Pamela J. Surkan

Reasons for increasing trends in large for gestational age births

OBJECTIVE: To describe the magnitude of change in the proportion of term and postterm (37 completed weeks or more) large for gestational age (LGA) infants between 1992–2001 in Sweden and to examine whether time trends in prevalence of LGA births can be explained by changes in maternal risk factors. METHODS: Using the population-based Swedish Birth Register, we analyzed data from 1992 through 2001 on births of women who delivered live, singleton, term infants without malformations (N = 874,163). Unconditional logistic regression was used to model the odds of LGA birth. RESULTS: Mean birth weight and proportions of LGA births and births 4,500 g or more rose during the period 1992 to 2001. An unadjusted analysis estimated that the risk of LGA birth increased by 23% over 10 years. However, the prevalence of overweight and obesity (body mass index of 25 or greater) increased from 25% to 36%, and the prevalence of smoking decreased from 23% to 11% during the same period. After adjusting trends in all covariates simultaneously, the association between risk of LGA birth and calendar year disappeared. CONCLUSION: The increasing proportions of LGA births over time is explained by concurrent increases in maternal body mass index and decreases in maternal smoking. With the increasing prevalence of overweight among adolescents and young women, the prevalence of LGA infants and associated risks may increase over time. LEVEL OF EVIDENCE II-2

Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis

OBJECTIVE To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis. METHODS Six databases were searched for studies from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies. FINDINGS Seventeen studies including a total of 13,923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2-1.8) or stunted (OR: 1.4; 95% CI: 1.2-1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5-3.2) and for stunting, 2.0 (95% CI: 1.0-3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted. CONCLUSION Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.

Effects of the Dietary Approaches to Stop Hypertension (DASH) Eating Plan on Cardiovascular Risks among Type 2 Diabetic Patients: A Randomized Crossover Clinical Trial

OBJECTIVE To determine the effects of the Dietary Approaches to Stop Hypertension (DASH) eating pattern on cardiometabolic risks in type 2 diabetic patients. RESEARCH DESIGN AND METHODS A randomized crossover clinical trial was undertaken in 31 type 2 diabetic patients. For 8 weeks, participants were randomly assigned to a control diet or the DASH eating pattern. RESULTS After following the DASH eating pattern, body weight (P = 0.007) and waist circumference (P = 0.002) reduced significantly. Fasting blood glucose levels and A1C decreased after adoption of the DASH diet (−29.4 ± 6.3 mg/dl; P = 0.04 and −1.7 ± 0.1%; P = 0.04, respectively). After the DASH diet, the mean change for HDL cholesterol levels was higher (4.3 ± 0.9 mg/dl; P = 0.001) and LDL cholesterol was reduced (−17.2 ± 3.5 mg/dl; P = 0.02). Additionally, DASH had beneficial effects on systolic (−13.6 ± 3.5 vs. −3.1 ± 2.7 mmHg; P = 0.02) and diastolic blood pressure (−9.5 ± 2.6 vs. −0.7 ± 3.3 mmHg; P = 0.04). CONCLUSIONS Among diabetic patients, the DASH diet had beneficial effects on cardiometabolic risks.

The Dietary Approaches to Stop Hypertension Eating Plan Affects C-Reactive Protein, Coagulation Abnormalities, and Hepatic Function Tests among Type 2 Diabetic Patients

Few studies exist regarding the effects of the Dietary Approaches to Stop Hypertension (DASH) diet on novel cardiovascular risk factors among type 2 diabetic patients. We evaluated the effects of the DASH eating pattern on C-reactive protein (CRP) level, coagulation abnormalities, and hepatic function tests in type 2 diabetic patients. In this randomized, crossover clinical trial, 31 type 2 diabetic patients consumed a control diet or the DASH diet for 8 wk. The DASH diet was rich in fruits, vegetables, whole grains, and low-fat dairy products and low in saturated fat, total fat, cholesterol, refined grains, and sweets, with a total of 2400 mg/d sodium. The control diet was a standard diet for diabetic patients. There was a 4-wk washout between the 2 trial phases. The main outcome measures were CRP level, coagulation indices, and hepatic function tests. The mean percent change for plasma CRP level was -26.9 ± 3.5% after the DASH diet period and -5.1 ± 3.8% after the control diet period (P = 0.02). Decreases in both alanine aminotransferase and aspartate aminotransferase levels were greater after consuming the DASH diet compared with the control diet (-14.8 ± 3.0% vs -6.6 ± 3.4%; P = 0.001; -29.4 ± 3.7% vs -5.9 ± 1.4%; P = 0.001, respectively). The decrease in the plasma fibrinogen level during the DASH diet period (-11.4 ± 3.6%) was greater than that during the control diet (0.5 ± 3.4%) (P = 0.03). Among diabetic patients, the DASH diet can play an important role in reducing inflammation, plasma levels of fibrinogen, and liver aminotransferases. Future longer term studies are recommended.

