Tegan K. Boehmer

Gestational weight gain and pregnancy outcomes in obese women: how much is enough?

OBJECTIVE: To examine the effect of gestational weight change on pregnancy outcomes in obese women. METHODS: A population-based cohort study of 120,251 pregnant, obese women delivering full-term, liveborn, singleton infants was examined to assess the risk of four pregnancy outcomes (preeclampsia, cesarean delivery, small for gestational age births, and large for gestational age births) by obesity class and total gestational weight gain. RESULTS: Gestational weight gain incidence for overweight or obese pregnant women, less than the currently recommended 15 lb, was associated with a significantly lower risk of preeclampsia, cesarean delivery, and large for gestational age birth and higher risk of small for gestational age birth. These results were similar for each National Institutes of Health obesity class (30–34.9, 35–35.9, and 40.0 kg/m2), but at different amounts of gestational weight gain. CONCLUSION: Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes. LEVEL OF EVIDENCE: II

Perceived and observed neighborhood indicators of obesity among urban adults

Objective:The global obesity epidemic has been partially attributed to modern environments that encourage inactivity and overeating, yet few studies have examined specific features of the physical neighborhood environment that influence obesity. Using two different measurement methods, this study sought to identify and compare perceived and observed neighborhood indicators of obesity and a high-risk profile of being obese and inactive.Design:Cross-sectional telephone surveys (perceived) and street-scale environmental audits (observed) were conducted concurrently in two diverse US cities to assess recreational facility access, land use, transportation infrastructure and aesthetics.Subjects:A total of 1032 randomly selected urban residents (20% obese, 32% black, 65% female).Analysis:Bivariate and multivariate logistic regression analyses were conducted to estimate the association (adjusted prevalence odds ratio (aOR)) between the primary outcome (obese vs normal weight) and perceived and observed environmental indicators, controlling for demographic variables.Results:Being obese was significantly associated with perceived indicators of no nearby nonresidential destinations (aOR=2.2), absence of sidewalks (aOR=2.2), unpleasant community (aOR=3.1) and lack of interesting sites (aOR=4.8) and observed indicators of poor sidewalk quality (aOR=2.1), physical disorder (aOR=4.0) and presence of garbage (aOR=3.7). Perceived and observed indicators of land use and aesthetics were the most robust neighborhood correlates of obesity in multivariate analyses.Conclusions:The findings contribute substantially to the growing evidence base of community-level correlates of obesity and suggest salient environmental and policy intervention strategies that may reduce population-level obesity prevalence. Continued use of both measurement methods is recommended to clarify inconsistent associations across perceived and observed indicators within the same domain.

High 5 for Kids: The impact of a home visiting program on fruit and vegetable intake of parents and their preschool children

OBJECTIVE The High 5 for Preschool Kids (H5-KIDS) program tested the effectiveness of a home based intervention to teach parents how to ensure a positive fruit-vegetable (FV) environment for their preschool child, and to examine whether changes in parent behavior were associated with improvements in child intake. METHODS A group randomized nested cohort design was conducted (2001 to 2006) in rural, southeast Missouri with 1306 parents and their children participating in Parents As Teachers, a national parent education program. RESULTS When compared to control parents, H5-KIDS parents reported an increase in FV servings (MN=0.20, p=0.05), knowledge and availability of FV within the home (p=0.01), and decreased their use of noncoercive feeding practices (p=0.02). Among preschoolers, FV servings increased in normal weight (MN=0.35, p=0.02) but not overweight children (MN=-0.10, p=0.48), relative to controls. The parents change in FV servings was a significant predictor of childs change in FV in the H5-KIDS group (p=0.001). CONCLUSION H5-KIDS suggests the need for, and promise of, early home intervention for childhood obesity prevention. It demonstrates the importance of participatory approaches in developing externally valid interventions, with the potential for dissemination across national parent education programs as a means for improving the intake of parents and young children.

