Peer Reviewed: Disparities in Chronic Disease Among Canada’s Low-Income Populations

Introduction

Many studies have found inequities in health among income groups in Canada. We report the variations in the major chronic disease risks among low-income populations, by province of residence, as a proxy measure of social environment.

Methods

We used estimates from the 2005 Canadian Community Health Survey to study residents who were aged 45 years or older and from the lowest income quintile nationally. Multivariate logistic regression was used to examine the relationship between province of residence and risk of chronic diseases.

Results

British Columbia is the healthiest province overall but not in terms of its low-income residents, whereas Quebec''s low-income residents are at the least risk for major chronic diseases. The significant differences in risk of hypertension, diabetes, and heart disease in favor of British Columbia over Quebec for the entire population disappear when considering only the low-income subset.

Conclusion

Quebec''s antipoverty strategy, formalized as law in 2002, has led to social and health care policies that appear to give its low-income residents advantages in chronic disease prevention. Our findings demonstrate that chronic disease prevalence is associated with investment in social supports to vulnerable populations.     

Consistency Between Increasing Trends in Added-Sugar Intake and Body Mass Index Among Adults: The Minnesota Heart Survey, 1980–1982 to 2007–2009

Objectives. We described 27-year secular trends in added-sugar intake and body mass index (BMI) among Americans aged 25 to 74 years.Methods. The Minnesota Heart Survey (1980–1982 to 2007–2009) is a surveillance study of cardiovascular risk factors among residents of the Minneapolis–St Paul area. We used generalized linear mixed regressions to describe trends in added-sugar intake and BMI by gender and age groups and intake trends by weight status.Results. BMI increased concurrently with added-sugar intake in both genders and all age and weight groups. Percentage of energy intake from added sugar increased by 54% in women between 1980 to 1982 and 2000 to 2002, but declined somewhat in 2007 to 2009; men followed the same pattern (all P < .001). Added-sugar intake was lower among women than men and higher among younger than older adults. BMI in women paralleled added-sugar intake, but men''s BMI increased through 2009. Percentage of energy intake from added sugar was similar among weight groups.Conclusions. Limiting added-sugar intake should be part of energy balance strategies in response to the obesity epidemic.The increasing prevalence of overweight and obesity over several decades has contributed significantly to the burden of cardiovascular disease (CVD).1,2 According to 2005 to 2006 National Health and Nutrition Examination Survey (NHANES) data, 33.4% of men and 36.5% of women in the United States were obese, representing a 55.3% increase among men and an 83.4% increase among women since NHANES I (1971–1975).3 Energy imbalance—excessive energy intake and a sedentary lifestyle—is considered to be the primary cause of the obesity epidemic. Although dietary fat consumption (as a percentage of energy) decreased between 1971 to 1975 and 2005 to 2006, total energy intake among the US population increased substantially and is mostly attributed to dietary carbohydrates.3 As reported in a cross-sectional analysis of NHANES 1999 to 2006 data, approximately 16% of calories consumed came from added sugar in the general US adult population,4 an increase of approximately 49% from intake reported in 1977 to 1978.5By contrast to natural occurring sugars from fruits and vegetables, added sugars, defined as caloric sweeteners, used by the food industry and consumers during food processing or preparation or added at the table, have potential adverse health effects.6 Sugar-sweetened beverages, such as soda and fruit drinks, are the primary source of added sugars in the US diet.7 Strong evidence exists that greater intake of sugar-sweetened beverages is associated with higher adiposity in children; moderate evidence has been presented for the same effect in adults.7 Potential explanations for these associations include the effect of lower satiety for liquid calories8 and the addictive effect of added sugars on total calorie consumption and macronutrient metabolism.9 Significant associations were also found among US adults between dietary added sugars and other CVD risk factors, such as dyslipidemia4 and high blood pressure.10According to US Department of Agriculture’s (USDA) food availability data, sugars and sweeteners available for consumption increased by 19% from 1970 to 2005,6,11 despite a slight decline after 2000.12,13 However, limited temporal trend data of added-sugar intake are available, especially in relation to body mass index (BMI). Most studies focus primarily on sugar-sweetened beverages rather than other sources of added sugars.12 Although almost half of the added sugar in American diets comes from sugar-sweetened beverages, desserts (e.g., grain-based desserts) and candy contribute about 24.3%.7 One analysis of national data from 1965 through 2004 described temporal trends of added sugar and high-fructose corn syrup (an important and commonly used caloric sweetener) intake.12We examined the secular trends of added sugar intake and BMI over 27 years (1980–1982 through 2007–2009) in data collected in the Minnesota Heart Survey (MHS), an ongoing surveillance study of trends in CVD risk factors among a large population living in the Minneapolis–St Paul metropolitan area.     