The role of social networks and support in postpartum women's depression: a multiethnic urban sample.

Objectives: This study examined the relationship of social support, and of social networks, to symptoms of depression in a multiethnic sample of women having recently given birth. Methods: Women at community health centers in a Northeastern city were randomly sampled from groups stratified by race/ethnicity (African American, Hispanic, and White) and postpartum interval. Mothers score on the Center for Epidemiologic Studies of Depression Scale (CES-D) was the dependent variable. Main independent variables included the Medical Outcomes Study (MOS) Social Support Survey and a social network item. Univariate statistics assessed the relationship between CES-D score and each of the independent variables. Multivariate linear regression models included core sociodemographic variables alone, the core model with each of the social support and social network variables added separately, and all variables together. We evaluated interactions between race and social support, race and social networks, and social support and social networks. Results: The multivariate models with MOS Social Support and core variables indicated that each 10-point increase in the MOS Social Support Survey was related to a 2.1-unit lower score on the CES-D (95% CI −2.4, −1.7). The inclusion of the social network variable into the core model showed that having two or more friends or family members available was associated with a 13.6-point lower mean score on the CES-D (95% CI −17.5, −9.6), compared to women reporting none or only one available person. Conclusions: Both social support and social networks were statistically significant and independently related to depressive symptomatology.

Is there a relationship between red or processed meat intake and obesity? A systematic review and meta‐analysis of observational studies

A body of literature exists regarding the association of red and processed meats with obesity; however, the nature and extent of this relation has not been clearly established. The aim of this study is to conduct a systematic review and meta‐analysis of the relationship between red and processed meat intake and obesity. We searched multiple electronic databases for observational studies on the relationship between red and processed meat intake and obesity published until July 2013. Odds ratios (ORs) and means for obesity‐related indices and for variables that may contribute to heterogeneity were calculated. A systematic review and a meta‐analysis were conducted with 21 and 18 studies, respectively (n = 1,135,661). The meta‐analysis (n = 113,477) showed that consumption of higher quantities of red and processed meats was a risk factor for obesity (OR: 1.37; 95% CI: 1.14–1.64). Pooled mean body mass index (BMI) and waist circumference (WC) trends showed that in comparison to those in the lowest ntile, subjects in the highest ntile of red and processed meat consumption had higher BMI (mean difference: 1.37; 95% CI: 0.90–1.84 for red meat; mean difference: 1.32; 95% CI: 0.64–2.00 for processed meat) and WC (mean difference: 2.79; 95% CI: 1.86–3.70 for red meat; mean difference: 2.77; 95% CI: 1.87–2.66 for processed meat). The current analysis revealed that red and processed meat intake is directly associated with risk of obesity, and higher BMI and WC. However, the heterogeneity among studies is significant. These findings suggest a decrease in red and processed meat intake.

Home care of a child dying of a malignancy and parental awareness of a child's impending death.

In this population-based study, we found that parents who are aware that their child will die from a malignancy are more likely to care for their child at home during the child’s last month of life compared to parents who are not aware. End-of-life home care was comparable to hospital care for satisfactory pain relief, access to pain relief and access to medications for other physical symptoms. Using an anonymous postal questionnaire, we obtained information from 449 parents in Sweden who had lost a child due to a malignancy between 1992 and 1997, 4 to 9 years before participating in our study. The prevalence of dying at home and being cared for at home during the last month of life was 23.7% when parents realized intellectually more than 1 month in advance that the child would die (versus 12% who did not), 28.7% for parents who sensed that the child was aware of his or her imminent death (versus 7.8% who did not sense this) and 21.9% for those who received information that the child’s illness was incurable (versus 9.4% who did not receive the information). Prevalence of children’s unrelieved pain was 11.6% for those receiving home care and 15.3% for those receiving care outside the home.

Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study.

Objectives:The objective of this study is to determine associations between intertwining epidemics (syndemics) and HIV medication adherence and viral load levels among HIV-positive MSM and to test whether adherence mediates the relationship between syndemics and viral load. Design:We analysed participant data collected between 2003 and 2009 from the Multicenter AIDS Cohort Study, a prospective HIV/AIDS cohort study in four U.S. cities. Methods:We conducted longitudinal analyses (repeated measures mixed models) to assess whether differences in viral load levels, undetectable viral load and self-reported HIV medication adherence were associated with count of syndemic conditions (substance use, depression symptoms and sexual risk behaviour, range 0–3), adjusting for race/ethnicity, age and income. Mediation analyses were conducted using structural equation modelling and the SAS %mediate macro. Results:Syndemics count was associated with higher viral loads (P < 0.0001) and lower adherence (P < 0.0001). Increased counts of concomitant syndemics were associated with viral load (P < 0.01), detectable viral load (P < 0.05) and adherence (P < 0.001). Black MSM experienced worse outcomes across domains than white MSM (P < 0.0001) and experienced higher overall rates of syndemics (P < 0.01). Adherence significantly mediated the relationship between syndemics and viral load, accounting for an estimated 32.3% of the effect (P < 0.05). Conclusion:Effectively lowering viral load levels among MSM has implications for both HIV/AIDS prevention and care. Our findings suggest that integrating substance use interventions, mental healthcare and sexual risk prevention into standard HIV care may be necessary to optimize treatment and Treatment as Prevention (TasP) models.

A Framework for Understanding Grocery Purchasing in a Low-Income Urban Environment

Research demonstrates that food desert environments limit low-income shoppers’ ability to purchase healthy foods, thereby increasing their likelihood of diet-related illnesses. We sought to understand how individuals in an urban American food desert make grocery-purchasing decisions, and specifically why unhealthy purchases arise. Analysis is based on ethnographic data from participant observation, 37 in-depth interviews, and three focus groups with low-income, primarily African American shoppers with children. We found participants had detailed knowledge of and preference for healthy foods, but the obligation to consistently provide food for their families required them to apply specific decision criteria which, combined with structural qualities of the supermarket environment, increased unhealthy purchases and decreased healthy purchases. Applying situated cognition theory, we constructed an emic model explaining this widely shared grocery-purchasing decision process and its implications. This context-specific understanding of behavior suggests that multifaceted, system-level approaches to intervention are needed to increase healthy purchasing in food deserts.

Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti

Abstract In many settings worldwide, HIV-positive individuals have experienced a significant level of stigma and discrimination. This discrimination may also impact other family members affected by the disease, including children. The aim of our study was to identify factors associated with stigma and/or discrimination among HIV-affected youth and their HIV-positive caregivers in central Haiti. Recruitment of HIV-positive patients with children aged 10–17 years was conducted in 2006–2007. Data on HIV-related stigma and/or discrimination were based on interviews with 451 youth and 292 caregivers. Thirty-two percent of caregivers reported that children were discriminated against because of HIV/AIDS. Commune of residence was associated with discrimination against children affected by HIV/AIDS and HIV-related stigma among HIV-positive caregivers, suggesting variability across communities. Multivariable regression models showed that lacking social support, being an orphan, and caregiver HIV-related stigma were associated with discrimination in HIV-affected children. Caregiver HIV-related stigma demonstrated a strong association with depressive symptoms. The results could inform strategies for potential interventions to reduce HIV-related stigma and discrimination. These may include increasing social and caregiver support of children affected by HIV, enhancing support of caregivers to reduce burden of depressive symptoms, and promoting reduction of HIV-related stigma and discrimination at the community-level.