I. Diana Fernandez

The EARLY trials: a consortium of studies targeting weight control in young adults

Young adulthood has been identified as a high-risk period for the development of obesity but few interventions have been tested in this population. One way to escalate our learning about effective interventions is to test a number of interventions simultaneously as a consortium of research trials. This paper describes the Early Adult Reduction of weight through LifestYle intervention (EARLY) trials. Seven research sites were funded to conduct intervention trials, agreeing to test similar primary outcomes and cooperating to use a set of common measurement tools. The EARLY consortium was able to work cooperatively using an executive committee, a steering committee, workgroups and subcommittees to help direct the common work and implement a set of common protocol and measurement tools for seven independent but coordinated weight-related intervention trials. Using a consortium of studies to help young adults reach or maintain a healthy weight will result in increased efficiency and speed in understanding the most effective intervention strategies.

Blood lead levels of refugee children resettled in Massachusetts, 2000 to 2007.

OBJECTIVES We described elevated blood lead level (BLL; ≥ 10 μg/dL) prevalence among newly arrived refugee children in Massachusetts. We also investigated the incidence of BLL increases and BLLs newly elevated to 20 μg/dL or higher in the year following initial testing, along with associated factors. METHODS We merged data from the Massachusetts Department of Public Healths Refugee and Immigrant Health Program and the Childhood Lead Poisoning Prevention Program on 1148 refugee children younger than 7 years who arrived in Massachusetts from 2000 to 2007. RESULTS Elevated BLL prevalence was 16% among newly arrived refugee children. The rate ratio for BLL elevation to 20 μg/dL or higher after arrival was 12.3 (95% confidence interval [CI] = 6.2, 24.5) compared with children in communities the state defines as high-risk for childhood lead exposure. Residence in a census tract with older housing (median year built before 1950) was associated with a higher rate of BLL increases after resettlement (hazard ratio = 1.7; 95% CI = 1.2, 2.3). CONCLUSIONS Refugee children are at high risk of lead exposure before and after resettlement in Massachusetts. A national surveillance system of refugee childrens BLLs following resettlement would allow more in-depth analysis.

A Systematic Review of Early Postpartum Medroxyprogesterone Receipt and Early Breastfeeding Cessation: Evaluating the Methodological Rigor of the Evidence

BACKGROUND Breastfeeding has numerous maternal and infant benefits. Progesterone contraception after birth is frequently recommended, but because a decrease in progesterone is required to initiate lactation, early postpartum progesterone contraception use could inhibit lactation. The purpose of this article is to critically evaluate the scientific basis for conflicting clinical recommendations related to postpartum medroxyprogesterone use among breastfeeding women. METHODS Relevant peer-reviewed literature was identified through a comprehensive search of PubMed through December 2010. The search was restricted to clinical trials, randomized clinical trials, or comparative studies written in English and conducted among humans. The studies included in this review addressed the effect of medroxyprogesterone administration at <6 weeks postpartum on breastfeeding exclusivity and/or duration and measured breastfeeding outcomes at ≥ 6 weeks postpartum. RESULTS Of the 20 articles identified, only three studies satisfied the inclusion criteria. However, all three studies were of low-quality methodological rigor, and none accounted for potential confounders. CONCLUSION Current evidence is methodologically weak and provides an inadequate basis for inference about a possible causal relationship between early postpartum medroxyprogesterone use and poor breastfeeding outcomes. However, given the presence of a strong biological model describing the potential deleterious effect of postpartum medroxyprogesterone use on lactation, further research that improves on current literature is warranted. Meanwhile, we recommend that potential breastfeeding risks associated with early (<6 weeks) postpartum medroxyprogesterone use be disclosed to allow for a fully informed consent and decision-making process.

The effect of immediate postpartum depot medroxyprogesterone on early breastfeeding cessation.

BACKGROUND This study evaluated the effect of immediate postpartum depot medroxyprogesterone (DMPA) on breastfeeding cessation within 6 weeks postpartum. STUDY DESIGN At low-income-serving obstetric and pediatric clinics, eligible mothers within 1 year postpartum were recruited to participate in a retrospective cohort study. The 183 participants completed a self-administered survey. Surveys were merged with birth certificate data and perinatal maternal/infant medical records. Kaplan-Meier distributions assessed the relationship between DMPA use and breastfeeding cessation. A multivariable Cox proportional hazards model estimated hazard ratios (HRs) and included five known risk factors (age, education, race, parity and parental cohabitation) and identified potential confounders. RESULTS Consistent with the biologic model, the Kaplan-Meier results raised the possibility of a detrimental effect of DMPA on duration of any breastfeeding, but differences in these distributions did not achieve statistical significance (p=.24); after adjustment for potential confounders, this nonstatistically significant association remained (HR: 1.22; confidence interval: 0.75-1.98). CONCLUSION Given the state of the evidence, it is unclear whether a causal effect does or does not exist. However, if there is a causal effect of DMPA on breastfeeding duration, it is minimal. Additional well-designed research is warranted.