Children’s School-Related Food and Physical Activity Behaviors Are Associated with Body Mass Index

Childhood obesity is a critical public health issue, with prevalence rates reaching nearly one in five children. Schools may be a promising public policy intervention point. The foods schools sell and the physical activity environments they foster can influence dietary behaviors and overall physical activity. Using secondary data from a nationally representative sample of children from the kindergarten class of 1998-1999 and nonexperimental methods, this study examines the associations between the food and physical activity environments in school and body mass index (BMI) for low-income boys and girls in the 8th grade during 2007. Results reveal that participating in school sports is associated with a 0.55 lower BMI score for boys. For low-income girls, eating the school breakfast is associated with a 0.70 higher BMI score and eating the school lunch is associated with a 0.65 higher BMI score. Each hour spent on homework is associated with a 0.02 higher BMI score for low-income girls. These findings suggest that schools may influence adolescent BMI and that there is room for improvement in school food and physical activity environments to promote healthier weights for low-income boys and girls.     

Body Mass Index and Mortality in a Prospectively Studied Cohort of Scandinavian Women: The Women’s Lifestyle and Health Cohort Study

Overweight and obesity increase the risk of numerous chronic diseases, including several forms of cancer. However, the association between excess body weight and all-cause mortality among young and middle-aged women is incompletely known, and the impact of menopausal status on the association has hardly been investigated. We studied prospectively a cohort comprising a population sample of 102,446 women from Norway and Sweden aged 30–50 years when they answered an extensive questionnaire in 1991/1992. During follow-up through year 2000, 1187 women in the cohort died. We used Cox proportional hazard models to estimate multivariate Hazard rate ratios (HRR) with 95% confidence intervals (CI) of death in relation to body mass index (BMI, weight (kg)/height (m²)) at start of follow-up. Both in age-adjusted models and in models adjusting for several variables (including smoking and physical activity) mortality increased with increasing BMI among premenopausal women, whereas a U-shaped relationship was seen among the postmenopausal women. Among premenopausal women obesity (BMI 30.0) doubled the mortality (HRR = 2.2, 95% CI: 1.7–3.0) when compared to women of normal weight (BMI 18.5–24.9), whilst the association was modest after menopause. Although we had limited power to analyze women who were underweight (BMI<18.5), an excess mortality of about 50% was seen among postmenopausal women. No excess risk was found for underweight premenopausal women. The data indicate that the rapidly growing prevalence of obesity in many Western countries will substantially increase premature deaths among young women.     

Peer Reviewed: Children’s Active Commuting to School: Current Knowledge and Future Directions

Introduction

Driven largely by international declines in rates of walking and bicycling to school and the noted health benefits of physical activity for children, research on children''s active commuting to school has expanded rapidly during the past 5 years. We summarize research on predictors and health consequences of active commuting to school and outline and evaluate programs specific to children''s walking and bicycling to school.

Methods

Literature on children''s active commuting to school published before June 2007 was compiled by searching PubMed, PsycINFO, and the National Transportation Library databases; conducting Internet searches on program-based activities; and reviewing relevant transportation journals published during the last 4 years.

Results

Children who walk or bicycle to school have higher daily levels of physical activity and better cardiovascular fitness than do children who do not actively commute to school. A wide range of predictors of children''s active commuting behaviors was identified, including demographic factors, individual and family factors, school factors (including the immediate area surrounding schools), and social and physical environmental factors. Safe Routes to School and the Walking School Bus are 2 public health efforts that promote walking and bicycling to school. Although evaluations of these programs are limited, evidence exists that these activities are viewed positively by key stakeholders and have positive effects on children''s active commuting to school.

