Laurie K. Twells

Vitamin D insufficiency common in newborns, children and pregnant women living in Newfoundland and Labrador, Canada

Vitamin D deficiency is associated with poor bone health, colorectal cancer, type 1 diabetes and multiple sclerosis. Two national health-related societies in Canada have made recommendations for vitamin D supplementation, yet little research has been reported on the vitamin D status of Canadians. Lifestyle changes, such as sunscreen use, spending less time outdoors and insufficient intake of vitamin D-containing foods as well as northern latitude, may be affecting human vitamin D status. A cross-sectional analysis of 25-hydroxyvitamin D [25-(OH)D] was conducted in pregnant women, newborns (umbilical cord blood) and children. Samples were analysed by liquid chromatography mass spectrometry. Published ranges for 25-(OH)D were used to determine vitamin D status. The prevalence of 25-(OH)D deficiency for the three groups studied revealed most concentrations in the 25-(OH)D deficiency or insufficiency ranges. There were significant differences in all groups studied between seasons, with the exception of maternal blood and female cord blood samples. 25-(OH)D insufficiency was common in all groups for winter and summer, more so in winter. 25-(OH)D insufficiency was common in the three groups studied. The Newfoundland and Labrador population may be at increased risk for vitamin D insufficiency because of factors such as northern latitude and lifestyle issues. Further research on the vitamin D status of this population is important, considering the potential adverse health-related outcomes and the recommendations on supplementation being made.

Obesity prevalence estimates in a Canadian regional population of preschool children using variant growth references

BackgroundChildhood obesity is a public health problem in Canada. Accurate measurement of a health problem is crucial in defining its burden. The objective of this study is to compare the prevalence estimates of overweight and obesity in preschool children using three growth references.MethodsWeights and heights were measured on 1026 preschool children born in Newfoundland and Labrador (NL), Canada, and body mass index calculated. The prevalence of overweight and obesity was determined and statistical comparisons conducted among the three growth references; the Centres for Disease Control (CDC), the International Obesity Task Force (IOTF) and the World Health Organization (WHO).ResultsCDC and IOTF produced similar estimates of the prevalence of overweight, 19.1% versus 18.2% while the WHO reported a higher prevalence 26.7% (p < .001). The CDC classified twice as many children as obese compared to the IOTF 16.6% versus 8.3% (p < .001) and a third more than the WHO 16.6% versus 11.3% (p < .01). There was variable level of agreement between methods.ConclusionsThe CDC reported a much higher prevalence of obesity compared to the other references. The prevalence of childhood obesity is dependent on the growth reference used.

Long-term health-related quality of life in bariatric surgery patients: A systematic review and meta-analysis.

Bariatric surgery results in significant weight loss in the majority of patients. Improvement in health‐related quality of life (HRQoL) is an equally important outcome; however, there are few studies reporting long‐term (≥5 years) HRQoL outcomes. This study assesses the quality of evidence and effectiveness of surgery on HRQoL ≥ 5 years.

Patients' perceptions of waiting for bariatric surgery: a qualitative study.

BackgroundIn Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients’ perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients’ perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience.MethodsTwenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery.ResultsThematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants’ accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon’s office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others.ConclusionPatients’ perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

How formula feeding mothers balance risks and define themselves as ‘good mothers’

Breast feeding provides protection from many diseases and reduces health risks for both mother and child; however, a significant percentage of mothers in Newfoundland and Labrador, Canada choose to formula feed their infants from birth. In order to understand this phenomenon, qualitative research in the form of focus groups was conducted in three communities in the province in 2010. The data elicited from the research question ‘Why did you choose to formula feed your baby?’ were analysed using qualitative thematic content analysis. A major theme that arose was how these women define themselves as ‘good mothers’ in an environment where breast feeding is considered the optimal nutritional choice. It is about balancing the risks of formula feeding their infants with the needs of the family and themselves.

Obesity predicts primary health care visits: a cohort study.