The Dietary Choices of Women Who Are Low-Income, Pregnant, and African American

INTRODUCTION Multiple factors influence the dietary choices of pregnant women that may increase the risk of excessive gestational weight gain. Several of these factors converge for African American women who are low income and reside in an urban setting. The objective of this study was to gain an understanding of how factors previously identified affect dietary decision making and determine the barriers that impede adoption of a healthy diet for this population. METHODS Twenty-five in-depth semistructured interviews were conducted with African American women who were low income, pregnant, and residing in an urban setting. The participants were recruited from a university obstetric clinic in a medium-sized urban northeastern city. Interviews were digitally recorded and transcribed. Analysis was a recursive process such that data analysis was done continually during data collection. Individual interviews were conducted until informational redundancy was reached. A directed content analysis approach was used, building from prior research and themes that emerged from focus groups with a similar population. Data were coded and grouped into meaningful clusters. RESULTS The participants indicated that food cravings, taste, and appetite influenced their food choices. Limited knowledge about healthy foods, cravings for unhealthy foods, time, and finances were barriers to making healthy dietary choices. Women indicated that if healthy food tasted better, they got more rest, and their schedules were regular, it would help them make the best possible food choices. DISCUSSION Women who are low income, African American, and pregnant could benefit from interventions targeting food cravings, taste, and appetite, and information about what constitutes a healthy diet. Cravings for calorie-dense, nutrient-poor foods were a driver of dietary choice and potentially increased the risk of excessive gestational weight gain. The complexities of cravings, taste, and appetite that converge with limited funds, tight schedules, and a knowledge deficit of important dietary information are critical to consider when providing care to pregnant women from this population.

Micronutrient Intake Is Inadequate for a Sample of Pregnant African-American Women

BACKGROUND Micronutrient intake is critical for fetal development and positive pregnancy outcomes. Little is known about the adequacy of micronutrient intake in pregnant African-American women. OBJECTIVE To describe nutrient sufficiency and top food groups contributing to dietary intake of select micronutrients in low-income pregnant African-American women and determine whether micronutrient intake varies with early pregnancy body mass index (BMI) and/or gestational weight gain. DESIGN Secondary analysis of data collected in a cohort study of pregnant African-American women. PARTICIPANTS/SETTING A total of 93 women aged 18 to 36 years, <20 weeks pregnant, with early pregnancy BMIs ≥18.5 and <40.0. The study was conducted during 2008 to 2012 with participants from university-affiliated obstetrics clinics in an urban setting in the northeastern United States. MAIN OUTCOME MEASURES Proportion of women with dietary intakes below Estimated Average Requirement (EAR) or Adequate Intake (AI) for vitamin D, folate, iron, calcium, and choline throughout pregnancy. Top food groups from which women derived these micronutrients was also determined. STATISTICAL ANALYSES PERFORMED Descriptive statistics included means, standard deviations, and percentages. Percent of women reaching EAR or AI was calculated. The χ2 test was used to assess micronutrient intake differences based on early pregnancy BMI and gestational weight gain. RESULTS A large percentage of pregnant women did not achieve the EAR or AI from dietary sources alone; EAR for folate (66%), vitamin D (100%), iron (89%), and AI for choline (100%). Mean micronutrient intake varied throughout pregnancy. Top food sources included reduced-fat milk, eggs, and mixed egg dishes, pasta dishes, and ready-to-eat cereal. CONCLUSIONS The majority of study participants had dietary micronutrient intake levels below EAR/AI throughout pregnancy. Findings suggest that practitioners should evaluate dietary adequacy in women to avoid deficits in micronutrient intake during pregnancy. Top food sources of these micronutrients can be considered when assisting women in improving dietary intake.

Medication identification in pediatric asthma (MED ID): The reliability and validity of a novel screening tool

ABSTRACT Objectives: To evaluate the reliability and validity of medication identification (MED ID), a novel survey assessing caregiver-perceived ability to identify inhaled asthma medications. Methods: We analyzed baseline data from the School-Based Asthma Care for Teens trial in Rochester, NY. Caregivers of adolescents with persistent asthma named the inhaled medications used by their child and identified medications on a pictorial chart. Accurate identification was defined as completed matches between listed names and selected images. Caregivers answered the MED ID survey of four scaled questions on perceived ability to identify inhaled medications. We determined internal consistency reliability using Cronbachs alpha; examined concurrent validity by comparing MED ID sum scores with accurate identification using bivariate and multivariate analyses; and assessed the diagnostic utility of MED ID through receiver operating characteristic analysis. Results: 126 caregivers (76% of enrolled) reported >1 inhaled medication; 52% of caregivers accurately identified medications. Two MED ID questions were removed during analysis. The two remaining questions had a score range of 2–10 points; higher scores indicate greater caregiver-perceived ability to identify medications. The Cronbachs alpha was 0.603. Accurate identification of medications was associated with a higher mean MED ID score (8.6 vs 7.6, p = 0.01). Accuracy was most strongly associated with MED ID scores ≥8 points (88% vs 60%, p < 0.001, Phi 0.32); findings were consistent in regression analysis. The greatest area under the curve was seen with MED ID scores ≥8 points (0.638). Conclusions: The two-item MED ID survey is a reliable and valid way to assess caregivers ability to identify inhaled asthma medications.

