Prevalence of Inadequate Hydration Among US Children and Disparities by Gender and Race/Ethnicity: National Health and Nutrition Examination Survey, 2009–2012

Objectives. We evaluated the hydration status of US children and adolescents.Methods. The sample included 4134 participants aged 6 to 19 years in the National Health and Nutrition Examination Survey from 2009 to 2012. We calculated mean urine osmolality and the proportion with inadequate hydration (urine osmolality > 800 mOsm/kg). We calculated multivariable regression models to estimate the associations between demographic factors, beverage intake, and hydration status.Results. The prevalence of inadequate hydration was 54.5%. Significantly higher urine osmolality was observed among boys (+92.0 mOsm/kg; 95% confidence interval [CI] = 69.5, 114.6), non-Hispanic Blacks (+67.6 mOsm/kg; 95% CI = 31.5, 103.6), and younger children (+28.5 mOsm/kg; 95% CI = 8.1, 48.9) compared with girls, Whites, and older children, respectively. Boys (OR = 1.76; 95% CI = 1.49, 2.07) and non-Hispanic Blacks (odds ratio [OR] = 1.34; 95% CI = 1.04, 1.74) were also at significantly higher risk for inadequate hydration. An 8-fluid-ounce daily increase in water intake was associated with a significantly lower risk of inadequate hydration (OR = 0.96; 95% CI = 0.93, 0.98).Conclusions. Future research should explore drivers of gender and racial/ethnic disparities and solutions for improving hydration status.Adequate hydration is essential for health. Water is crucial for the proper function of several physiological processes, including circulatory function, metabolism, temperature regulation, and waste removal.1 Dehydration, a state in which total body water is inadequate for proper cell, organ, and system functioning, is associated with poor health. Although excessive dehydration is associated with serious health problems, such as impaired renal, immune, and gastrointestinal functioning, confusion, and delirium, even mild dehydration can worsen health and well-being.2 Mild dehydration is associated with headache, irritability, poorer physical performance, and reduced cognitive functioning among both children and adults.2–5Children’s hydration status could have implications for both health and school performance. Two studies have shown that inadequate hydration, defined as urine osmolality of 800 milliosmoles per kilogram or higher, is associated with poorer performance on cognitive tests.6,7 However, despite a substantial body of research examining children’s beverage intake,8 little is known about children’s hydration status and whether it may be a population health concern. Kant et al. found that as of the period 2005 to 2006, US children and adolescents, on average, did not consume adequate water for their age group as defined by the Institute of Medicine,9 but hydration status was not evaluated. A small study in 2 major US cities using urine osmolality as an indicator of hydration status found that over 60% of a convenience sample of children aged 9 to 11 years were inadequately hydrated and that most children did not consume plain water, putting them at higher risk of inadequate hydration.10 However, we have identified no study describing children’s hydration status nationally. Additionally, although a review of international studies found significant differences in hydration status by age, gender, race/ethnicity, and culture,11 there is limited evidence about the population distribution of urine osmolality and inadequate hydration among US children, particularly whether disparities in hydration status exist across population groups defined by race/ethnicity, household income, gender, or age. Although small, laboratory-based studies of adults suggest that higher beverage intake is associated with better hydration status (regardless of beverage type),12,13 preliminary evidence has suggested that plain water may be associated with better hydration status in children.10 Given that little is known about how consumption of different beverages may affect population hydration status in children, the potential solutions to reducing inadequate hydration are unclear.Measuring hydration status outside of severe dehydration has proven challenging because the level of fluid in the body is constantly fluctuating. Plasma osmolality, a measure of the amount of solutes in the blood stream, is often used to measure severe dehydration, but it has a very limited range and is tightly regulated by homeostasis, rendering it insensitive to smaller changes in hydration status.12,14–16 Measures involving urine, such as urine volume or urine osmolality, are more sensitive to less dramatic changes in body water; however, the volume and timing of water intake can bias measurements. If individuals rapidly consume large amounts of water, their urine osmolality will be low and urine volume high as the body rapidly excretes the water, but their hydration status will be unaffected as the body will get rid of the excess water before it has a chance to rehydrate. Twenty-four-hour urine osmolality and 24-hour urine volume may be the most sensitive measures of 24-hour hydration status as time lags are better controlled.11,14–16 Although a single measure of urine osmolality may not accurately reflect an individual’s typical hydration status because of fluctuation in urine osmolality, it may still be useful for estimating population averages. We would expect that observed fluctuations in the population would not be systematically biased above or below the mean.We examined the prevalence of elevated urine osmolality and its population distribution by age, race/ethnicity, gender, and family income in a nationally representative sample of participants aged 6 to 19 years from the National Health and Nutrition Examination Survey (NHANES), 2009 to 2012,17 controlling for sample design and time of day the data were collected. We also examined whether consuming different types of beverages on the day before data collection, including water, milk, 100% juice, sugar-sweetened beverages (SSBs), and diet drinks, was associated with urine osmolality in this age group, hypothesizing that increased intake of water (compared with other beverages) would be associated with reduced urine osmolality.     

