Lisa G. Rosas

The pine river statement: human health consequences of DDT use.

Objectives Dichlorodiphenyltrichloroethane (DDT) was used worldwide until the 1970s, when concerns about its toxic effects, its environmental persistence, and its concentration in the food supply led to use restrictions and prohibitions. In 2001, more than 100 countries signed the Stockholm Convention on Persistent Organic Pollutants (POPs), committing to eliminate the use of 12 POPs of greatest concern. However, DDT use was allowed for disease vector control. In 2006, the World Health Organization and the U.S. Agency for International Development endorsed indoor DDT spraying to control malaria. To better inform current policy, we reviewed epidemiologic studies published from 2003 to 2008 that investigated the human health consequences of DDT and/or DDE (dichlorodiphenyldichloroethylene) exposure. Data sources and extraction We conducted a PubMed search in October 2008 and retrieved 494 studies. Data synthesis Use restrictions have been successful in lowering human exposure to DDT, but blood concentrations of DDT and DDE are high in countries where DDT is currently being used or was more recently restricted. The recent literature shows a growing body of evidence that exposure to DDT and its breakdown product DDE may be associated with adverse health outcomes such as breast cancer, diabetes, decreased semen quality, spontaneous abortion, and impaired neurodevelopment in children. Conclusions Although we provide evidence to suggest that DDT and DDE may pose a risk to human health, we also highlight the lack of knowledge about human exposure and health effects in communities where DDT is currently being sprayed for malaria control. We recommend research to address this gap and to develop safe and effective alternatives to DDT.

Translating the Diabetes Prevention Program Lifestyle Intervention for Weight Loss Into Primary Care A Randomized Trial

BACKGROUND The Diabetes Prevention Program (DPP) lifestyle intervention reduced the incidence of type 2 diabetes mellitus (DM) among high-risk adults by 58%, with weight loss as the dominant predictor. However, it has not been adequately translated into primary care. METHODS We evaluated 2 adapted DPP lifestyle interventions among overweight or obese adults who were recruited from 1 primary care clinic and had pre-DM and/or metabolic syndrome. Participants were randomized to (1) a coach-led group intervention (n = 79), (2) a self-directed DVD intervention (n = 81), or (3) usual care (n = 81). During a 3-month intensive intervention phase, the DPP-based behavioral weight-loss curriculum was delivered by lifestyle coach-led small groups or home-based DVD. During the maintenance phase, participants in both interventions received lifestyle change coaching and support remotely-through secure email within an electronic health record system and the American Heart Association Heart360 website for weight and physical activity goal setting and self-monitoring. The primary outcome was change in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) from baseline to 15 months. RESULTS At baseline, participants had a mean (SD) age of 52.9 (10.6) years and a mean BMI of 32.0 (5.4); 47% were female; 78%, non-Hispanic white; and 17%, Asian/Pacific Islander. At month 15, the mean ± SE change in BMI from baseline was -2.2 ± 0.3 in the coach-led group vs -0.9 ± 0.3 in the usual care group (P < .001) and -1.6 ± 0.3 in the self-directed group vs usual care (P = .02). The percentages of participants who achieved the 7% DPP-based weight-loss goal were 37.0% (P = .003) and 35.9% (P = .004) in the coach-led and self-directed groups, respectively, vs 14.4% in the usual care group. Both interventions also achieved greater net improvements in waist circumference and fasting plasma glucose level. CONCLUSION Proven effective in a primary care setting, the 2 DPP-based lifestyle interventions are readily scalable and exportable with potential for substantial clinical and public health impact. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00842426.