What Constitutes an Obesogenic Environment in Rural Communities

Purpose. To identify perceived indicators of the physical environment associated with obesity in rural communities. Design. Cross-sectional telephone survey. Setting. Thirteen communities in rural Missouri, Tennessee, and Arkansas, 2003. Subjects. A total of 2510 adults completed the survey and 2210 respondents were included in the analysis (74% female, 93% white, and 27% obese). Measures. The 106-item survey measured perceptions of the neighborhood environment (recreational facilities, land use, transportation/safety, aesthetics, and food environment) and health-related behaviors. The primary outcome was obese (body mass index [BMI] ≥ 30 kg/m2) vs. normal weight (BMI = 18.5–24.9 kg/m2). Analysis. Logistic regression was used to control for age, gender, and education. Results. Several indicators of the perceived neighborhood environment were associated with being obese (adjusted odds ratio [95% confidence interval]), including furthest distance to the nearest recreational facility (1.8 [1.3–2.4]), unpleasant community for physical activity (1.8 [1.3–2.6]), feeling unsafe from crime (2.1 [1.5–2.9]) or traffic (1.7 [1.2–2.3]), and few nonresidential destinations (1.4 [1.0–1.9]). Distance to recreational facilities and crime safety remained significant in the multivariate model, along with dietary-fat intake, sedentary behavior, and moderate/vigorous physical activity. Conclusion. This study adds to a growing evidence base of environmental correlates of obesity and makes a unique contribution regarding rural communities. If causality is established, environmental interventions that target obesogenic neighborhood features may reduce the prevalence of obesity on a population level.

Preventing Childhood Obesity Through State Policy Predictors of Bill Enactment

BACKGROUND To address the epidemic of childhood obesity, health professionals are examining policies that address obesogenic environments; however, there has been little systematic examination of state legislative efforts in childhood obesity prevention. Using a policy research framework, this study sought to identify factors that predict successful enactment of childhood obesity prevention in all 50 states. METHODS A legislative scan of bills introduced during 2003-2005 in all 50 states identified 717 bills related to childhood obesity prevention. Multilevel logistic regression modeling was performed in 2006 to identify bill-level (procedure, composition, and content) and state-level (sociodemographic, political, economic, and industrial) factors associated with bill enactment. RESULTS Seventeen percent of bills were enacted. Bill-level factors associated with increased likelihood of enactment included having more than one sponsor; bipartisan sponsorship; introduction in the state senate; budget proposals; and content areas related to safe routes to school, walking/biking trails, model school policies, statewide initiatives, and task forces and studies. State-level political factors, including 2-year legislative session and Democratic control of both chambers, increased enactment. An indicator of state socioeconomic status was inversely associated with bill enactment; economic and industrial variables were not significantly related to bill enactment. CONCLUSIONS In general, bill-level factors were more influential in their effect on policy enactment than state-level factors. This study provides policymakers, practitioners, and advocacy groups with strategies to develop more politically feasible childhood obesity prevention policies, including the identification of several modifiable bill characteristics that might improve bill enactment.

Personal, neighbourhood and urban factors associated with obesity in the United States

Introduction: Growing evidence suggests the built environment impacts obesity within urban areas; however, little research has investigated these relationships across levels of urbanisation in diverse and representative populations. This study aimed to determine whether personal and neighbourhood barriers differ by the level of urbanisation and the relative importance of personal barriers, neighbourhood barriers and land-use development patterns measured by a county-level sprawl index. Methods: Population-based, cross-sectional telephone survey data were collected on 1818 United States adults of diverse ethnicity and income level. Primary analyses were stratified by the level of urbanisation at the county level (large metropolitan, small metropolitan, non-metro, rural). Associations between obesity and neighbourhood and personal barriers were estimated with logistic regression, controlling for demographic variables. Within metropolitan areas, the association between body mass index (BMI) and county-level sprawl was estimated using hierarchical linear modelling, controlling for individual-level neighbourhood and personal barriers and demographic variables and then assessing cross-level interaction. Results: The prevalence of neighbourhood, but not personal, barriers differed widely across levels of urbanisation. Specific neighbourhood (eg traffic, unattended dogs) and personal (eg time, injury) barriers differentially correlated with obesity across strata. The impact of sprawl on BMI (B  =  −0.005) was consistent with previous findings; standardised coefficients indicate that personal (β  =  0.10) and neighbourhood (β  =  0.05) barriers had a stronger association than sprawl (β  =  −0.02). Furthermore, the effect of sprawl on BMI increased by −0.006 with each additional personal barrier. Conclusions: Future intervention planning and policy development should consider that personal barriers and built environment characteristics may interact with each other and influence obesity differently across urbanisation levels.

Preventing Childhood Obesity through State Policy: Qualitative Assessment of Enablers and Barriers

As the prevalence of obesity rapidly climbs among youth in the United States, public health practitioners and policymakers seek effective means of slowing and reversing these trends. Recently, many state laws and regulations addressing childhood obesity have been introduced and enacted. Understanding determinants of such legislation may inform the development and passage of future policies. For this study, key-informant interviews were conducted with 16 legislators and staffers from 11 states in 2005–2006 to examine qualitative factors that enable and impede state-level childhood obesity prevention legislation. Commonly cited factors positively influencing the passage of childhood obesity prevention legislation included national media exposure, introduction of the policy by senior legislators, and gaining the support of key players including parents, physicians, and schools. Noteworthy barriers included powerful lobbyists of companies that produce unhealthy foods and misconceptions about legislating foods at schools. Although the total number of informants was modest, their valuable insights provide policymakers and practitioners with a set of enablers and barriers to be considered when pursuing state-level policy.

