Seasonal effect of PM10 concentrations on mortality and morbidity in Seoul, Korea: A temperature-matched case-crossover analysis

Background

Explorations of interactions between air pollution and seasonal changes have represented one approach in examining the consequences of global warming. However, only a few studies have focused on evaluating the effects of seasonal air pollution using data on both morbidity and mortality in Asia.

Method

We examined the associations between PM₁₀ concentrations and mortality and hospital admissions in Seoul, Korea for the periods 2000-2006 and 2001-2006. We employed a temperature-matched case-crossover design, where reference periods matched case days in regard to temperature (same rounded to degrees celsius (°C)), month, and year.

Results

A total of 238,826 deaths were identified, along with 98,570 and 93,553 inpatient admissions for cardiovascular and respiratory diseases, respectively. We found that the association with PM₁₀ and mortality/morbidity increased during the summer. During the study period, 10μg/m³ increase in PM₁₀ was associated with the increase in mortality by 0.28% (95% confidence interval: 0.12, 0.44), 0.51% (0.19, 0.83), and 0.59% (-0.08, 1.26) for non-accidental, cardiovascular, and respiratory causes. 10μg/m³ increase in PM₁₀ was also associated with increase in hospitalization from cardiovascular and respiratory causes by 0.77% (0.53, 1.01) and 1.19% (0.94, 1.44). In the summer, the increase in mortality and hospitalization was 0.57% (0.20, 0.93), 0.64% (-0.10, 1.38), 0.50% (-1.02, 2.05), 1.52% (0.89, 2.16), and 1.55% (0.87, 2.22).

Conclusions

This study provides evidence that the effect of PM₁₀ on mortality and morbidity varies with season and increases during the summer season.     

Emergency Admissions for Cardiovascular and Respiratory Diseases and the Chemical Composition of Fine Particle Air Pollution

Background

Population-based studies have estimated health risks of short-term exposure to fine particles using mass of PM_2.5 (particulate matter ≤ 2.5 μm in aerodynamic diameter) as the indicator. Evidence regarding the toxicity of the chemical components of the PM_2.5 mixture is limited.

Objective

In this study we investigated the association between hospital admission for cardiovascular disease (CVD) and respiratory disease and the chemical components of PM_2.5 in the United States.

Methods

We used a national database comprising daily data for 2000–2006 on emergency hospital admissions for cardiovascular and respiratory outcomes, ambient levels of major PM_2.5 chemical components [sulfate, nitrate, silicon, elemental carbon (EC), organic carbon matter (OCM), and sodium and ammonium ions], and weather. Using Bayesian hierarchical statistical models, we estimated the associations between daily levels of PM_2.5 components and risk of hospital admissions in 119 U.S. urban communities for 12 million Medicare enrollees (≥ 65 years of age).

Results

In multiple-pollutant models that adjust for the levels of other pollutants, an interquartile range (IQR) increase in EC was associated with a 0.80% [95% posterior interval (PI), 0.34–1.27%] increase in risk of same-day cardiovascular admissions, and an IQR increase in OCM was associated with a 1.01% (95% PI, 0.04–1.98%) increase in risk of respiratory admissions on the same day. Other components were not associated with cardiovascular or respiratory hospital admissions in multiple-pollutant models.

Conclusions

Ambient levels of EC and OCM, which are generated primarily from vehicle emissions, diesel, and wood burning, were associated with the largest risks of emergency hospitalization across the major chemical constituents of PM_2.5.     

Social disadvantage, air pollution, and asthma physician visits in Toronto, Canada

Background

Previous research demonstrates that ambient air pollution exacerbates asthma. Asthma morbidity also varies with socioeconomic position (SEP). Few studies have examined if ambient air pollution has a differential impact on income subgroups of the population. This paper investigates socioeconomic variation in ambulatory physician consultations for asthma and assesses possible effect modification of SEP on the association between physician visits and air pollution for children aged 1-17 and adults aged 18-64 in Toronto, Canada, between 1992 and 2001.

Methods

Generalized additive models and generalized linear models were used to estimate the adjusted risk of asthma physician visits associated with an interquartile range increase in sulfur dioxide (SO₂), nitrogen dioxide (NO₂), particulate matter (PM_2.5), and ozone (O₃).