Disability Trends Among Older Americans: National Health and Nutrition Examination Surveys, 1988�C1994 and 1999�C2004

Objectives. We investigated trends in disability among older Americans from 1988 through 2004 to test the hypothesis that more recent cohorts show increased burdens of disability.Methods. We used data from 2 National Health and Nutrition Examination Surveys (1988–1994 and 1999–2004) to assess time trends in basic activities of daily living, instrumental activities, mobility, and functional limitations for adults aged 60 years and older. We assessed whether changes could be explained by sociodemographic, body weight, or behavioral factors.Results. With the exception of functional limitations, significant increases in each type of disability were seen over time among respondents aged 60 to 69 years, independent of sociodemographic characteristics, health status, relative weight, and health behaviors. Significantly greater increases occurred among non-Whites and persons who were obese or overweight (2 of the fastest-growing subgroups within this population). We detected no significant trends among respondents aged 70 to 79 years; in the oldest group (aged ≥ 80 years), time trends suggested lower prevalence of functional limitations among more recent cohorts.Conclusions. Our results have significant and sobering implications: older Americans face increased disability, and society faces increased costs to meet the health care needs of these disabled Americans.The impact on society of the health and health care needs of older adults has been the subject of growing debate in the United States. This population is expanding more rapidly now that baby boomers (born in 1946–1964) are beginning to reach their 60s.^1–3 Heightened concern with our aging population was highlighted by a recent Institute of Medicine report, Retooling for an Aging America: Building the Health Care Workforce.⁴ Questions about potential burdens of disability are salient because increased disability in our rapidly growing population of older adults may exert enormous strains on available human and financial resources.Concerns about levels of disability were allayed somewhat by encouraging evidence from the 1980s and 1990s of downward trends in disability.^5–13 More recent findings are mixed: data from the National Long-Term Care Survey showed declines,^14–16 but other studies suggest that these trends may be reversing, with newer cohorts (including the oldest of the baby boomers) reporting worse health status and more disability than did their earlier counterparts.^9,17,18The current epidemic of obesity has been suggested as a contributor to current and future increases in disability. Obesity among US adults has increased dramatically, rising from 11% to 16% in the early 1960s to 28% to 34% by 2000,^19,20 resulting in rapidly increasing proportions of overweight, obese, and severely obese members of cohorts now reaching their 60s.^21,22 Worse still, forecasts are for levels of obesity as high as 45.4% within 20 years if trends persist.²³ Evidence also suggests that the disability risks associated with obesity may be greater than those experienced 15 to 20 years ago,^9,21,24 possibly because of earlier onset of obesity (and thus longer lifetime exposure).^25,26The changing racial/ethnic composition of cohorts now reaching their 60s is another potential contributor to changing disability trends. The most rapid growth is projected to be among Blacks and Hispanics,^27,28 groups with significantly higher rates of obesity (45% of non-Hispanic Blacks and 36.8% of Hispanics versus 30% non-Hispanic Whites²⁰) and disproportionately lower socioeconomic status—both factors associated with increased risks for functional limitations and disability.^29,30We used data from the National Health and Nutrition Examination Survey (NHANES) for 1988 to 1994 and 1999 to 2004 to examine trends in the prevalence of reported disability for adults aged 60 to 69 years, 70 to 79 years, and 80 years and older, with particular attention to whether trends differed between the youngest and the older 2 groups. For respondents aged 60 to 69 years, the more recent NHANES data included individuals born just prior to the baby boomer generation (1930–1944), providing potential clues to likely trends in the large generation that will immediately follow. We assessed the extent to which differences in reported disability between the 2 survey periods could be explained by changes in the sociodemographic composition of the population, changes in the prevalence of overweight and obesity, or changes in lifestyle or other aspects of health status.     