The objective of this study was to explore the relationship between body mass index (BMI), its association with chronic disease, and its impact on health services utilization in the province of Newfoundland and Labrador, Canada, from 1998 to 2002. A data linkage study was conducted involving a provincial health survey linked to 2 health care use administrative databases. The study population comprised 2345 adults between the ages of 20 and 64 years. Self-reported height and weight measures and other covariates, including chronic diseases, were obtained from a provincial survey. BMI categories include: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese class I (BMI 30-34.9), obese class II (BMI ≥ 35), and obese class III (BMI ≥ 40). Survey responses were linked with objective physician and hospital health services utilization over a 5-year period. Weight classifications in the study sample were as follows: 37% normal, 39% overweight, 17% obese, and 6% morbidly obese. The obese and morbidly obese were more likely to report having serious chronic conditions after adjusting for age and sex. Only the morbidly obese group (BMI ≥ 35 kg/m(2)) had a significantly higher number of visits to a general practitioner (GP) over a 5-year period compared to the normal weight group (median 22.0 vs. 17.0, P<0.05). Using multivariate models and controlling for the number of chronic conditions and other relevant covariates, being morbidly obese remained a significant predictor of GP visits (P<0.001), but was not a predictor for visits to a specialist or any type of hospital use. The increase in the prevalence of obesity is placing a burden at the primary health care level. More resources are needed in order to support GPs in their efforts to manage and treat obese adults who have associated comorbidities.

A qualitative study exploring factors associated with mothers’ decisions to formula-feed their infants in Newfoundland and Labrador, Canada

BackgroundBreastfeeding has numerous health benefits. In 2010, the province of Newfoundland and Labrador had the lowest breastfeeding initiation rate (64.0%) in Canada. Formula feeding is associated with well-known health risks. Exclusive formula feeding is the “cultural norm” in some regions of the province. Women appear resistant to changing their infant feeding behaviors and remain committed to their decision to formula-feed. The primary aim of this qualitative study was to examine individual factors that shaped mothers’ decisions to formula-feed their infants. Nineteen mothers who were currently formula feeding their children participated in the study.MethodsQualitative research in the form of focus groups was conducted in three communities in the province in 2010. A thematic content analysis identified the main themes that influenced mothers’ decisions to formula-feed their infants.ResultsThe main themes included issues concerning the support needed to breastfeed, the convenience associated with formula feeding, and the embarrassment surrounding breastfeeding in public.ConclusionsThese findings help to better understand why mothers choose formula feeding over breastfeeding and may help to inform the development of public health interventions targeted at this population of mothers.

Association of insulin dosage with mortality or major adverse cardiovascular events: a retrospective cohort study

BACKGROUND Existing studies have shown conflicting evidence regarding the safety of exogenous insulin therapy in patients with type 2 diabetes. In particular, observational studies have reported an increased risk of death and cardiovascular disease among users of higher versus lower doses of insulin. We aimed to quantify the association between increasing dosage of insulin exposure and death and cardiovascular events, while taking into account time-dependent confounding and mediation that might have biased previous studies. METHODS We did a cohort study using primary care records from the UK-based Clinical Practice Research Datalink (CPRD). New users of metformin monotherapy were identified in the period between Jan 1, 2001, and Dec 31, 2012. We then identified those in this group with a new prescription for insulin. Insulin exposure was categorised into groups according to the mean dose (units) per day within 180-day time segments throughout each patients follow-up. Relative differences in mortality and major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, cardiovascular-related mortality) were assessed using conventional multivariable Cox proportional hazards models. Marginal structural models were then applied to reduce bias introduced by the time-dependent confounders affected by previous treatment. FINDINGS We identified 165 308 adults with type 2 diabetes in the CPRD database. After applying our exclusion criteria, 6072 (mean age 60 years [SD 12·5], 3281 [54%] men, mean HbA1c 8·5% [SD 1·75], and median follow-up 3·1 years [IQR 1·7-5·3) were new add-on insulin users and were included in the study cohort; 3599 were new add-on insulin users and were included in the subcohort linked to hospital records and death certificate information. Crude mortality rates were comparable between insulin dose groups; <25 units per day (46 per 1000 person-years), 25 to <50 units per day (39 per 1000 person-years), 50 to <75 units per day (27 per 1000 person-years), 75 to <100 units per day (34 per 1000 person-years), and at least 100 units per day (32 per 1000 person-years; p>0·05 for all; mean rate of 31 deaths per 1000 person-years [95% CI 29-33]). With adjustment for baseline covariates, mortality rates were higher for increasing insulin doses: less than 25 units per day [reference group]; 25 to <50 units per day, hazard ratio (HR) 1·41 [95% CI 1·12-1·78]; 50 to <75 units per day, 1·37 [1·04-1·80]; 75 to <100 units per day, 1·85 [1·35-2·53]; and at least 100 units per day, 2·16 [1·58-2·93]. After applying marginal structural models, insulin dose was not associated with mortality in any group (p>0·1 for all). INTERPRETATION In conventional multivariable regression analysis, higher insulin doses are associated with increased mortality after adjustment for baseline covariates. However, this effect seems to be confounded by time-dependent factors such as insulin exposure, glycaemic control, bodyweight gain, and the occurrence of cardiovascular and hypoglycaemic events. This study provides reassurance of the overall safety of insulin use in the treatment of type 2 diabetes and contributes to our understanding of the contrasting conclusions from non-randomised and randomised studies regarding dose-dependent effects of insulin on cardiovascular events and mortality. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and the Newfoundland and Labrador Research and Development Corporation.