Results

A socioeconomic gradient in the number of physician visits was observed among children and adults and both sexes. SO₂, NO₂, and PM_2.5 had positive associations with physician visits. The risk ratios for the low socioeconomic group were significantly greater than those for the high socioeconomic group in several of the models of SO₂ and PM_2.5.

Conclusions

These findings suggest increased ambulatory physician visits represent another component of the public health impact of urban air pollution. The burden of this impact may be borne disproportionately by those with lower SEP. Clarifying the role of SEP in altering susceptibility to the effects of air pollution is essential not only to inform revisions of ambient air quality standards, but also to design public health interventions to reduce health impacts on sensitive subgroups of the population.     

Association between daily mortality from respiratory and cardiovascular diseases and air pollution in Taiwan

Background

Many studies have investigated the effects of air pollutants on disease and mortality. However, the results remain inconsistent and inconclusive. We thought that the impact of different seasons or ages of people may explain these differences.

Methods

Measurement of the five pollutants (particulate matter <10 μm in aerodynamic diameter (PM₁₀), SO₂, NO₂, O₃, and CO) was monitored by automated measuring units at five different stations. Monitoring stations were provided by the Taiwan Environmental Protection Agency (EPA) from 1997 to 1999. The subjects in the study were classified in two groups: those 65 years of age and older, and those of all ages (including the subjects in the ?65 group). Data on daily mortality caused by respiratory disease, cardiovascular disease, and all other causes including the two aforementioned was collected by the Taiwan Department of Health (DOH). A time-series regression model was used to analyze the relative risk of respiratory and cardiovascular diseases due to air pollution in the summer and winter seasons.

Results

Risk of death from all causes and mortality from cardiovascular diseases during winter was significantly positively correlated with levels of SO₂, CO, and NO₂ for both groups of subjects and additionally with PM₁₀ for the elderly (?65 years old) group. There were significant positive correlations with respiratory diseases and levels of O₃ for both groups. However, the only significant positive correlation was with O₃ (RR=1.283) for the elderly group during summer. No other parameters showed significance for either group.

Conclusion

Our findings contribute to the evidence of an association between SO₂, CO, NO₂, and PM₁₀ and mortality from respiratory and cardiovascular diseases, especially among elderly people during the winter season.     

Ingresos hospitalarios en el área de la Bahía de Algeciras. Comparación con Andalucía y España (2001-2005)

Objectives

To describe hospital admissions data in the Bay of Algeciras from 2001 to 2005 compared with the rest of Andalusia and Spain and to analyze the relationship between these data and the most frequent diagnoses leading to excessive premature mortality in this area.

Methods

We carried out a cross-sectional study. The study population consisted of the residents of the municipalities of the Bay of Algeciras, obtained from the Population and Household Census of 2001. Age-adjusted annual average hospital admission rates were compared between the Bay of Algeciras (2001-2005) and the rest of Andalusia and Spain using the relative and attributable risk. Hospital admissions and premature mortality rates were compared by means of the relative risk of the most important causes.

Results

Hospital admissions in the Bay of Algeciras were significantly lower for most of the diagnoses studied. There was also excessive premature mortality, especially for circulatory diseases (RR for hospital admissions: 0.79 in men and 0.87 in women; RR for premature mortality: 1.39 in men and 1.70 in women). Notable specific diseases were diabetes in both genders and cerebrovascular disease and liver cirrhosis in men.

Conclusions

This study found a lower use of healthcare services and a higher risk of premature mortality due to severe diseases in this region. Further studies analyzing the potential socioeconomic and environmental determinants of the area are required.     

The effect of urinary cadmium on cardiovascular fitness as measured by VO2 max in white, black and Mexican Americans

Objectives

We explored potential effects of cadmium exposure on cardiovascular fitness measures, including gender and racial/ethnic differences.

Methods

Data were from the 1999 to 2000 National Health and Nutrition Examination Survey (NHANES); 1963 participating subjects were included in our analysis. Volume of oxygen consumed at sub-maximum activity (VO₂ max) were recorded in a series of graded exercises; the goal was to elicit 75% of predetermined age-specific heart rates. Cadmium from urine samples was measured in the laboratory using standard methods. Multivariate linear regression analyses were performed to determine potential relationships.

Results

Increased urinary cadmium concentrations were generally associated with decreased estimated VO₂ max values. Gender and racial/ethnic differences were also observed. Specifically, associations were statistically significant for white males and Mexican American females.