Health Disparities Among Mexican American Women Aged 15�C44 Years: National Health and Nutrition Examination Survey, 1999�C2004

Objectives. We analyzed the health of Mexican American women aged 15 to 44 years, by generation and language preference, to guide planning for reproductive health services in this growing population.Methods. We used personal interview and medical examination data from the 1999 to 2004 National Health and Nutrition Examination Surveys. We used SUDAAN for calculating age-adjusted prevalence estimates of demographic and health characteristics. The Satterthwaite adjusted F test and Student t test were used for subgroup comparisons.Results. The women had different health profiles (P < .05) by generation and language preference. Second- and later-generation women and women who used more English were more likely to be sexually active, to have been younger at first intercourse, and to have had more male sexual partners than were first-generation women and women who used more Spanish. Compared with their first-generation counterparts, second- and later-generation women drank more alcohol, were better educated, had higher incomes, and were more likely to have health insurance. Third-generation women were more likely to have delivered a low-birthweight baby than were first-generation women.Conclusions. Differences by generation and language preference suggest that acculturation should be considered when planning interventions to promote healthy reproductive behaviors among Mexican American women.The Hispanic population in the United States increased from 35.7 million in 2000 to 44.3 million in 2006.^1–3 In 2005, there were an estimated 10.2 million Hispanic women aged 15 to 44 years, representing an increase of about 19% from 8.6 million in 2000.² The rapid increase in the Hispanic population has been attributed to immigration and high fertility.⁴About two thirds of Hispanics in the United States are Mexican American,³ and Mexican American women of reproductive age have higher birth rates than do women of other races and Hispanic origins.⁴ This top ranking has not changed appreciably over time even though fertility and birth rates declined for Mexican and other Hispanic populations between 1990 and 2005.⁵ Young Mexican American women aged 15 to 19 years also have higher fertility and birth rates than do young women of other races and Hispanic origins.⁴ Preliminary US birth data for 2006 show that birth rates for Hispanic women aged 15–44 years are on the rise again and that more than 1 million Hispanic women gave birth in 2006, a record high.⁶ Furthermore, Hispanic women of reproductive age are less likely to be using contraception (59%) than are non-Hispanic White women (65%).⁷Recognizing the growing need for reproductive health services among the rapidly increasing Hispanic population, we studied demographics, measures of access to health care, sexual activity, pregnancy history, contraceptive use, and other health behaviors among Mexican American women aged 15–44 years from the 1999–2004 National Health and Nutrition Examination Surveys (NHANES), which collected nationally representative data through in-person interviews and physical and laboratory examinations. Many previous reports have focused more generally on Hispanic, Latina, or foreign-born women or on a single health behavior or outcome.^8–28To provide relevant and culturally appropriate information for program assessment, appropriate intervention planning, and resource allocation, we restricted our analysis to Mexican American women and stratified the sample by generational status and English or Spanish language preference. These factors are surrogate measures of acculturation, the process through which immigrant groups exchange cultural traits from their country of origin for those of their host country, and have been tied to reproductive health behaviors in previous research.^{9,10,18–20,22–25,27,28} We hypothesized that their reproductive health would vary by level of acculturation.     

Disparities in Adolescent Health and Health Care: Does Socioeconomic Status Matter?

