Esa M. Davis

Racial and Socioeconomic Differences in the Weight-Loss Experiences of Obese Women

Focus groups stratified by race and socioeconomic status were used to examine obese womens experiences with weight-loss methods. Six themes emerged: failure of weight maintenance, use of psychological and spiritual approaches, role of family influences and societal expectations, role of African American subculture, method affordability, and racial differences in weight-loss methods. Tailored weight-management interventions for women, particularly African Americans and those of low socioeconomic status, should account for features of African American subculture and address affordability concerns, include maintenance strategies that incorporate psychological and spiritual principles, and target family attitudes and behaviors.

Racial, ethnic, and socioeconomic differences in the incidence of obesity related to childbirth.

OBJECTIVES We investigated the relationship between childbirth and 5-year incidence of obesity. METHODS We performed a prospective analysis of data on 2923 nonobese, nonpregnant women aged 14 to 22 years from the 1979 National Longitudinal Survey of Youth Cohort, which was followed from 1980 to 1990. We used multivariable logistic regression analyses to determine the adjusted relative risk of obesity for mothers 5 years after childbirth compared with women who did not have children. RESULTS The 5-year incidence of obesity was 11.3 per 100 parous women, compared with 4.5 per 100 nulliparous women (relative risk [RR] = 3.5; 95% confidence interval [CI] = 2.4, 4.9; P < .001). The 5-year incidence of obesity was 8.6 for primiparous women (RR = 2.8; 95% CI = 1.5, 5.0) and 12.2 for multiparous women (RR = 3.8; 95% CI = 2.6, 5.6). Among parous women, White women had the lowest obesity incidence (9.1 per 100 vs 15.1 per 100 for African Americans and 12.5 per 100 for Hispanics). CONCLUSIONS Parous women have a higher incidence of obesity than do nulliparous women, and minority women have a higher incidence of parity-related obesity than do White women. Thus, efforts to reduce obesity should target postpartum women and minority women who give birth.

Racial-Ethnic Differences in Pregnancy-Related Weight

This review examines published literature to answer 2 questions: 1) Are there racial-ethnic differences in excessive or inadequate gestational weight gain (GWG) and postpartum weight retention (PPWR)? and 2) Is there evidence that approaches to promote healthy weight during and after pregnancy should vary by race-ethnicity? We identified a limited number of articles that explicitly looked at racial-ethnic differences in either GWG or PPWR after controlling for relevant covariates. These studies suggest that black and Hispanic women are more likely to gain inadequately based on the Institute of Medicines pregnancy weight gain guidelines compared to white women. Black women are more likely to retain considerable amounts of weight postpartum compared to both Hispanic and white mothers. Studies were inconclusive as to whether Hispanic women retained more or less weight postpartum, so more research is needed. Interventions to increase GWG were few and those designed to reduce GWG and PPWR showed mixed results. Future studies should address the methodological and conceptual limitations of prior research as well as investigate biological mechanisms and behavioral risk factors to determine the reasons for the racial-ethnic differences in pregnancy-related weight outcomes. Interventions would benefit from a mixed-methods approach that specifically identifies race-relevant barriers to weight management during and after pregnancy. Attention to the greater social context in which pregnancy-related weight exists is also needed.

Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department

OBJECTIVE: To determine if race/ethnicity-based differences exist in the management of pediatric abdominal pain in emergency departments (EDs). METHODS: Secondary analysis of data from the 2006–2009 National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients ≤21 years old who presented to EDs with abdominal pain. Main outcomes were documentation of pain score and receipt of any analgesics, analgesics for severe pain (defined as ≥7 on a 10-point scale), and narcotic analgesics. Secondary outcomes included diagnostic tests obtained, length of stay (LOS), 72-hour return visits, and admission. RESULTS: Of patient visits, 70.1% were female, 52.6% were from non-Hispanic white, 23.5% were from non-Hispanic black, 20.6% were from Hispanic, and 3.3% were from “other” racial/ethnic groups; patients’ mean age was 14.5 years. Multivariate logistic regression models adjusting for confounders revealed that non-Hispanic black patients were less likely to receive any analgesic (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.43–0.87) or a narcotic analgesic (OR: 0.38; 95% CI: 0.18–0.81) than non-Hispanic white patients (referent group). This finding was also true for non-Hispanic black and “other” race/ethnicity patients with severe pain (ORs [95% CI]: 0.43 [0.22–0.87] and 0.02 [0.00–0.19], respectively). Non-Hispanic black and Hispanic patients were more likely to have a prolonged LOS than non-Hispanic white patients (ORs [95% CI]: 1.68 [1.13–2.51] and 1.64 [1.09–2.47], respectively). No significant race/ethnicity-based disparities were identified in documentation of pain score, use of diagnostic procedures, 72-hour return visits, or hospital admissions. CONCLUSIONS: Race/ethnicity-based disparities exist in ED analgesic use and LOS for pediatric abdominal pain. Recognizing these disparities may help investigators eliminate inequalities in care.