Conclusion

Inverse associations between urinary cadmium concentrations and estimated VO₂ max values were observed, including racial and gender differences. The implications of such gender and racial/ethnic differences on long-term cardiovascular health and health disparities of present public health concern warrant further investigation.     

Distributed lag analyses of daily hospital admissions and source-apportioned fine particle air pollution

Background

Past time-series studies of the health effects of fine particulate matter [aerodynamic diameter ≤ 2.5 μm (PM_2.5)] have used chemically nonspecific PM_2.5 mass. However, PM_2.5 is known to vary in chemical composition with source, and health impacts may vary accordingly.

Objective

We tested the association between source-specific daily PM_2.5 mass and hospital admissions in a time-series investigation that considered both single-lag and distributed-lag models.

Methods

Daily PM_2.5 speciation measurements collected in midtown Manhattan were analyzed via positive matrix factorization source apportionment. Daily and distributed-lag generalized linear models of Medicare respiratory and cardiovascular hospital admissions during 2001–2002 considered PM_2.5 mass and PM_2.5 from five sources: transported sulfate, residual oil, traffic, steel metal works, and soil.

Results

Source-related PM_2.5 (specifically steel and traffic) was significantly associated with hospital admissions but not with total PM_2.5 mass. Steel metal works–related PM_2.5 was associated with respiratory admissions for multiple-lag days, especially during the cleanup efforts at the World Trade Center. Traffic-related PM_2.5 was consistently associated with same-day cardiovascular admissions across disease-specific subcategories. PM_2.5 constituents associated with each source (e.g., elemental carbon with traffic) were likewise associated with admissions in a consistent manner. Mean effects of distributed-lag models were significantly greater than were maximum single-day effect models for both steel- and traffic-related PM_2.5.

Conclusions

Past analyses that have considered only PM_2.5 mass or only maximum single-day lag effects have likely underestimated PM_2.5 health effects by not considering source-specific and distributed-lag effects. Differing lag structures and disease specificity observed for steel-related versus traffic-related PM_2.5 raise the possibility of distinct mechanistic pathways of health effects for particles of differing chemical composition.     

Accuracy of hospital morbidity data and the performance of comorbidity scores as predictors of mortality

Objectives

The main objectives of this study were to validate the hospital morbidity data (HMD) and to compare the performance of three comorbidity adjusting methods in predicting 1-year and 5-year all-cause mortality in a male general hospital population in Western Australia (WA).

Study Design and Setting

Population-based data were integrated with WA-linked data system. Deyo-Charlson Index, Enhanced-Charlson Index, and Elixhauser's method measured comorbidity. Mortality was modeled using Cox regression, and model discrimination was assessed by Harrell's C statistics.

Results

The HMD were most likely to identify major comorbidities, such as cancer, myocardial infarction, diabetes mellitus, and major operations. The presence of comorbidity was independently associated with an increased risk of adverse outcomes. All models achieved acceptable levels of discrimination (Harrell's C: 0.70-0.76). The Enhanced-Charlson Index matched the Deyo-Charlson Index in predicting mortality. Elixhauser's method outperformed the other two. Including information from past admissions achieved nonsignificant improvement in model discrimination. A dose-response effect was observed in the effect of repeated episodes on risk of 5-year mortality.

Conclusion

Comorbidities diagnosed at different points in time may have different associations with the risk of adverse outcomes. More research is required to integrate the effect of repeated episodes in currently used methods that measure and adjust for comorbidity.     

Accurate reporting of expected delivery date by mothers 9 months after birth

Objective

To measure agreement between gestational age based on maternal report of expected date of delivery (EDD) 9 months after birth and gestational age at birth in routine hospital data. Furthermore, to examine whether sociodemographic and perinatal factors influenced agreement and whether disagreement affected classification of infants in preterm groups.

Study Design and Setting

The study used data on 8,058 singleton infants from the UK Millennium Cohort Study. Women were interviewed 9 months after birth and interviews were linked to routine hospital data. The infant’s date of birth and EDD were used to calculate gestational age in completed weeks.

Results

Agreement between maternal report and hospital data was 72% for exact number of weeks’ gestation and 94% for agreement within 1 week. Disagreement was associated with the infant not being firstborn, unplanned pregnancy, late or no antenatal care, and low socioeconomic status. Maternal report of gestational age resulted in slightly more children being classified as preterm (6.4%) than gestational age based on hospital data (6.1%). Agreement was found to be poor for postterm births.

