Linda F. Cushman

Snacking patterns among 1,800 adults and children

OBJECTIVE To study snacking behavior, including frequency, time of day, location, and qualities sought in snack choices. DESIGN A survey questionnaire was designed for use by trained telephone interviewers to interview adults and for self-administration by students in the fifth and sixth grades. SETTING A national random sample was drawn of 1,510 adults, and a nonrandom sample was drawn of 290 fifth and sixth graders attending schools in four states. SUBJECTS Adults were randomly selected by a computerized telephone directory system from 48 states (Hawaii and Alaska were excluded). The five schools surveyed were selected to represent a major inner city (Atlanta, Ga), a suburban area (Englewood, NJ), a midsize city (two schools in St Louis, Mo), and a rural area (Hickman, Calif). RESULTS The majority of children in all age groups snacked at least once daily. Morning was the least common and afternoon was the most common time for snacking. Almost all snacking occurred at home. In the selection of snacks, taste outranked nutrition as the most important characteristic of a snack. Fruits were popular with all age groups, but overall they were chosen less often at snacktime than foods from other categories. APPLICATIONS Snacking should be targeted with specific nutrition education messages that address the influences of time of day, location, and qualities of foods on snack choices.

Race/Ethnicity and Women’s Use of Complementary and Alternative Medicine in the United States: Results of a National Survey

OBJECTIVES We studied the use of complementary and alternative medicine (CAM) among women in 4 racial/ethnic groups: non-Hispanic Whites, African Americans, Mexican Americans, and Chinese Americans. METHODS We obtained a nationally representative sample of women aged 18 years and older living in the United States in 2001. Oversampling obtained 800 interviews in each group, resulting in a sample of 3068 women. RESULTS Between one third and one half of the members of all groups reported using at least 1 CAM modality in the year preceding the survey. In bivariate analyses, overall CAM use among Whites surpassed that of other groups; however, when CAM use was adjusted for socioeconomic factors, use by Whites and Mexican Americans were equivalent. Despite the socioeconomic disadvantage of African American women, socioeconomic factors did not account for differences in CAM use between Whites and African Americans. CONCLUSIONS CAM use among racial/ethnic groups is complex and nuanced. Patterns of CAM use domains differ among groups, and multivariate models of CAM use indicate that ethnicity plays an independent role in the use of CAM modalities, the use of CAM practitioners, and the health problems for which CAM is used.

Quick Start: a novel oral contraceptive initiation method.

Conventional oral contraceptive (OC) starting instructions require waiting until menses to begin the OC. The conventional approach requires detailed patient education about when to begin and also may require the use of less effective or less acceptable interim contraceptive protection until menses. At our urban family planning clinic, we routinely offer patients starting the OC the option of taking the first tablet sooner. We prospectively evaluated predictors of short-term OC continuation among 250 OC requestors who were offered several approaches to OC initiation. Telephone follow-up of 91% of participants showed that women who swallowed the first OC in the clinic were more likely to continue the OC until the second package than women who planned to start the OC later (adjusted OR 2.8, 95% C.I. 1.1-7.3). Other factors associated with short-term continuation were: partners knowledge of planned OC use, older age, and participants agreement that she would be very unhappy about becoming pregnant in the next 6 months.

Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial.

OBJECTIVE: To estimate whether young women taking the first pill on the day of prescription had higher continuation rates and lower pregnancy rates than women who waited until menses to start the oral contraceptive pill (OCP). METHODS: We recruited 1,716 women aged younger than 25 years seeking to initiate the oral contraceptive at three publicly funded family planning clinics, and randomly assigned them to conventional initiation of the pill (conventional start) or immediate, directly observed ingestion of the first pill (quick start) during the clinic visit. Women underwent follow-up interviews at 3 and 6 months. RESULTS: Sixty percent of participants discontinued the pill, and 8% became pregnant during follow-up. Women who took the first pill in the clinic were more likely to continue to the second OCP pack (odds ratio 1.5, 95% confidence interval 1.0–2.1.); however, the Quick Start approach did not improve OCP continuation rates at 3 and 6 months. Those assigned to Quick Start were slightly less likely to become pregnant within 6 months from the time they started the pill (hazard ratio 0.90, 95% confidence interval 0.64—1.25). Eighty-one percent of women rated the Quick Start approach as acceptable or preferable to waiting. Rates of serious adverse events were low and similar in the two groups. CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068848 LEVEL OF EVIDENCE: I

Depressive symptoms and Depo-Provera.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptives. Women choosing Depo-Provera (n = 495) were evaluated before starting these contraceptives and were reinterviewed 1 year later. Women who continued the method had lower depressive symptom scores at baseline than did the women who discontinued the method or who were lost to follow-up. Among the continuing Depo-Provera users, the depressive symptom scores improved slightly at 1 year (7.4 vs 6.7). Those subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores at follow-up.