Health care provider outcomes during and shortly after acute care restructuring in Newfoundland and Labrador.

Objectives To monitor changes in human resource indicators during six years of restructuring in Newfoundland and Labrador, and to measure providers’ perceptions of reform impact and attitudinal and behavioural reactions comparing changes in the St Johns region, where hospital aggregation occurred, to other regions. Methods Data on human resource indicators from 1995/96 to 2001/02 were obtained and analysed. The Employee Attitude Survey was sent to acute care staff (n=5353) to assess perceptions of reform impact on workplace conditions, work-related attitudes, turnover intentions and personal characteristics. The response rate for 2000 and 2002 was approximately 42% (n=1222 and 1034, respectively). Only respondents to both surveys (n=589) were used in the analysis. Results Increases in average employee and full-time equivalent numbers occurred in the St Johns region, despite hospital closure and aggregation. Increases in staff dislocation and turnover were observed, but paid sick hours decreased. Sick leave and overtime costs increased. Although perceived workplace conditions, and attitudes and behaviours were generally negative, there was evidence of improvement over time, especially in St Johns. Few significant regional or provider group differences were observed on most study variables. Conclusions Aggregation of hospitals in StJohns did not lead to a decrease in employee counts, or deterioration in human resource indicators or attitudes. However, province-wide initiatives are needed to promote more positive work environments and increase organizational effectiveness.

Assessing Infant Feeding Attitudes of Expectant Women in a Provincial Population in Canada: Validation of the Iowa Infant Feeding Attitude Scale.

Background: Maternal attitudes to infant feeding are predictive of intent and initiation of breastfeeding. Objectives: The Iowa Infant Feeding Attitude Scale (IIFAS) has not been validated in the Canadian population. This study was conducted in Newfoundland and Labrador, a Canadian province with low breastfeeding rates. Objectives were to assess the reliability and validity of the IIFAS in expectant mothers; to compare attitudes to infant feeding in urban and rural areas; and to examine whether attitudes are associated with intent to breastfeed. Methods: The IIFAS assessment tool was administered to 793 pregnant women. Differences in the total IIFAS scores were compared between urban and rural areas. Reliability and validity analysis was conducted on the IIFAS. The receiver operating characteristic (ROC) of the IIFAS was assessed against mother’s intent to breastfeed. Results: The mean ± SD of the total IIFAS score of the overall sample was 64.0 ± 10.4. There were no significant differences in attitudes between urban (63.9 ± 10.5) and rural (64.4 ± 9.9) populations. There were significant differences in total IIFAS scores between women who intend to breastfeed (67.3 ± 8.3) and those who do not (51.6 ± 7.7), regardless of population region. The high value of the area under the curve (AUC) of the ROC (AUC = 0.92) demonstrates excellent ability of the IIFAS to predict intent to breastfeed. The internal consistency of the IIFAS was strong, with a Cronbach’s alpha greater than .80 in the overall sample. Conclusion: The IIFAS examined in this provincial population provides a valid and reliable assessment of maternal attitudes toward infant feeding. This tool could be used to identify mothers less likely to breastfeed and to inform health promotion programs.