Conclusion

Gestational age based on retrospective maternal reporting of EDD is reliable within 1 week or when used to assign infants to broad gestational groups.     

La auditoría energética: una herramienta de gestión en atención primaria

Objective

The aim of this study was to evaluate the viability of energy audit as a management tool in primary care to improve the energy efficiency and environmental performance of a health center by reducing its operating costs.

Method

We conducted 55 energy audits in health centers from 2005-2010. The health centers were sized between 500 and 3,500 m², were located in health areas with 3,500 to 25,000 users, and were built between 1985 and 2007.

Results

With an average investment of 11,601€ per site, energy consumption can be reduced by 10,801 kWh per year, saving 2,961€ with a mean payback period of 3.92 years, and preventing emission of 7,010 kg of CO₂.

Conclusions

Energy auditing is a practical tool to reduce the operating and maintenance costs of health centers and of improving the comfort of the facilities.     

Comorbidity scores for administrative data benefited from adaptation to local coding and diagnostic practices

Objective

The Charlson and Elixhauser indices are the most commonly used comorbidity indices with risk prediction models using administrative data. Our objective was to compare the original Charlson index, a modified set of Charlson codes after advice from clinical coders, and a published modified Elixhauser index in predicting in-hospital mortality.

Study Design and Setting

Logistic regression using two separate years of administrative hospital data for all acute nonspecialist public hospitals in England.

Results

For all admissions combined, discrimination was similar for the Charlson index using the original codes and weights and the Charlson index using the original codes but England-calibrated weights (c = 0.73), although model fit was superior for the latter. The new Charlson codes improved discrimination (c = 0.76), model fit, and consistency of recording between admissions. The modified Elixhauser had the best performance (c = 0.80). For admissions for acute myocardial infarction and chronic obstructive pulmonary disease, the weights often differed, although the patterns were broadly similar.

Conclusion

Recalibration of the original Charlson index yielded only modest benefits overall. The modified Charlson codes and weights offer better fit and discrimination for English data over the original version. The modified Elixhauser performed best of all, but its weights were perhaps less consistent across the different patient groups considered here.     

Malaria severity criteria and prognostic factors among children in Dakar

Introduction

Severity factors associated with malaria as well as prognostic factors for death were assessed at the Dakar Centre Hospitalier National d’Enfants Albert Royer de Fann (CHNEAR).

Patients and methods

A prospective study was carried out from January 1 to December 31, 2007 involving children from 0 to15 years of age, admitted for plasmodium falciparum malaria with positive thick drop examination, meeting at least one of the WHO 2000 malaria severity criteria. Acidosis was not studied.

Outcome

The rate of severe malaria cases in our hospital was 6.4%. The sex ratio was 1.4 and the median age of patients at 91 months. A peak was observed during the 4th trimester (75.5%). Convulsions (52.5%) and obtundation (49.4%) were the most common signs of clinical severity while hyperparasitemia and severe anemia ranged at 27.2% and 21.6%, respectively. Lethality was 11.1 % and the main death risk factors were young age (p = 0.025), coma (p = 0.007), respiratory distress (p = 0.04), or hypoglycemia (p = 0.001).

Conclusion

Reducing malaria hospital mortality in Senegal may be obtained by proper management of poor prognostic factors such as coma, respiratory distress, and hypoglycemia.     

Association Between PM10 and O3 Levels and Hospital Visits for Cardiovascular Diseases in Bangkok,Thailand

Background

The association between air pollution and cardiovascular diseases is well known, but previous studies only assessed mortality and hospital admissions in North America, Europe, and Northeast Asia. Few studies have been conducted in less-developed countries in regions with a tropical climate. This study evaluated whether short-term exposures to fine particulate matter (PM₁₀) and ozone (O₃) were associated with hospital visits for cardiovascular diseases (CVD; ICD-10th, I00–I99) in central Bangkok, Thailand.

Methods

Data from hospital records were obtained from 3 major government hospitals. All hospital visits were stratified by age group and category of CVD. Daily PM₁₀ and O₃ levels reported by the Pollution Control Department from April 2002 to December 2006 (1736 days) were used in a time-series analysis with a generalized additive model procedure.