Filovirus Outbreak Detection and Surveillance: Lessons From Bundibugyo

The first outbreak of Ebola hemorrhagic fever (EHF) due to Bundibugyo ebolavirus occurred in Uganda from August to December 2007. During outbreak response and assessment, we identified 131 EHF cases (44 suspect, 31 probable, and 56 confirmed). Consistent with previous large filovirus outbreaks, a long temporal lag (approximately 3 months) occurred between initial EHF cases and the subsequent identification of Ebola virus and outbreak response, which allowed for prolonged person-to-person transmission of the virus. Although effective control measures for filovirus outbreaks, such as patient isolation and contact tracing, are well established, our observations from the Bundibugyo EHF outbreak demonstrate the need for improved filovirus surveillance, reporting, and diagnostics, in endemic locations in Africa.

Residential Traffic Exposure and Childhood Leukemia

CONTEXT Exposure to elevated concentrations of traffic-related air pollutants in the near-road environment is associated with numerous adverse human health effects, including childhood cancer, which has been increasing since 1975. Results of individual epidemiologic studies have been inconsistent. Therefore, a meta-analysis was performed to examine the association between residential traffic exposure and childhood cancer. EVIDENCE ACQUISITION Studies published between January 1980 and July 2011 were retrieved from a systematic search of 18 bibliographic databases. Nine studies meeting the inclusion criteria were identified. Weighted summary ORs were calculated using a random effects model for outcomes with four or more studies. Subgroup and sensitivity analyses were performed. EVIDENCE SYNTHESIS Childhood leukemia was positively associated (summary OR=1.53, 95% CI=1.12, 2.10) with residential traffic exposure among seven studies using a postnatal exposure window (e.g., childhood period or diagnosis address) and there was no association (summary OR=0.92, 95% CI=0.78, 1.09) among four studies using a prenatal exposure window (e.g., pregnancy period or birth address). There were too few studies to analyze other childhood cancer outcomes. CONCLUSIONS Current evidence suggests that childhood leukemia is associated with residential traffic exposure during the postnatal period, but not during the prenatal period. Additional well-designed epidemiologic studies that use complete residential history to estimate traffic exposure, examine leukemia subtypes, and control for potential confounding factors are needed to confirm these findings. As many people reside near busy roads, especially in urban areas, precautionary public health messages and interventions designed to reduce population exposure to traffic might be warranted.

Use of Hospital Discharge Data to Evaluate Notifiable Disease Reporting to Colorado's Electronic Disease Reporting System

Objective. Notifiable disease surveillance systems are critical for communicable disease control, and accurate and timely reporting of hospitalized patients who represent the most severe cases is important. A local health department in metropolitan Denver used inpatient hospital discharge (IHD) data to evaluate the sensitivity, timeliness, and data quality of reporting eight notifiable diseases to the Colorado Electronic Disease Reporting System (CEDRS). Methods. Using IHD data, we detected hospitalized patients admitted from 2003 through 2005 with a discharge diagnosis associated with one of eight notifiable diseases. Initially, we compared all cases identified through IHD diagnoses fields with cases reported to CEDRS. Second, we chose four diseases and conducted medical record review to confirm the IHD diagnoses before comparison with CEDRS cases. Results. Relying on IHD diagnoses only, shigellosis, salmonellosis, and Neisseria meningitidis invasive disease had high sensitivity (≥90%) and timeliness (≥75%); legionellosis, pertussis, and West Nile virus infection were intermediate; and hepatitis A and Haemophilus influenzae (H. influenzae) invasive disease had low sensitivity (≤25%) and timeliness (≤33%). Medical record review improved the sensitivity to ≥90% and timeliness to ≥80% for H. influenza invasive disease, legionellosis, and pertussis; however, hepatitis A retained suboptimal sensitivity (67%) and timeliness (25%). Conclusions. Hospital discharge data are useful for evaluating notifiable disease surveillance systems. Limitations encountered by using discharge diagnoses alone can be overcome by conducting medical record review. Public health agencies should conduct periodic surveillance system evaluations among hospitalized patients and reinforce notifiable disease reporting among the people responsible for this activity.