Gillian Santorelli

Association between hyperglycaemia and adverse perinatal outcomes in south Asian and white British women: analysis of data from the Born in Bradford cohort

Summary Background Diagnosis of gestational diabetes predicts risk of infants who are large for gestational age (LGA) and with high adiposity, which in turn aims to predict a future risk of obesity in the offspring. South Asian women have higher risk of gestational diabetes, lower risk of LGA, and on average give birth to infants with greater adiposity than do white European women. Whether the same diagnostic criteria for gestational diabetes should apply to both groups of women is unclear. We aimed to assess the association between maternal glucose and adverse perinatal outcomes to ascertain whether thresholds used to diagnose gestational diabetes should differ between south Asian and white British women. We also aimed to assess whether ethnic origin affected prevalence of gestational diabetes irrespective of criteria used. Methods We used data (including results of a 26–28 week gestation oral glucose tolerance test) of women from the Born in Bradford study, a prospective study that recruited women attending the antenatal clinic at the Bradford Royal Infirmary, UK, between 2007 and 2011 and who intended to give birth to their infant in that hospital. We studied the association between fasting and 2 h post-load glucose and three primary outcomes (LGA [defined as birthweight >90th percentile for gestational age], high infant adiposity [sum of skinfolds >90th percentile for gestational age], and caesarean section). We calculated adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) for a 1 SD increase in fasting and post-load glucose. We established fasting and post-load glucose thresholds that equated to an OR of 1·75 for LGA and high infant adiposity in each group of women to identify ethnic-specific criteria for diagnosis of gestational diabetes. Findings Of 13 773 pregnancies, 3420 were excluded from analyses. Of 10 353 eligible pregnancies, 4088 women were white British, 5408 were south Asian, and 857 were of other ethnic origin. The adjusted ORs of LGA per 1 SD fasting glucose were 1·22 (95% CI 1·08–1·38) in white British women and 1·43 (1·23–1·67) in south Asian women (pinteraction with ethnicity = 0·39). Results for high infant adiposity were 1·35 (1·23–1·49) and 1·35 (1·18–1·54; pinteraction with ethnicity=0·98), and for caesarean section they were 1·06 (0·97–1·16) and 1·11 (1·02–1·20; pinteraction with ethnicity=0·47). Associations between post-load glucose and the three primary outcomes were weaker than for fasting glucose. A fasting glucose concentration of 5·4 mmol/L or a 2 h post-load level of 7·5 mmol/L identified white British women with 75% or higher relative risk of LGA or high infant adiposity; in south Asian women, the cutoffs were 5·2 mmol/L or 7·2 mml/L; in the whole cohort, the cutoffs were 5·3 mmol/L or 7·5 mml/L. The prevalence of gestational diabetes in our cohort ranged from 1·2% to 8·7% in white British women and 4% to 24% in south Asian women using six different criteria. Compared with the application of our whole-cohort criteria, use of our ethnic-specific criteria increased the prevalence of gestational diabetes in south Asian women from 17·4% (95% CI 16·4–18·4) to 24·2% (23·1–25·3). Interpretation Our data support the use of lower fasting and post-load glucose thresholds to diagnose gestational diabetes in south Asian than white British women. They also suggest that diagnostic criteria for gestational diabetes recommended by UK NICE might underestimate the prevalence of gestational diabetes compared with our criteria or those recommended by the International Association of Diabetes and Pregnancy Study Groups and WHO, especially in south Asian women. Funding The National Institute for Health Research.

Developing prediction equations and a mobile phone application to identify infants at risk of obesity.

Background Advancements in knowledge of obesity aetiology and mobile phone technology have created the opportunity to develop an electronic tool to predict an infant’s risk of childhood obesity. The study aims were to develop and validate equations for the prediction of childhood obesity and integrate them into a mobile phone application (App). Methods and Findings Anthropometry and childhood obesity risk data were obtained for 1868 UK-born White or South Asian infants in the Born in Bradford cohort. Logistic regression was used to develop prediction equations (at 6±1.5, 9±1.5 and 12±1.5 months) for risk of childhood obesity (BMI at 2 years >91st centile and weight gain from 0–2 years >1 centile band) incorporating sex, birth weight, and weight gain as predictors. The discrimination accuracy of the equations was assessed by the area under the curve (AUC); internal validity by comparing area under the curve to those obtained in bootstrapped samples; and external validity by applying the equations to an external sample. An App was built to incorporate six final equations (two at each age, one of which included maternal BMI). The equations had good discrimination (AUCs 86–91%), with the addition of maternal BMI marginally improving prediction. The AUCs in the bootstrapped and external validation samples were similar to those obtained in the development sample. The App is user-friendly, requires a minimum amount of information, and provides a risk assessment of low, medium, or high accompanied by advice and website links to government recommendations. Conclusions Prediction equations for risk of childhood obesity have been developed and incorporated into a novel App, thereby providing proof of concept that childhood obesity prediction research can be integrated with advancements in technology.