Results

Exposure on the previous day to PM₁₀ and O₃ had a positive association with hospital visits for CVD among elderly (≥65 years) individuals. The increase in CVD hospital visits in this age group was 0.10% (95% CI, 0.03–0.19) with a 10 µg/m³ increase in PM₁₀, and 0.50% (95% CI, 0.19–0.81) with an increase in O₃.

Conclusions

In central Bangkok, a short-term association was observed between increases in daily levels of PM₁₀ and O₃ and the number of daily emergency hospital visits for CVD, particularly among individuals aged ≥65 years.Key words: PM₁₀, ozone, cardiovascular diseases, hospital visits, Bangkok, air pollution     

Association between characteristics of current menses and preference for induced amenorrhea

Background

Several studies suggest that many women would prefer to avoid menses altogether, but few studies have examined the social or clinical predictors of such preference.

Study Design

In total, 1224 healthy women of reproductive age were surveyed in Brazil, Germany and the United States regarding social, menstrual and reproductive characteristics and preferences for various dimensions of menstruation, including the ideal interval between menses. The extent to which a preference to never bleed was predicted by current experiences with menses was evaluated.

Results

Long menses, menstrual pain and a perceived high cost of pads and tampons were predictive of preferring amenorrhea over all other menstrual patterns after controlling for age, parity and education. Independent significant associations were also found with increasing degrees of life stress and ever use of injectable contraceptives.

Conclusion

A negative experience with menstruation, a high ranking of life stress and ever use of injectable contraception were independently associated with a preference to avoid menses altogether.     

Antioxidant activity and hepatoprotective effects of whey protein and Spirulina in rats

Objectives

The aims of the present study were to evaluate the antioxidant, radical scavenging, and metal-chelating activity of whey protein concentrate (WPC) and Spirulina alone or in combination in vitro and to evaluate their hepatoprotective effects against CCl₄ in vivo.

Methods

Five concentrations (20, 40, 60, 80, and 100 mg/100 mL) of WPC, Spirulina, and their combination were tested in vitro. In the in vivo study, eight groups of male rats comprised the control group and the groups treated with WPC, Spirulina alone, or in combination with or without CCl₄ were used.

Results

The in vitro study showed that WPC and Spirulina showed antioxidant, radical scavenging, and metal-chelating activities in dose-dependent manner. The in vivo study showed that both agents succeeded in preventing liver damage induced by CCl₄. This prevention was more pronounced in rats receiving the combination of WPC and Spirulina.

Conclusion

Whey protein concentrate and Spirulina have free radical scavenging properties and antioxidant activity.     

Gastrointestinal Tolerance of Chicory Inulin Products

Background

The use of inulin in foods as a fiber source has increased recently. Consumption of inulin products can cause gastrointestinal (GI) distress. Acceptable intakes of inulin need to be determined.

Objective

To determine the GI tolerance of two inulin fibers, shorter chain length oligofructose and native inulin, at 5- and 10-g doses compared to a placebo.

Design

A randomized, double-blind, controlled, crossover design that included a phone screening and five visits for breakfast fiber challenges consisting of a bagel, cream cheese, and orange juice.

Subjects/setting

Twenty-six healthy men and women ages 18 to 60 years participated in the study. Healthy subjects with no history of GI conditions consumed diets with typical amounts of fiber.

Main outcome measures

GI tolerance was calculated as the sum of scores on seven GI tolerance domains via questionnaire administered at t=0, 2, 4, 24, and 48 hours following fiber challenge.

Statistical analyses performed

A mixed effects linear model was used to compare the tolerance scores among the five fiber challenges.

Results

The two inulin fibers tended to increase GI symptoms mildly. Most frequently reported symptoms were flatulence followed by bloating. The 10-g dose of oligofructose substantially increased GI symptoms compared to control.

Conclusions

Doses up to 10 g/day of native inulin and up to 5 g/day of oligofructose were well-tolerated in healthy, young adults.     

Air pollution exposure and self-reported cardiovascular disease

Background

Studies suggest that increases of fine particle concentrations (PM_2.5) could be linked with a rise in cardiovascular disease. With approximately 25% of American adults aged 30 and older reporting having either heart disease or hypertension it is possible that exposure to air pollution could have significant public health consequences. This study examined the relationship between PM_2.5 and the prevalence of self-reported hypertension and heart disease using data from a large nation-wide survey.