Condom Use Among Women Choosing Long-Term Hormonal Contraception

CONTEXT Women who rely on long-term hormonal contraception may neglect to use condoms, and thus increase their risk of contracting sexually transmitted diseases, including AIDS. METHODS Data from a prospective, multisite study were collected to examine the probability of condom use among 1,073 new users of either the contraceptive implant or injectable; users were interviewed when they accepted their method and again six months to one year later. Multivariate logistic regression analyses identified factors that significantly predicted the likelihood of dual method use. RESULTS Condom use dropped markedly among women who adopted long-term hormonal contraception. The proportion who always used condoms in the previous three months fell from 21% at the time of adoption to 11% at follow-up. Among women with one sexual partner, this decrease was from 20% to 10%; however, among those with more than one partner, use increased from 25% to 31%. The factors significantly predicting dual method use included previous condom use (odds ratio of 2.5), receipt of AIDS-specific counseling (odds ratio of 1.6), the perception of being at some risk of AIDS at baseline (odds ratio of 1.4) and having had more than one sexual partner over the study period (odds ratio of 5.4). In addition, injectable users, teenagers and black women were more likely than other women to use condoms with their hormonal method. CONCLUSIONS Although condom use among all women declined markedly once they initiated long-term hormonal contraception, frequency of condom use varied by subgroup and was associated with several factors. Most importantly, women with more than one sexual partner and those who received a message during counseling on the need to continue using condoms were more likely than others to use condoms in conjunction with the implant or injectable.

Medical Pluralism among American Women: Results of a National Survey

BACKGROUND Medical pluralism can be defined as the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness. American women use a variety of health services and practices for womens health conditions, yet no national study has specifically characterized womens medical pluralism. Our objective was to describe medical pluralism among American women. METHODS A nationally representative telephone survey of 808 women >or=18 years of age was conducted in 2001. Cross-sectional observations of the use of 11 CAM domains and the use of an additional domain--spirituality, religion, or prayer for health--during the past year are reported. Womens health conditions, treatments used, reasons for use, and disclosure to conventional physicians are described, along with predictors of CAM use. RESULTS Over half (53%) of respondents used CAM for health conditions, especially for those involving chronic pain. The majority of women disclosed such practices at clinical encounters with conventional providers. Biologically based CAM therapies, such as nutritional supplements and herbs, were commonly used with prescription and over-the-counter (OTC) pharmaceuticals for health conditions. CONCLUSIONS Medical pluralism is common among women and should be accepted as a cultural norm. Although disclosure rates of CAM use to conventional providers were higher than in previous population-based studies, disclosure should be increased, especially for women who are pregnant and those with heart disease and cancer. The health risks and benefits of polypharmacy should be addressed at multiple levels of the public health system.

Use of complementary and alternative medicine among Dominican emergency department patients

This small, pilot study examined presenting complaint, brief health history, use of complementary and alternative medicine (CAM), and sociodemographic characteristics, among patients attending the emergency department (ED) of a large urban hospital. The sample (n = 50) was primarily Dominican and of low socioeconomic status. Almost half had used CAM for their presenting complaint or another health problem during the past year, most commonly in the form of medicinal plants made into herbal teas. CAM users were more likely to be female, longer-term residents of the United States, and to have also used religious practices for health problems. Subjects who had used CAM for any problem other than the presenting complaint during the past year rated its effectiveness higher than subjects who had used CAM for their presenting complaint. In conclusion, it is likely that a significant proportion of Dominican ED patients use CAM, suggesting that they should be asked about their CAM use during triage.

Determinants of early implant discontinuation among low-income women.

The determinants of contraceptive implant discontinuation within six months of insertion were examined among 786 low-income women attending family planning clinics in three U.S. cities. The six-month cumulative life-table discontinuation rate was 7.6%. Menstrual side effects were the most common reasons given for early implant removal, although women who discontinued use were no more likely than those who continued with the method to report menstrual irregularities. Women who opted for early removal were more likely than those who continued with the method to experience headaches, hair loss, weight gain and arm infection. Logistic regression analysis indicates that dissatisfaction with prior contraceptive methods, a partner who wants a child within the next two years, perceived pressure from health care providers to choose the implant, exposure to negative media coverage and the number of implant side effects significantly predict early implant discontinuation. Womens social and demographic characteristics, Medicaid status and motivation to avoid an unplanned pregnancy were not significantly related to early removal.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women.

OBJECTIVES This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy. METHODS A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later. RESULTS The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%. CONCLUSIONS DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.