A comparison of South Asian specific and established BMI thresholds for determining obesity prevalence in pregnancy and predicting pregnancy complications: findings from the Born in Bradford cohort

Objective:To describe how maternal obesity prevalence varies by established international and South Asian specific body mass index (BMI) cut-offs in women of Pakistani origin and investigate whether different BMI thresholds can help to identify women at risk of adverse pregnancy and birth outcomes.Design:Prospective bi-ethnic birth cohort study (the Born in Bradford (BiB) cohort).Setting:Bradford, a deprived city in the North of the UK.Participants:A total of 8478 South Asian and White British pregnant women participated in the BiB cohort study.Main outcome measures:Maternal obesity prevalence; prevalence of known obesity-related adverse pregnancy outcomes: mode of birth, hypertensive disorders of pregnancy (HDP), gestational diabetes, macrosomia and pre-term births.Results:Application of South Asian BMI cut-offs increased prevalence of obesity in Pakistani women from 18.8 (95% confidence interval (CI) 17.6–19.9) to 30.9% (95% CI 29.5–32.2). With the exception of pre-term births, there was a positive linear relationship between BMI and prevalence of adverse pregnancy and birth outcomes, across almost the whole BMI distribution. Risk of gestational diabetes and HDP increased more sharply in Pakistani women after a BMI threshold of at least 30 kg m−2, but there was no evidence of a sharp increase in any risk factors at the new, lower thresholds suggested for use in South Asian women. BMI was a good single predictor of outcomes (area under the receiver operating curve: 0.596–0.685 for different outcomes); prediction was more discriminatory and accurate with BMI as a continuous variable than as a binary variable for any possible cut-off point.Conclusion:Applying the new South Asian threshold to pregnant women would markedly increase those who were referred for monitoring and lifestyle advice. However, our results suggest that lowering the BMI threshold in South Asian women would not improve the predictive ability for identifying those who were at risk of adverse pregnancy outcomes.

The Link Between Information and Communication Technologies and Global Public Health: Pushing Forward

.Global public health (GPH) continues to be a challenging field. It focuses on health-related issues that transcend national boundaries and thus requires global cooperation for implementing solutions to public health problems. Information and communication technologies (ICTs) have the potential to contribute to GPH by improving the quality of healthcare services. The purpose of this commentary article is to discuss the nature and characteristics of the existing link between ICTs and GPH. The key underlying questions discussed in this article are (a) whether ICTs can truly reduce the burden of current GPH problems and (b) how to effectively achieve it. We selected three widely recognized GPH challenges: diarrheal disease among children under 5 years old, malaria, and type 2 diabetes mellitus. These are considered to be examples of salient global issues that, despite the availability of cost-effective preventive and therapeutic interventions, still remain a major burden of morbidity and mortality worldwide. We conclude that there is a growing global interest in ICT-related solutions in GPH. We recommend the development of more transparent frameworks, more theory-informed solutions, and clearer translational links between ICTs and GPH matters. Ten further specific recommendations are also discussed in this article.