DATA COLLECTION/EXTRACTION METHODS: National household survey. DATA SOURCES/STUDY SETTING: We analyzed data on 12,434 adolescents (10 through 18 years old) included in the 1999 and 2000 editions of the National Health Interview Survey. STUDY DESIGN: We assessed the presence of income gradients using four income groups. Outcome variables included health status, health insurance coverage, access to and satisfaction with care, utilization, and unmet health needs. PRINCIPAL FINDINGS: After adjustment for confounding variables using multivariate analysis, statistically significant disparities were found between poor adolescents and their counterparts in middle- and higher-income families for three of four health status measures, six of eight measures of access to and satisfaction with care, and for six of nine indicators of access to and use of medical care, dental care, and mental health care. CONCLUSION: Our analyses indicate adolescents in low-income families remain at a disadvantage despite expansions of the Medicaid program and the comparatively new State Children's Health Insurance Program (SCHIP). Additional efforts are needed to ensure eligible adolescents are enrolled in these programs. Nonfinancial barriers to care must also be addressed to reduce inequities.     

Maternal Education and Excessive Gestational Weight Gain in New York City, 1999–2001: The Effect of Race/Ethnicity and Neighborhood Socioeconomic Status

To examine the association between maternal education and excessive gestational weight gain (EGWG) and whether this association differs by maternal race/ethnicity and neighborhood socio-economic status (SES). A sample of 56,911 New York City births between 1999 and 2001 was used. Self-reported EGWG was defined as gaining >40 pounds. Maternal education and race/ethnicity were obtained from birth record data. Neighborhood SES was determined from 2000 US Census data. Women with a high school [prevalence ratio (PR) = 1.21; 95 % CI 1.10–1.32] and some college (PR = 1.33; 95 % CI 1.21–1.47) education were more likely to gain excessive weight during pregnancy than their counterparts with less than a high school education. Having a college or more education was associated with a decreased EGWG for non-Hispanic white women (PR = 0.81; 95 % CI 0.67–0.96) but an increased EGWG for Hispanic women (PR = 1.25; 95 % CI 1.12–1.44). EGWG increased for women with a college or more education in medium and low SES neighborhoods (1.26; 95 % CI 1.04–1.53 and 1.20; 95 % CI 1.10–1.30, respectively); whereas a college or more education was not significant in the high SES neighborhoods. Our findings suggest that maternal education is associated with EGWG. However, this association depends on race/ethnicity and SES of the neighborhood of residence.     

Peer Reviewed: Workers’ Health Risk Behaviors by State,Demographic Characteristics,and Health Insurance Status

Introduction

Employers often lack data about their workers'' health risk behaviors. We analyzed state-level prevalence data among workers for 4 common health risk behaviors: obesity, physical inactivity, smoking, and missed influenza vaccination (among workers older than 50 years).

Methods

We analyzed 2007 and 2008 Behavioral Risk Factor Surveillance System data, restricting the sample to employed respondents aged 18 to 64 years. We stratified health risk behavior prevalence by annual household income, educational attainment, health insurance status, and race/ethnicity.

Results

For all 4 health risk behaviors, we found significant differences across states and significant disparities related to social determinants of health — income, education, and race/ethnicity. Among uninsured workers, prevalence of smoking was high and influenza vaccinations were lacking.

Conclusion

In this national survey study, we found that workers'' health risk behaviors vary substantially by state and by workers'' socioeconomic status, insurance status, and race/ethnicity. Employers and workplace health promotion practitioners can use the prevalence tables presented in this article to inform their workplace health promotion programs.     

Positive Youth, Healthy Adults: Does Positive Well-being in Adolescence Predict Better Perceived Health and Fewer Risky Health Behaviors in Young Adulthood?

Purpose

To examine the prospective, longitudinal associations between positive well-being during adolescence and health outcomes in young adulthood, using a large, nationally representative sample of youth.

Methods

On the basis of the data from the first three waves of the National Longitudinal Study of Adolescent Health, we examined positive well-being during adolescence (averaged across Waves I-II) as a predictor of perceived young adult general health and risky health behaviors (Wave III). Each model included a full set of health and demographic baseline covariates. Missing values were assigned using multiple imputation methods (n = 10,147).

Results

Positive well-being during adolescence was significantly associated with reporting better perceived general health during young adulthood, independent of depressive symptoms. Positive well-being was also significantly associated with fewer risky health behaviors in Wave III, after adding all covariates, including depressive symptoms and baseline risky health behaviors.