Conclusion

Future efforts to promote walking and bicycling to school will be facilitated by building on current research, combining the strengths of scientific rigor with the predesign and postdesign provided by intervention activities, and disseminating results broadly and rapidly.     

Interdisciplinary Discrepancies Between Parenteral Nutrition Macronutrient Prescribing and Recommendations: Is Body Mass Index a Factor?

Background: Formal nutrition training in medical schools and residencies is lacking and needed. Registered dietitians (RDs) are formally trained in nutrition support and considered experts in the nutrition field. Our purpose was to examine prescribing and recommending discrepancies of parenteral nutrition macronutrients between medical residents (MRs) and RDs and compare results with the ASPEN clinical care guidelines. We also looked at discrepancies among obese patients, due to their increased risk of mortality. Materials and Methods: The primary end point of this retrospective review was discrepancies in nonprotein calories (NPCs) and grams of protein (PRO) between MRs and RDs. The secondary end point was discrepancies in NPCs and PRO between MRs and RDs among patients stratified by body mass index category. Results: MRs prescribed 300 NPCs more versus RDs (P < .001). When compared with RDs, MRs prescribed fewer NPCs for underweight patients and more for obese patients (P < .001). The same analysis found that the PRO discrepancies significantly varied by body mass index classification as well (P = .022). When these results were compared with the ASPEN clinical care guidelines, RDs adhered closer to the guidelines than did MRs in terms of permissive underfeeding of obese patients. Conclusion: It is widely accepted that MRs are in need of increased formal training, and the results of our study confirm this need and suggest a short‐term solution of increasing order‐writing privileges for the RD. RDs with this privilege may adhere more closely to clinical care guidelines and therefore increase patient safety.     

The Influence of Home and School Environments on Children’s Diet and Physical Activity,and Body Mass Index: A Structural Equation Modelling Approach

Introduction The home and school environments play important roles in influencing children’s health behaviours. However, their simultaneous influence on childhood obesity has not yet been examined. We explore the relationship of the home and school environments with childhood obesity, to determine whether this relationship is mediated by children’s fruit and vegetable intake and physical behaviours. Methods This study uses baseline data from 9 to 11 year old children, their parents and school principals (matched data n?=?2466) from the Obesity Prevention and Lifestyle Project. Child-reported behaviours, parent-reported home environment and principal-reported school environment data were collected via questionnaires. Trained researchers measured children’s height and weight, and Body Mass Index (BMI, kg/m²) was calculated. Structural equation modelling was used to assess the relationship of the home and school environments with children’s fruit and vegetable intake, physical activity behaviours, and children’s BMI. Result The home diet environment was positively associated with child diet (β?=?0.18, p?<?0.001). The home physical activity environment had the largest inverse association with BMI (β?=???0.11, p?<?0.001), indirectly through child physical activity (β?=?0.28 ,p?<?0.001). Schools’ healthy eating policy implementation was significantly associated with child diet (β?=?0.52, p?<?0.05), but physical activity policy was not associated with child activity (β?=???0.007, p?>?0.05). The school environment was not associated with child BMI. Discussion The home environment had a stronger association with healthier child behaviours, compared to the school environment. These findings suggest that future childhood obesity interventions targeting healthier home environments and supporting parents can promote healthier child eating and physical activity behaviours.     

Peer Reviewed: Cognitive Health Messages in Popular Women’s and Men’s Magazines, 2006-2007

Introduction

Growing evidence suggests that physical activity, healthy diets, and social engagement may promote cognitive health. Popular media helps establish the public health agenda. In this study, we describe articles about cognitive health in top-circulating women''s and men''s magazines.

Methods

To identify articles on cognitive health, we manually searched all pages of 4 top-circulating women''s magazines and 4 top-circulating men''s magazines published in 2006 and 2007 to identify articles on cognitive health. We examined article volume, narrative and illustrative content, information sources, and contact resources.

Results

Women''s magazines had 27 cognitive health articles (5.32/1,000 pages), and men''s magazines had 26 (5.26/1,000 pages). Diet was the primary focus (>75% of content) in 30% of articles in women''s magazines and 27% of men''s magazines. Vitamins/supplements were the focus of 15% of articles in men''s magazines and 11% in women''s magazines. Articles mentioned physical activity, cognitive activity, and social interaction, although these subjects were rarely the focus. Articles focused more on prevention than treatment. Topics were primarily "staying sharp," memory, and Alzheimer''s disease. Colleges/universities were most often cited as sources; contacts for further information were rare. Most articles were illustrated.

