income), as well as the year of scholastic assessment (parental cohabitation, household income and parental education). Conclusions Maternal smoking during pregnancy was negatively related to scholastic achievement in the offspring during 4th, 7th and 10th grade.