Conclusion

Few studies of adolescent health have examined positive psychological characteristics, tending to focus instead on the effect of negative mood states and cognitions on health. This study demonstrates that positive well-being during adolescence predicts better perceived general health and fewer risky health behaviors during young adulthood. Aligned with the goals of the positive youth development perspective, promoting and nurturing positive well-being during the transition from childhood to adolescence may present a promising way to improve long-term health.     

Differences in Breastfeeding Initiation by Maternal Diabetes Status and Race,Ohio 2006–2011

To examine breastfeeding trends at hospital discharge from 2006 to 2011 by diabetes status and to determine associations between diabetes status and breastfeeding. Ohio Vital Statistics birth certificate data from 2006 to 2011, including all singleton births to Ohio resident mothers of reproductive age (16–44 years), were used to analyze trends in breastfeeding by diabetes status [prepregnancy diabetes (PDM), gestational diabetes (GDM)]. Logistic regression was used to evaluate the relationship between breastfeeding at discharge and diabetes type. Because a significant interaction between diabetes status and race existed, the model was stratified by race. This study includes 803,222 Ohio births from 2006 to 2011. A significant, increasing trend of breastfeeding (P < .0001) existed among women with GDM (63–70 %) and no DM (62–69 %). GDM breastfeeding rates were frequently the highest, while women with PDM often had the lowest breastfeeding initiation rates, regardless of sample characteristic. In models stratified by race, Black women were often the least likely to breastfeed, but overweight or obese and diabetes were not associated with a decreased likelihood of breastfeeding as they were among White women. While breastfeeding rates have increased in Ohio, they have still not reached the Healthy People 2020 goals. Our study shows that breastfeeding initiation rates vary by diabetes status and race. This study can aid in tailoring breastfeeding intervention and counseling efforts to women least likely to initiate breastfeeding, such as women with pregnancy diabetes, to improve the health of both infants and mothers.     

Disparities in Whites’ Versus Blacks’ Self-Rated Health: Social Status, Health-Care Services, and Health Behaviors

Using 2009 National Health Interview Survey data, we examined how social-status factors, variables describing health services, and health-related behaviors explained self-rated health among Black adults and among White adults. We wanted to evaluate whether self-rated health’s relationships with these three sets of variables were conditional on race. Our results overall indicated that social-status, health-care-services, and health-behaviors variables are important to the explanation of both groups’ self-rated health. But in this study, when all social-status, health-care-services, and health-behaviors variables were controlled, Black respondents’ self-reported health did not differ, on average, from White respondents’. Such a finding firmly suggests that the three sets of variables partially explain disparities in the groups’ self-reported health. In the end, our results showed racial health disparities to be partially explained by racial differences in distribution of health resources and health behaviors.     

Time Trends in Liver Cancer Mortality, Incidence, and Risk Factors by Unemployment Level and Race/Ethnicity, United States, 1969–2011

This study examined unemployment and racial/ethnic disparities in liver cancer mortality, incidence, survival, and risk factors in the United States between 1969 and 2011. Census-based unemployment rates were linked to 1969–2009 county-level mortality and incidence data, whereas 2006–2011 National Health Interview Surveys were used to examine variations in hepatitis infection and alcohol consumption. Age-adjusted mortality rates, risk-ratios, and rate-differences were calculated by year, sex, race, and county-unemployment level. Log-linear, Poisson, and logistic regression and disparity indices were used to model trends and differentials. Although liver-cancer mortality rose markedly for all groups during 1969–2011, higher unemployment levels were associated with increased mortality and incidence rates in each time period. Both absolute and relative inequalities in liver cancer mortality according to unemployment level increased over time for both males and females and for those aged 25–64 years. Compared to the lowest-unemployment group, those aged 25–64 in the highest-unemployment group had 56 and 115 % higher liver-cancer mortality in 1969–1971 and 2005–2009, respectively. Regardless of unemployment levels, Asian/Pacific Islanders and Hispanics had the highest mortality and incidence rates. The adjusted odds of hepatitis infection and heavy drinking were 38–39 % higher among the unemployed than employed. Liver-cancer mortality and incidence have risen steadily among all racial/ethnic, sex, and socioeconomic groups. Faster increases in mortality among the highest-unemployment group have led to a widening gap in mortality over time. Disparities in mortality and incidence are consistent with similar inequalities in hepatitis infection and alcohol consumption.     