Maternal and child dietary intake: The role of maternal healthy-eater self-schema

BACKGROUND Mothers play a key role in shaping the dietary intake of their young children through their own dietary intake and the foods they make available at home. Therefore, understanding the mechanisms underlying maternal food choices is crucial. Cognitions about the self as a healthy eater, referred to as healthy-eater self-schema (HESS), predict dietary intake in diverse samples, but the linkage has not been investigated in mothers and their feeding behaviors. This study examined the relationship between a maternal HESS, maternal and child intake of fruits, vegetables, saturated fat, and added sugar, and home food availability. METHODS A cross-sectional, descriptive design was used with mothers and their 2-5 year old children (N = 124 dyads). Kendzierskis Healthy-Eater Self-Schema questionnaire was used to measure HESS. Block Food Frequency Screeners were used to measure diets (mother and child) and the Home Environment Survey was used to measure home availability of fruits/vegetables and fats/sweets. Multiple regression and multiple mediation analyses were performed. RESULTS Maternal HESS was positively associated with maternal intake of fruits and vegetables, and negatively associated with intake of added sugar. Maternal HESS was not directly associated with child dietary intake, but was indirectly associated with child intake of fruits, vegetables, and added sugar through maternal intake of the same foods. Home food availability was not significantly associated with HESS. CONCLUSION This study found that a mothers HESS was positively associated with her diet, which was subsequently associated with aspects of her childs diet. Interventions to foster development of HESS in mothers may be an effective means to promote healthy dietary intake in mothers and their young children.

Obesity candidate genes, gestational weight gain, and body weight changes in pregnant women

OBJECTIVE To examine the associations of two obesity-associated genes, FTO (rs9939609) and GNB3 (rs5443) single nucleotide polymorphisms (SNPs), with early pregnancy body mass index, gestational weight gain, and postpartum weight retention. METHODS Secondary data analysis of self-identified white (n = 580) and black (n = 194) women who participated in a randomized controlled trial (2009-2014) and provided a saliva sample of DNA. Bivariate relationships were assessed using analysis of variance. Multiple regression models assessed the relationship between outcomes and gene SNPs, controlling for income, parity, and smoking status. RESULTS FTO and GNB3 gene associations with pregnancy weight were different by racial group and early pregnancy body mass index. Obese black women homozygote for the FTO risk allele (AA) had a higher gestational weight gain compared with non-risk homozygotes (TT) (P = 0.006). GNB3 non-risk CC homozygotes tended to have a lower gestational weight gain compared with heterozygotes (P = 0.05). White GNB3 C carriers tended to be heavier in early pregnancy (P <0.1) and GNB3 homozygote (TT) overweight women tended to have lower postpartum weight retention than C carriers. CONCLUSIONS The FTO gene and possibly the GNB3 gene are associated with high gestational weight gain in obese black women. Obese carriers of the FTO risk allele gained 4.1 kg (AT) and 7.6 kg (TT) more than those without risk alleles. Overweight GNB3 heterozygotes (CT) gained 6.6 kg less than homozygotes (CC). Overweight or obese black women who have either risk variant are at risk for high gestational weight gain.

Using Television-Viewing Hours and Total Hours Sitting as Interchangeable Measures of Sedentary Behavior

Sedentary behaviors, activities spent sitting, or lying down during waking hours, are of significant public health importance. Television-viewing (TV-viewing) hours and total hours sitting are common self-report measures of sedentary behaviors. Given the widespread usage of these measures, the study purpose was to measure the concordance between TV-viewing hours and total hours sitting to determine whether they can be used as interchangeable measures of time spent in sedentary behavior. Using a sample (n = 2687) of workers from a group-randomized control trial, the current study assessed the concordance between weekday total hours sitting and TV-viewing hours. Tertiles were created based on the distribution of total hours sitting and TV-viewing hours. Weighted Kappa (Kappaw) statistics were calculated for the full sample and subgroups. Half of the sample reported 2 to 3 daily hours of TV-viewing hours and the most reported total hours sitting was 8 hours (14%). Kappaw statistics for tertiles of total hours sitting and TV-viewing hours were 0.005 (95% CI = −0.02 to 0.03), indicating little agreement. Kappaw statistics for subgroup analyses (body mass index categories, gender, and intervention assignment) showed poor agreement. Results do not support the use of total hours sitting and TV-viewing hours as interchangeable measures of sedentary behavior.