Prevalence and Risk Factors of Strabismus in a UK Multi-ethnic Birth Cohort

ABSTRACT Purpose: To determine the prevalence, types and early-life risk factors associated with strabismus in a multi-ethnic birth cohort of children aged 4-5 years in the first year of school. Methods: Data were collected prospectively over a 3-year period (2012-2015) from children participating in the vision screening program provided by orthoptists and carried out in schools located in the city of Bradford, UK. Prevalence of strabismus was determined for 17,018 children aged 4 to 5 years. Data linkage was undertaken for 4563 children participating in the Born in Bradford birth cohort study and the vision screening program. 4067 children had complete data and were included in the multivariable regression analyses to determine associated factors. Results: 401/17018 (2.4%) children were found to have either a constant or an intermittent strabismus; 179/401 (45%) had an esotropic deviation, 214 (53%) an exotropic deviation, and 8 (2%) had a vertical deviation. No significant difference in the overall prevalence of strabismus was found between the white British, Pakistani, or children of other ethnic origin (P=0.41). Multivariable analysis showed that children of white British ethnicity have twice the odds of having esotropia (OR 2.4, 95% CI: 1.1, 5.3). The odds of having esotropia were highest in children with a hyperopic mean spherical equivalent (OR 2.0, 95% CI: 1.7, 2.6). There was some evidence of an interaction between ethnicity and mean spherical equivalent in children with esotropia (P=0.058). Conclusions: Prevalence of strabismus is consistent with other population-based studies in this cohort of children aged 4-5 years. Prevalence of esotropia (constant or intermittent) is greater in the white British population, odds of esotropia increased with increasing hyperopic refractive error in both white British and Pakistani children. Exotropia (constant or intermittent) was not found to be associated with refractive error, ethnicity, or other early life factors.

What factors explain pregnant women’s feeding intentions in Bradford, England: A multi-methods, multi-ethnic study

BackgroundUsing a multi-methods approach we aimed to explore the relative prediction of demographic, socioeconomic and modifiable predictors from the Theory of Planned behaviour (TPB) in explaining feeding intentions amongst a multi-ethnic sample.Methods476 women completed a questionnaire at 28 weeks gestation. They were grouped into breastfeeding (N = 258), mixed-feeding (N = 50), bottle-feeding (N = 88) intenders, or a no clear intention (N = 88). Multinomial adjusted regressions explored the influence of modifiable TPB factors, along with ethnicity and socioeconomic status in predicting group membership. Free-text responses allowed women to elaborate on reasons behind their intention.ResultsTPB factors were significant predictors of feeding intention. Women with high intention to breastfeed were less likely to report high attitudes in any other feeding alternative. Bottle-feeding intenders reported poorer self-efficacy regarding breastfeeding compared to breastfeeding intenders (prevalence rate ratio, PRR = 0.10). Mixed and bottle-feeding intenders reported greater self-efficacy for mixed-feeding (PRR = 1.80, 5.50 respectively). Descriptive norms for mixed (PRR = 13.77) and bottle-feeding (PRR = 10.68) were predictive of mixed-feeding intention. Reasons for breastfeeding intentions related to health considerations, whilst bottle-feeding reasons related to convenience. Mixed-feeding intenders reported both breast and bottle-related factors.ConclusionsUnderstanding modifiable predictors related to feeding intentions like TPB factors can help professionals target appropriate interventions to encourage breastfeeding.

Ethnic Differences in the Initiation and Duration of Breast Feeding - Results from the Born in Bradford Birth Cohort Study

BACKGROUND Initiation of breast feeding and duration of any breast feeding are known to differ by ethnic group, but there are limited data on differences in exclusive breast feeding. This study aimed to determine if there are ethnic differences in the initiation and duration of any and exclusive breast feeding. METHODS Breast-feeding data were obtained from a subsample of 1365 women recruited to a multi-ethnic cohort study (Born in Bradford) between August 2008 and March 2009. Poisson regression was used to investigate the impact of socio-economic, life style and birth factors on ethnic differences in the prevalence of breast feeding. RESULTS Compared with white British mothers, initiation of breast feeding was significantly higher in all ethnic groups and this persisted after adjustment for socio-economic, life style and birth factors [Pakistani: prevalence rate ratio (PRR) = 1.19 (95% confidence interval 1.10, 1.29); Other South Asian: PRR = 1.29 (1.18, 1.42); Other ethnicities: PRR = 1.33 (1.21, 1.46)]. There were no differences in exclusive breast feeding at 4 months [Pakistani: PRR = 0.77 (0.54, 1.09); Other South Asian: PRR = 1.55 (0.99, 2.43); Other ethnicities: PRR = 1.50 (0.88, 2.56)]. Any breast feeding at 4 months was significantly higher in mothers of all non-white British ethnicities [Pakistani: PRR = 1.27 (1.02, 1.58); Other South Asian: PRR = 1.99 (1.52, 2.62); Other ethnicities: 2.45 (1.86, 3.21)]. CONCLUSIONS Whilst women of ethnic minority groups were significantly more likely to initiate breast feeding and continue any breast feeding for 4 months compared with white British women, the rates of exclusive breast feeding at 4 months were not significantly different once socio-economic, life style and birth factors were accounted for.

An exploration and comparison of food and drink availability in homes in a sample of families of White and Pakistani origin within the UK.