Socioeconomic Characteristics,Dietary and Lifestyle Patterns,and Health and Weight Status of Older Adults in NHANES, 1999–2002: A Comparison of Caucasians and African Americans

There are disparities among older Caucasian and African American adults in many areas. The study used data from the National Health and Nutrition Examination Survey conducted from 1999 to 2002 and compared the self-reported dietary intakes, physical activity, and economic and health status of Caucasian (N = 1,398) and African American (N = 354) adults aged 65 years and older. Regression models and t-tests (α = 0.05) were used for comparisons. More African Americans than Caucasians lived in low-income households (40.4% vs. 21.3%), lived in households that were not fully food-secure (15.6% vs. 4.9%), watched five or more hours of television (34% vs. 20%), and were told that they had diabetes (10% vs. 4%) or high blood pressure (67 % vs. 52 %). They consumed 253 fewer calories than Caucasians. About 75 % of African American women were overweight. Our findings indicate that for those greater than 65 years of age, low-income African Americans are at a greater risk for poor nutrition and chronic health conditions than Caucasians.     

Testing the Invariance of the National Health and Nutrition Examination Survey’s Sexual Behavior Questionnaire Across Gender,Ethnicity/Race,and Generation

Federal and state policies are based on data from surveys that examine sexual-related cognitions and behaviors through self-reports of attitudes and actions. No study has yet examined their factorial invariance—specifically, whether the relationship between items assessing sexual behavior and their underlying construct differ depending on gender, ethnicity/race, or age. This study examined the factor structure of four items from the sexual behavior questionnaire part of the National Health and Nutrition Examination Survey (NHANES). As NHANES provided different versions of the survey per gender, invariance was tested across gender to determine whether subsequent tests across ethnicity/race and generation could be done across gender. Items were not invariant across gender groups so data files for women and men were not collapsed. Across ethnicity/race for both genders, and across generation for women, items were configurally invariant, and exhibited metric invariance across Latino/Latina and Black participants for both genders. Across generation for men, the configural invariance model could not be identified so the baseline models were examined. The four item one factor model fit well for the Millennial and GenerationX groups but was a poor fit for the baby boomer and silent generation groups, suggesting that gender moderated the invariance across generation. Thus, comparisons between ethnic/racial and generational groups should not be made between the genders or even within gender. Findings highlight the need for programs and interventions that promote a more inclusive definition of “having had sex.”     

Driving After Drinking Among Young Adults of Different Race/Ethnicities in the United States: Unique Risk Factors in Early Adolescence?

PurposeNational guidelines for alcohol screening and brief interventions advise practitioners to consider age, drinking frequency, and context to identify at-risk youth. The purpose of this study was to identify the contextual risk and protective factors in high school-aged adolescents associated with future driving after drinking (Drinking Under the Influence [DUI] at age 21) by race/ethnicity.MethodsData included 10,271 adolescents (67% white, 12% Hispanic, 16% black, 3.6% Asian; 49% Male) who participated in the National Longitudinal Study of Adolescent Health (Waves I, II, and III) from 1995 to 2001. A lagged panel design and survey logistic regression was used to examine the association between multiple contextual factors (e.g., demographics, parents, peers, social context) during adolescence and self-reported DUI in young adulthood.ResultsAs expected, the likelihood of DUI was higher among whites followed by Hispanics, Asians, and blacks in all models. Perception of easy home access to alcohol increased risk for future DUI for whites (OR: 1.25 CI: 1.04–1.49), Hispanics (OR: 2.02 CI: 1.29–3.16), and Asians (OR: 1.90 CI: 1.13–3.22), but not for black youth. Drinking frequency and prior DUI were not risk factors for Hispanics. Risk-taking attitudes, marijuana use, and religious affiliation were risk factors for whites only.ConclusionsFindings suggest that in addition to screening for drinking behaviors, brief interventions and prevention efforts should assess perceived home access to alcohol and other race-specific factors to reduce alcohol-related injuries and harm.