Discussion

Although the volume of cognitive health articles was similar in the magazines, content differed. More articles in men''s magazines discussed multiple chronic conditions (eg, Alzheimer''s disease), whereas more in women''s magazines discussed memory. Including more articles that focus on physical activity and direct readers to credible resources could enhance the quality of cognitive health communication in the popular media.     

Peer Reviewed: Reproductive Health Surveillance in the US-Mexico Border Region, 2003-2006: The Brownsville-Matamoros Sister City Project for Women’s Health

Introduction

High birth and immigration rates in the US-Mexico border region have led to large population increases in recent decades. Two national, 10 state, and more than 100 local government entities deliver reproductive health services to the region''s 14 million residents. Limited standardized information about health risks in this population hampers capacity to address local needs and assess effectiveness of public health programs.

Methods

We worked with binational partners to develop a system for reproductive health surveillance in the sister communities of Matamoros, Tamaulipas, Mexico, and Cameron County, Texas, as a model for a broader regional approach. We used a stratified, systematic cluster-sampling design to sample women giving birth in hospitals in each community during an 81-day period (August 21-November 9) in 2005. We conducted in-hospital computer-assisted personal interviews that addressed prenatal, behavioral, and lifestyle factors. We evaluated survey response rates, data quality, and other attributes of effective surveillance systems. We estimated population coverage using vital records data.

Results

Among the 999 women sampled, 947 (95%) completed interviews, and the item nonresponse rate was low. The study sample included 92.7% of live births in Matamoros and 98.3% in Cameron County. Differences between percentage distributions of birth certificate characteristics in the study and target populations did not exceed 2.0. Study population coverage among hospitals ranged from 92.9% to 100.0%, averaging 97.3% in Matamoros and 97.4% in Cameron County.

Conclusion

Results indicate that hospital-based sampling and postpartum interviewing constitute an effective approach to reproductive health surveillance. Such a system can yield valuable information for public health programs serving the growing US-Mexico border population.     

A Longitudinal Cohort Study of Body Mass Index and Childhood Exposure to Secondhand Tobacco Smoke and Air Pollution: The Southern California Children’s Health Study

Background:

Childhood body mass index (BMI) and obesity prevalence have been associated with exposure to secondhand smoke (SHS), maternal smoking during pregnancy, and vehicular air pollution. There has been little previous study of joint BMI effects of air pollution and tobacco smoke exposure.

Methods:

Information on exposure to SHS and maternal smoking during pregnancy was collected on 3,318 participants at enrollment into the Southern California Children’s Health Study. At study entry at average age of 10 years, residential near-roadway pollution exposure (NRP) was estimated based on a line source dispersion model accounting for traffic volume, proximity, and meteorology. Lifetime exposure to tobacco smoke was assessed by parent questionnaire. Associations with subsequent BMI growth trajectory based on annual measurements and attained BMI at 18 years of age were assessed using a multilevel modeling strategy.

Results:

Maternal smoking during pregnancy was associated with estimated BMI growth over 8-year follow-up (0.72 kg/m² higher; 95% CI: 0.14, 1.31) and attained BMI (1.14 kg/m² higher; 95% CI: 0.66, 1.62). SHS exposure before enrollment was positively associated with BMI growth (0.81 kg/m² higher; 95% CI: 0.36, 1.27) and attained BMI (1.23 kg/m² higher; 95% CI: 0.86, 1.61). Growth and attained BMI increased with more smokers in the home. Compared with children without a history of SHS and NRP below the median, attained BMI was 0.80 kg/m² higher (95% CI: 0.27, 1.32) with exposure to high NRP without SHS; 0.85 kg/m² higher (95% CI: 0.43, 1.28) with low NRP and a history of SHS; and 2.15 kg/m² higher (95% CI: 1.52, 2.77) with high NRP and a history of SHS (interaction p-value 0.007). These results suggest a synergistic effect.

Conclusions:

Our findings strengthen emerging evidence that exposure to tobacco smoke and NRP contribute to development of childhood obesity and suggest that combined exposures may have synergistic effects.