Attitudes and cardiovascular disease

Psychological attitudes are prospectively related to cardiovascular disease (CVD), but a causal relationship has not been demonstrated. Trait optimism/pessimism (positive or negative future expectation, respectively), and cynical hostility (mistrust of people), are attitudes with features of personality traits. These attitudes may affect CVD risk in several ways, by influencing an individuals (1) adoption of health behaviors, (2) maladaptive stress responding resulting in direct alteration of physiology (i.e., autonomic dysfunction, thrombosis, arrhythmias), (3) development of traditional CVD risk factors, and (4) lack of adherence to therapy in both primary and secondary prevention. More adaptive attitudes may favorably influence CVD risk at each of these critical junctures. The genetic and environmental (i.e., social, economic, racial/ethnic) determinants of attitudes have not been extensively studied. In addition, it is important to understand how some of these environmental determinants may also moderate the association between attitudes and CVD. Clinical trials to modify attitudes for CVD risk reduction (either by reducing negative attitudes or by increasing positive attitudes) are difficult to conduct, but are necessary to determine whether attitudes can indeed be modified, and if, so, to quantify any CVD-related benefits. To address these questions we present a broad, multidisciplinary research agenda utilizing mixed methods and integrating principles of epidemiology, genetics, psychophysiology, and behavioral medicine over the lifecourse (first figure). This overview focuses on attitudes and CVD, but has broader implications for understanding how psychological factors relate to chronic diseases of adulthood.

Limitations of Analyses Based on Achieved Blood Pressure: Lessons From the African American Study of Kidney Disease and Hypertension Trial

Blood pressure (BP) guidelines that set target BP levels often rely on analyses of achieved BP from hypertension treatment trials. The objective of this paper was to compare the results of analyses of achieved BP to intention-to-treat analyses on renal disease progression. Participants (n=1,094) in the African-American Study of Kidney Disease and Hypertension Trial were randomized to either: (1) usual BP goal defined by a mean arterial pressure (MAP) goal of 102–107 mmHg or (2) lower BP goal defined by a MAP goal of ≤ 92 mmHg. Median follow-up was 3.7 years. Primary outcomes were rate of decline in measured glomerular filtration rate (GFR) and a composite of a decrease in GFR by > 50% or >25 ml/min/1.73m2, requirement for dialysis, transplantation, or death. Intention-to-treat analyses showed no evidence of a BP effect on either the rate of decline in GFR or the clinical composite outcome. In contrast, the achieved BP analyses showed that each 10 mm Hg increment in mean follow-up achieved MAP was associated with a 0.35 (95% CI 0.08 – 0.62, p = 0.01) ml/min/1.73m2 faster mean GFR decline and a 17% (95% CI 5% – 32%, p = 0.006) increased risk of the clinical composite outcome. Analyses based on achieved BP lead to markedly different inferences than traditional intention-to-treat analyses, due in part to confounding of achieved BP with co- morbidities, disease severity and adherence. Clinicians and policy makers should exercise caution when making treatment recommendations based on analyses relating outcomes to achieved BP.Blood pressure (BP) guidelines that set target BP levels often rely on analyses of achieved BP from hypertension treatment trials. The objective of this article was to compare the results of analyses of achieved BP to intention-to-treat analyses on renal disease progression. Participants (n=1094) in the African-American Study of Kidney Disease and Hypertension Trial were randomly assigned to either usual BP goal defined by a mean arterial pressure goal of 102 to 107 mm Hg or lower BP goal defined by a mean arterial pressure goal of ⩽92 mm Hg. Median follow-up was 3.7 years. Primary outcomes were rate of decline in measured glomerular filtration rate and a composite of a decrease in glomerular filtration rate by >50% or >25 mL/min per 1.73 m2, requirement for dialysis, transplantation, or death. Intention-to-treat analyses showed no evidence of a BP effect on either the rate of decline in glomerular filtration rate or the clinical composite outcome. In contrast, the achieved BP analyses showed that each 10-mm Hg increment in mean follow-up achieved mean arterial pressure was associated with a 0.35 mL/min per 1.73 m2 (95% CI: 0.08 to 0.62 mL/min per 1.73 m2; P=0.01) faster mean glomerular filtration rate decline and a 17% (95% CI: 5% to 32%; P=0.006) increased risk of the clinical composite outcome. Analyses based on achieved BP lead to markedly different inferences than traditional intention-to-treat analyses, attributed in part to confounding of achieved BP with comorbidities, disease severity, and adherence. Clinicians and policy makers should exercise caution when making treatment recommendations based on analyses relating outcomes to achieved BP.