Study design

Adults, 30 years of age or older, who participated in the National Health Interview Survey (NHIS) from 1999 to 2005 were linked to annual PM_2.5 data from the US Environmental Protection Agency (N=132,224). Annual air quality estimates were averaged from monitors within 20 miles of the respondent's residential block group. Respondents who reported being told they had hypertension by a health professional on two or more separate occasions were defined as hypertensive. Heart disease was defined as answering, “yes” to one or more of three NHIS questions on heart disease.

Results

A 10 μg/m³ increase in PM_2.5 exposure was associated with a small elevated risk of hypertension (adjusted odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00-1.10) risk of heart disease (1.08 95% CI 1.00-1.16). The association between PM_2.5 and hypertension was found in non-Hispanic white adults (OR 1.10 95% CI 1.04-1.17) but not in non-Hispanic black or Hispanic adults.

Conclusions

Findings from this study complement those from other studies and indicate that PM_2.5 adversely affects cardiovascular health. Our results are consistent with other studies in showing a small association between exposure to PM_2.5 and cardiovascular outcomes.     

Development of a meat frequency questionnaire for use in diet and cancer studies

Objective

To develop a meat frequency questionnaire to assess dietary heterocyclic amine intake. The meat frequency questionnaire is designed to obtain information on meat types, cooking methods, and doneness preferences that predict heterocyclic amine concentrations in different meats.

Design

Total and specific meat intakes were determined by a standard food frequency questionnaire (FFQ) and compared with that determined by the meat frequency questionnaire.

Subjects/setting

Three-hundred fourteen African-American males participating in a clinic-based study of prostate disease and heterocyclic amine intake were administered the two questionnaires in a cancer education center prior to undergoing screening evaluations for prostate disease.

Main outcome measures

Fried, broiled, and grilled vs total meat intake was assessed using the meat frequency questionnaire vs FFQ, respectively. Specific meat items included in the meat frequency questionnaire were evaluated as factors potentially explaining discrepancies in meat intake estimated using the two questionnaires. Seasonal variation in meat intake was also examined.

Statistical analysis

Correlation coefficients for intake of total meat and individual meat groups determined by FFQ vs meat frequency questionnaire were calculated. Seasonal differences in meat and estimated heterocyclic amine intakes were evaluated by t test, adjusted for multiple comparisons.

Results

Meat intakes determined by the two questionnaires were well-correlated (Pearson r=0.69); however, total meat assessed by the meat frequency questionnaire exceeded total meat assessed by the FFQ in 30% of participants. Total energy and intake of heterocyclic amine−associated meat were greatest when the meat frequency questionnaire was administered during winter months.

Conclusions

The heterocyclic amine meat frequency questionnaire provided a fractional measure of total meat intake and identified specific heterocyclic amine-containing meat items underreported in a standard FFQ.     

Nutrition Knowledge Is Associated with Greater Weight Loss in Obese and Overweight Low-Income Mothers

Objective

To examine if greater nutrition knowledge vs gains in knowledge promote more successful weight loss in low-income, overweight and obese mothers with young children.

Design

A convenience sample of mothers and their children were measured for height and weight; mothers completed demographic and nutrition knowledge questionnaires pre- and postintervention.

Subjects/setting

Participants (N=141) were recruited from government and public health clinics and elementary schools. Inclusion criteria for mothers were: family income <200% federal poverty level; overweight/obese; and Hispanic, African-American, or white race/ethnicity.

Intervention

Eight weekly weight-loss classes emphasizing diet, physical activity, and behavior modification based on Social Cognitive Theory were administered to mothers.

Main Outcome Measures

Improvements in maternal nutrition knowledge and weight loss.

Statistical Analyses Performed

Paired-samples t tests, repeated measures analysis of variance, analysis of covariance, Pearson correlations, and χ² statistics.

Results

Nutrition knowledge of mothers increased in all areas. Participants with weight loss ≥2.27 kg (responders) had greater knowledge than those who did not; however, the actual net gain was similar for those who lost and did not lose weight. Weight gainers only improved in two areas on the test, whereas weight-loss responders increased knowledge in all six. Responders appeared more cognizant of diet, weight loss, and health information.

Conclusions

Weight-management programs should include a strong component of nutrition education to alleviate knowledge inequalities and promote more effective weight control. In low-income mothers, greater initial knowledge may be more predictive of weight loss than gains in knowledge during an intervention.