OBJECTIVE Knowledge of the types and quantities of foods and drinks available in family homes supports the development of targeted intervention programmes for obesity prevention or management, or for overall diet improvement. In the UK, contemporary data on foods that are available within family homes are lacking. The present study aimed to explore home food and drink availability in UK homes. DESIGN An exploratory study using researcher-conducted home food availability inventories, measuring all foods and drinks within the categories of fruits, vegetables, snack foods and beverages. SETTING Bradford, a town in the north of the UK. SUBJECTS Opportunistic sample of mixed ethnicity families with infants approximately 18 months old from the Born in Bradford birth cohort. RESULTS All homes had at least one type of fruit, vegetable and snack available. Fresh fruits commonly available were oranges, bananas, apples, satsumas and grapes. Commonly available fresh vegetables included potatoes, cucumber, tomatoes and carrots. The single greatest non-fresh fruit available in homes was raisins. Non-fresh vegetables contributing the most were frozen mixed vegetables, tinned tomatoes and tinned peas. Ethnic differences were found for the availability of fresh fruits and sugar-sweetened beverages, which were both found in higher amounts in Pakistani homes compared with White homes. CONCLUSIONS These data contribute to international data on availability and provide an insight into food availability within family homes in the UK. They have also supported a needs assessment of the development of a culturally specific obesity prevention intervention in which fruits and vegetables and sugar-sweetened beverages are targeted.

Agreement between routine and research measurement of infant height and weight

In many countries, routine data relating to growth of infants are collected as a means of tracking health and illness up to school age. These have potential to be used in research. For health monitoring and research, data should be accurate and reliable. This study aimed to determine the agreement between length/height and weight measurements from routine infant records and researcher-collected data. Methods Height/length and weight at ages 6, 12 and 24 months from the longitudinal UK birth cohort (born in Bradford; n=836–1280) were compared with routine data collected by health visitors within 2 months of the research data (n=104–573 for different comparisons). Data were age adjusted and compared using Bland Altman plots. Results There was agreement between data sources, albeit weaker for height than for weight. Routine data tended to underestimate length/height at 6 months (0.5 cm (95% CI −4.0 to 4.9)) and overestimate it at 12 (−0.3 cm (95% CI −0.5 to 4.0)) and 24 months (0.3 cm (95% CI −4.0 to 3.4)). Routine data slightly overestimated weight at all three ages (range −0.04 kg (95% CI −1.2 to 0.9) to −0.04 (95% CI −0.7 to 0.6)). Limits of agreement were wide, particularly for height. Differences were generally random, although routine data tended to underestimate length in taller infants and underestimate weight in lighter infants. Conclusions Routine data can provide an accurate and feasible method of data collection for research, though wide limits of agreement between data sources may be observed. Differences could be due to methodological issues; but may relate to variability in clinical practice. Continued provision of appropriate training and assessment is essential for health professionals responsible for collecting routine data.

Sleep Duration and Adiposity in Early Childhood: Evidence for Bidirectional Associations from the Born in Bradford Study

Study Objectives: To examine independent associations of sleep duration with total and abdominal adiposity, and the bidirectionality of these associations, in a young biethnic sample of children from a disadvantaged location. Methods: Child sleep duration (h/day) was parent‐reported by questionnaire and indices of total (body weight, body mass index, percent body fat (%BF), sum of skinfolds) and abdominal adiposity (waist circumference) were measured using standard anthropometric procedures at approximately 12, 18, 24, and 36 months of age in 1,338 children (58% South Asian; 42% White). Mixed effects models were used to quantify independent associations (expressed as standardised &bgr;‐coefficients (95% confidence interval (CI)) of sleep duration with adiposity indices using data from all four time‐points. Factors considered for adjustment in models included basic demographics, pregnancy and birth characteristics, and lifestyle behaviours. Results: With the exception of the sum of skinfolds, sleep duration was inversely and independently associated with indices of total and abdominal adiposity in South Asian children. For example, one standard deviation (SD) higher sleep duration was associated with reduced %BF by ‐0.029 (95% CI: −0.053, −0.0043) SDs. Higher adiposity was also independently associated with shorter sleep duration in South Asian children (for example, %BF: &bgr; = ‐0.10 (‐0.16, ‐0.028) SDs). There were no significant associations in White children. Conclusions: Associations between sleep duration and adiposity are bidirectional and independent among South Asian children from a disadvantaged location. The results highlight the importance of considering adiposity as both a determinant of decreased sleep and a potential consequence.