Citation:

McConnell R, Shen E, Gilliland FD, Jerrett M, Wolch J, Chang CC, Lurmann F, Berhane K. 2015. A longitudinal cohort study of body mass index and childhood exposure to secondhand tobacco smoke and air pollution: the Southern California Children’s Health Study. Environ Health Perspect 123:360–366; http://dx.doi.org/10.1289/ehp.1307031     

The Association Between Fathers’ Depression and Children’s Socioemotional Development: Evidence from a Longitudinal Household Survey in China

Prevention Science - Depression is highly prevalent among parents around the world. Although there has been substantial research on maternal depression, few studies have additionally considered...     

Peer Reviewed: Prior Contraceptive Use Among Women Who Gave Birth in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women’s Health

Introduction

Dramatic population growth in  the US-Mexico border region suggests more effective family planning services are needed, yet binational data are scarce. The Brownsville-Matamoros Sister City Project for Women''s Health collected binational, standardized data from 947 postpartum women in Cameron County (Texas) and Matamoros (Tamaulipas, Mexico) hospitals from August through November 2005.

Methods

We analyzed these data to estimate the proportion of women with unintended pregnancy and the proportion of these women who reported contraceptive use, and to identify associated factors.

Results

The current pregnancy was unintended for 48% of women overall. Almost half of these women reportedly used birth control at conception, but many used low-efficacy methods. Among women with unintended pregnancy who did not use contraception, 34.1% of Mexico residents believed they could not become pregnant and 28.4% of US residents reported no reason for nonuse. Overall, contraceptive use to prevent pregnancy was less common among younger than older women and among women who had not graduated high school compared with those who had. Among Mexico residents, those who had a source of routine health care were more likely than those who did not to have used contraception.

Conclusion

More effective contraceptive practices are needed in this population, especially among younger and less-educated women. A cooperative binational approach that integrates reproductive and family planning services may be most effective.     

Trends in Body Mass Index and Prevalence of Extreme High Obesity Among Pennsylvania Children and Adolescents, 2007–2011: Promising but Cautionary

Objectives. We determined current trends and patterns in overweight, obesity, and extreme high obesity among Pennsylvania pre-kindergarten (pre-K) to 12th grade students and simulated future trends.Methods. We analyzed body mass index (BMI) of pre-K to 12th grade students from 43 of 67 Pennsylvania counties in 2007 to 2011 to determine trends and to discern transition patterns among BMI status categories for 2009 to 2011. Vinsem simulation, confirmed by Markov chain modeling, generated future prevalence trends.Results. Combined rates of overweight, obesity, and extreme high obesity decreased among secondary school students across the 5 years, and among elementary students, first increased and then markedly decreased. BMI status remained constant for approximately 80% of normal and extreme high obese students, but both decreased and increased among students who initially were overweight and obese; the increase in BMI remained significant.Conclusions. Overall trends in child and adolescent BMI status seemed positive. BMI transition patterns indicated that although overweight and obesity prevalence leveled off, extreme high obesity, especially among elementary students, is projected to increase substantially over time. If current transition patterns continue, the prevalence of overweight, obesity, and extreme high obesity among Pennsylvania students in 2031 is projected to be 16.0%, 6.6%, and 23.2%, respectively.The economic consequences of obesity in the United States were estimated at $147 billion annually in 2008.1 To better understand these costs, obesity trends to the year 2030 were predicted.2 Obesity prevalence could reach 51% by 2030, but is more likely to stay at more than 40% because of recently emerging positive developments. A subcategory, severe obesity, that is, body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) of 40 or greater for adults, has increased faster than overall obesity and is projected to grow from 5% of adults in 2010 to 11% of adults by 2030.2 This growth, with its attendant increased risks of disease, will escalate costs even if overall obesity prevalence stabilizes.2Because obesity rates vary across states, the financial burden is not uniform.3 State-specific differences, such as lower cost of less healthy foods, can affect obesity and severe obesity prevalence together with current and projected health care costs.2 Because of the state-specific nature of Medicaid and Medicare expenditures, much of the high cost of obesity-related disease is borne by public sector health plans.Today’s children and adolescents will be the youngest adults in 2030; therefore, obesity prevention for the future requires monitoring of obesity prevalence rates among this population over time. Prevalence and trends in obesity among US children from 1999 to 2010 were determined based on National Health and Nutrition Examination Survey data.4 Prevalence of high BMI in US children and adolescents has also been studied.5 By 2010, fewer than 12% of those aged 2 to 19 years nationwide were at or above the 97th percentile (extreme high obese [ExHi obese]); 17% were above the 95th percentile (obese), and 32% were above the 85th percentile (overweight). A statistically significant increase among 6- to 19-year-old males with a BMI at or above the 97th percentile was found between 1999 and 2008.4To inform prevention efforts, state governments have a vested interest in monitoring obesity prevalence among all age groups, and especially among children and adolescents. Pennsylvania, for example, mandates annual height and weight screening with BMI calculation for all public school students statewide.6 One recent study assessed child and adolescent BMI trends in Pennsylvania, excluding Philadelphia and surrounding counties, for 2005 to 20097 and found combined overweight and obese rates decreased from 28.5% to 23.1% at the middle school level and from 24.6% to 20.9% at high school levels, but increased from 10.9% to 20% at the elementary level. The largest shift in BMI over the subset of years from 2007 to 2009 was among overweight elementary students; 58% of those who were overweight in 2007 were obese in 2009. Overweight and obese increased for the study population as a whole because of this sharp increase among elementary students. In a second, separate study,8 trends in obese (BMI ≥ 95th percentile) and ExHi obese (defined8 as BMI ≥ 35 kg/m²) among 5- to 18-year-old students attending Philadelphia schools in 2006 to 2010 were determined; obesity across all ages decreased from 21.5% to 20.5% and ExHi obese from 8.5% to 7.9%. Obese and ExHi obese were most prevalent among middle school students, Hispanic boys, and Black girls.8The purpose of our study was to determine prevalence, trends, and patterns in overweight, obese, and ExHi obese among Pennsylvania school children. Specific research questions were:

1. What were the prevalence and trends in overweight, obese, and ExHi obese from 2007 to 2011 among elementary, middle, and high school students?
2. What movement patterns, if any, occurred in normal weight, overweight, obese, and ExHi obese among Pennsylvania elementary, middle, and high school students from 2009 to 2011?
3. If current patterns continue, what percentage of children and adolescents would be overweight, obese, and ExHi obese in 2030?

     

Peer Reviewed: Cervical Cancer Screening Among Women Who Gave Birth in the US-Mexico Border Region, 2005: The Brownsville-Matamoros Sister City Project for Women’s Health

Introduction

The objective of this study was to examine correlates of ever having had a Papanicolaou (Pap) test among women who recently delivered a live infant and who resided near the US-Mexico border.

Methods

This cross-sectional study included women who delivered a live infant in Matamoros, Mexico (n = 488) and Cameron County, Texas (n = 453). Women were interviewed in the hospital before discharge between August 21 and November 9, 2005. Multivariable logistic regression was used to estimate the odds of ever having had a Pap test.

Results

Significantly fewer Matamoros women (62.1%) than Cameron County women (95.7%) reported ever having had a Pap test. Only 12% of Matamoros women said they received their most recent Pap test during prenatal care, compared with nearly 75% of Cameron County women. After adjusting for potential confounders, the odds of ever having had a Pap test were 7.41 times greater in Cameron County than in Matamoros (95% confidence interval, 4.07-13.48).

Conclusion

The Healthy Border 2010 goals are to cut cervical cancer mortality by 20% to 30% in the border region. The significant difference in Pap test prevalence among our survey respondents may reflect that routine prenatal Pap testing is more common in the United States than in Mexico. Because women who are receiving prenatal care have increased interaction with health care providers, Matamoros providers may need to be educated about the need to screen for cervical cancer during this time.     

Associations of Alcoholic Beverage Consumption with Dietary Intake,Waist Circumference,and Body Mass Index in US Adults: National Health and Nutrition Examination Survey 2003-2012

Background

Findings from studies of alcohol and obesity measures (eg, waist circumference [WC] and body mass index [BMI; calculated as kg/m²]) are conflicting. Residual confounding by dietary intake, inconsistent definitions of alcohol consumption across studies, and the inclusion of former drinkers in the nondrinking comparison group can contribute to the mixed literature.