Parity and body mass index in US women: A prospective 25-year study

To investigate long‐term body mass index (BMI) changes associated with childbearing.

Adolescent self-defined neighborhoods and activity spaces: spatial overlap and relations to physical activity and obesity.

Defining the proper geographic scale for built environment exposures continues to present challenges. In this study, size attributes and exposure calculations from two commonly used neighborhood boundaries were compared to those from neighborhoods that were self-defined by a sample of 145 urban minority adolescents living in subsidized housing estates. Associations between five built environment exposures and physical activity, overweight and obesity were also examined across the three neighborhood definitions. Limited spatial overlap was observed across the various neighborhood definitions. Further, many places where adolescents were active were not within the participants׳ neighborhoods. No statistically significant associations were found between counts of facilities and the outcomes based on exposure calculations using the self-defined boundaries; however, a few associations were evident for exposures using the 0.75mile network buffer and census tract boundaries. Future investigation of the relationship between the built environment, physical activity and obesity will require practical and theoretically-based methods for capturing salient environmental exposures.

Patterns of gestational weight gain related to fetal growth among women with overweight and obesity

Objective Maternal obesity is associated with increased risk of large-for-gestational-age (LGA) and small-for-gestational-age (SGA) births. Both are related to childhood obesity. We considered that patterns of gestational weight gain (GWG) may help to disentangle these competing risks. Design and methods Patterns of GWG were characterized among a cohort of overweight or obese women (n=651). Polytomous logistic regression models tested for associations between GWG patterns and birthweight outcomes: SGA (<10th) and LGA (>90th percentile). Results Rates of SGA were higher than those for LGA (14.9% vs. 7.8%). Four GWG patterns were identified: consistently high (29%), early adequate/late high (33%), consistently adequate (18%), and consistently low (20%). Risk of LGA was highest in women with consistently high GWG (adjusted odds ratio [OR] 4.62 [1.53, 13.96]), and risk was elevated, but with lower magnitude, among women with early adequate/late high gains (OR 3.07 [1.01, 9.37]). High GWG before 20 weeks, regardless of later gain, was related to LGA. Low gain before 20 weeks accompanied by high gain later may be associated with reduced SGA risk (0.55 [0.29, 1.07]). Conclusions The pattern of weight gain during pregnancy may be an important contributor to or marker of abnormal fetal growth among overweight and obese women.Maternal obesity is associated with increased risk of large‐for‐gestational‐age (LGA) and small‐for‐gestational‐age (SGA) births. Both are related to childhood obesity. This study considers that the patterns of gestational weight gain (GWG) may help to disentangle these competing risks.

eReferral Between Hospitals and Quitlines: An Emerging Tobacco Control Strategy.

522 Am eReferral Between Hospitals and Quitlines An Emerging Tobacco Control Strategy Hilary A. Tindle, MD, MPH, Robin Daigh, MBA, Vivek K. Reddy, MD, Linda A. Bailey, JD, MHS, Judy A. Ochs, Marty H. Maness, MBA, Esa M. Davis, MD, MPH, Anna E. Schulze, MSW, Kristi M. Powers, MHA, Thomas E. Ylioja, MSW, LSW, Hilary B. Baca, BS, Jay L. Mast, BA, Matthew S. Freiberg, MD, MSc on behalf of the Pennsylvania eReferral Workgroup