Pesticide Toxicity and the Developing Brain

Organochlorine pesticides are used in some countries for malaria control and organophosphate pesticides are widely used in agriculture and in homes. Previous literature documents childrens exposure to these chemicals both in utero and during development. Animal studies suggest that many of these chemicals are neurodevelopmental toxicants even in moderate doses, but there are few studies in human beings. Associations of childrens pesticide exposure with neurodevelopment from studies being conducted worldwide are summarized. In addition, we present the work of the CHAMACOS study, a longitudinal birth cohort study of Mexican-American children living in the Salinas Valley of California. In this study, we investigated the relationship of childrens neurodevelopment with maternal dichlorodiphenyltrichloroethane and dichlorodiphenyldichloroethylene serum levels, as well as prenatal and child organophosphate urinary metabolite levels. We have examined the association with childrens performance on the Brazelton Neonatal Assessment Scales and at 6, 12 and 24 months on the Bayley Scales of Infant Development (mental development and psychomotor development) and mothers report on the Child Behaviour Checklist. We observed a negative association of prenatal dichlorodiphenyltrichloroethane exposure and child mental development. We also observed adverse associations of prenatal but not postnatal organophosphate pesticide exposure with mental development and pervasive developmental disorder at 24 months.

Pesticides and child neurodevelopment

Purpose of review This review summarizes the recent research on pesticide exposure and child neurobehavioral development with a focus on in-utero exposure to organochlorine and organophosphate pesticides. Recent findings Recent studies on in-utero exposure to the organochlorine pesticide dichlorodiphenyltrichloroethane and its breakdown product, dichlorodiphenyldichloroethene, indicate that exposure is associated with poorer infant (6 months and older) and child neurodevelopment. Yet, the studies differ on the domain of development that is affected. Research on organophosphate pesticide exposure and neurodevelopment is limited but suggests some negative association of exposure and neurodevelopment at certain ages. Two reports agree that increased levels of organophosphate exposure in utero result in greater numbers of abnormal reflexes in neonates and studies in older infants and young children also point to a negative association with development. In young children (2–3 years) two separate studies observed an increase in maternally reported pervasive developmental disorder with increased levels of organophosphate exposure. Summary Given that the literature suggests a link between organochlorine and in-utero pesticide exposure and impaired child neurodevelopment, clinicians should educate parents about prevention of exposure, especially in populations living in agricultural areas or where household use is common.

Dietary Associations of Household Food Insecurity among Children of Mexican Descent: Results of a Binational Study

BACKGROUND/OBJECTIVE Children of Mexican descent frequently experience household food insecurity both in the United States and Mexico. However, little is known about the associations of food insecurity with dietary intake. This study aimed to understand the level of perceived food insecurity and its association with dietary intake among children of Mexican descent residing in the United States and Mexico. DESIGN This cross-sectional study utilized data from a 2006 binational study of 5-year-old children of Mexican descent living in migrant communities in California and Mexico. METHODS In California, children were 301 participants from the Center for the Health Assessment of Mothers and Children of Salinas study, a longitudinal birth cohort in a Mexican immigrant community. Mexican children (n=301) were participants in the Proyecto Mariposa study, which was designed to capture a sample of women and their children living in Mexico who closely resembled the California sample, yet who never migrated to the United States. Household food insecurity was measured using the US Department of Agriculture Food Security Scale and dietary intake was assessed with food frequency questionnaires. Analysis of variance was used to examine unadjusted and adjusted differences in total energy, nutrient intake, and consumption of food groups by household food security status. RESULTS Approximately 39% of California mothers and 75% of Mexico mothers reported low or very low food security in the past 12 months (P<0.01). Children in the United States experiencing food insecurity consumed more fat, saturated fat, sweets, and fried snacks than children not experiencing food insecurity. In contrast, in Mexico food insecurity was associated with lower intake of total carbohydrates, dairy, and vitamin B-6. CONCLUSIONS Programs and policies addressing food insecurity in the United States and Mexico may need to take steps to address dietary intake among children in households experiencing food insecurity, possibly through education and programs to increase resources to obtain healthful foods.

A Comparison of PBDE Serum Concentrations in Mexican and Mexican-American Children Living in California

Background: Polybrominated diphenyl ethers (PBDE), which are used as flame retardants, have been found to be higher in residents of California than of other parts of the United States. Objectives: We aimed to investigate the role of immigration to California on PBDE levels in Latino children. Methods: We compared serum PBDE concentrations in a population of first-generation Mexican-American 7-year-old children (n = 264), who were born and raised in California [Center for Health Analysis of Mothers and Children of Salinas (CHAMACOS) study], with 5-year-old Mexican children (n = 283), who were raised in the states in Mexico where most CHAMACOS mothers had originated (Proyecto Mariposa). Results: On average, PBDE serum concentrations in the California Mexican-American children were three times higher than their mothers’ levels during pregnancy and seven times higher than concentrations in the children living in Mexico. The PBDE serum concentrations were higher in the Mexican-American children regardless of length of time their mother had resided in California or the duration of the child’s breast-feeding. These data suggest that PBDE serum concentrations in these children resulted primarily from postnatal exposure. Conclusions: Latino children living in California have much higher PBDE serum levels than their Mexican counterparts. Given the growing evidence documenting potential health effects of PBDE exposure, the levels in young children noted in this study potentially present a major public health challenge, especially in California. In addition, as PBDEs are being phased out and replaced by other flame retardants, the health consequences of these chemical replacements should be investigated and weighed against their purported fire safety benefits.

Physical Education Policy Compliance and Children's Physical Fitness

BACKGROUND Physical education policies have received increased attention as a means for improving physical activity levels, enhancing physical fitness, and contributing to childhood obesity prevention. Although compliance at the school and district levels is likely to be critical for the success of physical education policies, few published studies have focused on this issue. PURPOSE This study investigated whether school district-level compliance with California physical education policies was associated with physical fitness among 5th-grade public-school students in California. METHODS Cross-sectional data from FITNESSGRAM(®) 2004-2006, district-level compliance with state physical education requirements for 2004-2006, school- and district-level information, and 2000 U.S. Census data were combined to examine the association between district-level compliance with physical education policies and childrens fitness levels. The analysis was completed in 2010. RESULTS Of the 55 districts with compliance data, 28 (50%) were in compliance with state physical education mandates; these districts represented 21% (216) of schools and 18% (n=16,571) of students in the overall study sample. Controlling for other student-, school-, and district-level characteristics, students in policy-compliant districts were more likely than students in noncompliant districts to meet or exceed physical fitness standards (AOR=1.29, 95% CI=1.03, 1.61). CONCLUSIONS Policy mandates for physical education in schools may contribute to improvements in childrens fitness levels, but their success is likely to depend on mechanisms to ensure compliance.

Baseline reach and adoption characteristics in a randomized controlled trial of two weight loss interventions translated into primary care: A structured report of real-world applicability

BACKGROUND Although the Diabetes Prevention Program (DPP) lifestyle intervention reduced type 2 diabetes incidence by 58% among high-risk adults at academic centers, it requires translation into typical primary care settings. Using baseline data from the Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care (E-LITE) randomized controlled trial, we evaluated the potential of its two DPP-based interventions to reach their target populations and be adopted into routine use. METHODS Overweight/obese adults with increased cardiometabolic risk enrolled from one primary care clinic. Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model, we assessed reach with data on patient identification, participation, and representativeness, and adoption with data on intervention feasibility and potential for organizational diffusion. RESULTS The target population was identified by searching electronic health records. Contact was attempted for 2391 patients who completed initial screening by phone (56% uptake) or online (44%). Most (88%) of those screened ineligible were not within the target population; 12% were excluded because of research requirements. Conservatively estimated participation rate was 44%. Participants (n=241) included 54% men and had a mean (SD) age of 52.9 years (10.6) and body mass index of 32 kg/m(2) (5.4). Regarding adoption, all clinic physicians agreed to participate. The feasibility of intervention implementation and dissemination was enhanced by leveraging existing intervention, training, and primary care resources. CONCLUSIONS E-LITEs lifestyle interventions had fair-to-good potential for primary care reach and adoption. Our trial evidence and structured reporting may inform real-world implementation of translational trials by health networks, physicians, and payers.

The Effectiveness of Two Community-Based Weight Loss Strategies among Obese, Low-Income US Latinos

BACKGROUND Latino immigrants have high rates of obesity and face barriers to weight loss. OBJECTIVE To evaluate the effectiveness of a case-management (CM) intervention with and without community health workers (CHWs) for weight loss. DESIGN This was a 2-year, randomized controlled trial comparing two interventions with each other and with usual care (UC). PARTICIPANTS/SETTING Eligible participants included Latinos with a body mass index of 30 to 60 and one or more heart disease risk factors. The 207 participants recruited during 2009-2010 had a mean age of 47 years and were mostly women (77%). At 24 months, 86% of the sample was assessed. INTERVENTION The CM+CHW (n=82) and CM (n=84) interventions were compared with each other and with UC (n=41). Both included an intensive 12-month phase followed by 12 months of maintenance. The CM+CHW group received home visits. MAIN OUTCOME MEASURES Weight change at 24 months. STATISTICAL ANALYSES Generalized estimating equations using intent-to-treat. RESULTS At 6 months, mean weight loss in the CM+CHW arm was -2.1 kg (95% CI -2.8 to -1.3) or -2% of baseline weight (95% CI -1% to -2%) compared with -1.6 kg (95% CI -2.4 to -0.7; % weight change, -2%, -1%, and -3%) in CM and -0.9 kg (95% CI -1.8 to 0.1; % weight change, -1%, 0%, and -2%) in UC. By 12 and 24 months, differences narrowed and CM+CHW was no longer statistically distinct. Men achieved greater weight loss than women in all groups at each time point (P<0.05). At 6 months, men in the CM+CHW arm lost more weight (-4.4 kg; 95% CI -6.0 to -2.7) compared with UC (-0.4 kg; 95% CI -2.4 to 1.5), but by 12 and 24 months differences were not significant. CONCLUSIONS This study demonstrated that incorporation of CHWs may help promote initial weight loss, especially among men, but not weight maintenance. Additional strategies to address social and environmental influences may be needed for Latino immigrant populations.

Pilot randomised trial of a healthy eating behavioural intervention in uncontrolled asthma

Rigorous research on the benefit of healthy eating patterns for asthma control is lacking. We randomised 90 adults with objectively confirmed uncontrolled asthma and a low-quality diet (Dietary Approaches to Stop Hypertension (DASH) scores <6 out of 9) to a 6-month DASH behavioural intervention (n=46) or usual-care control (n=44). Intention-to-treat analyses used repeated-measures mixed models. Participants were middle-aged, 67% female and multiethnic. Compared with controls, intervention participants improved on DASH scores (mean change (95% CI) 0.6 (0, 1.1) versus −0.3 (−0.8, 0.2); difference 0.8 (0.2, 1.5)) and the primary outcome, Asthma Control Questionnaire scores (−0.2 (−0.5, 0) versus 0 (−0.3, 0.3); difference −0.2 (−0.5, 0.1)) at 6 months. The mean group differences in changes in Mini Asthma Quality of Life Questionnaire overall and subdomain scores consistently favoured the intervention over the control group: overall 0.4 (95% CI 0, 0.8), symptoms 0.5 (0, 0.9), environment 0.4 (−0.1, 1.0), emotions 0.4 (−0.2, 0.9) and activities 0.3 (0, 0.7). These differences were modest, but potentially clinical significant. The DASH behavioural intervention improved diet quality with promising clinical benefits for better asthma control and functional status among adults with uncontrolled asthma. A full-scale efficacy trial is warranted. A dietary programme has clinical benefits for asthma control and functional status in adults with uncontrolled asthma http://ow.ly/R8zUn