Temporal Trends in Social Disparities in Maternal Smoking and Breastfeeding in Canada, 1992–2008

A steady decrease in maternal smoking during pregnancy and a steady increase in breastfeeding rates have been observed in Canada in the past two decades. However, the extent to which all socioeconomic classes have benefited from this progress is unknown. Therefore, this study was undertaken to determine: (1) whether progress achieved benefited the entire population or was limited to specific strata; and (2) whether disparities among strata decreased, stayed the same, or increased over time. We used data from the National Longitudinal Survey of Children and Youth, which enrolled children aged 0–3 years between 1994 and 2008. Data collected at entry was analyzed in a cross-sectional manner. Between birth years 1992–1996 and 2005–2008, smoking during pregnancy decreased from 11.5 % (95 % CI 10.0–13.0 %) to 5.2 % (95 % CI 4.1–6.3 %) among mothers with a college or university degree and from 43.0 % (95 % CI 38.8–47.2 %) to 38.6 % (95 % CI 32.9–44.2 %) among those with less than secondary education. During the same period, the rate of breastfeeding initiation increased from 83.8 % (95 % CI 81.9–85.6 %) to 91.5 % (95 % CI 90.2–92.8 %) among mothers with a college or university degree and from 63.1 % (95 % CI 58.9–67.4 %) to 74.7 % (95 % CI 69.8–79.7 %) among those with less than secondary education. The risks of smoking and of not breastfeeding remained significantly higher in the least educated category than in the most educated throughout the study period, and these associations remained statistically significant after controlling for maternal age. Gaps between the least and the most educated mothers narrowed for breastfeeding but widened for smoking during pregnancy.     

Socioeconomic Status and Foodborne Pathogens in Connecticut,USA, 2000–2011

Foodborne pathogens cause >9 million illnesses annually. Food safety efforts address the entire food chain, but an essential strategy for preventing foodborne disease is educating consumers and food preparers. To better understand the epidemiology of foodborne disease and to direct prevention efforts, we examined incidence of Salmonella infection, Shiga toxin–producing Escherichia coli infection, and hemolytic uremic syndrome by census tract–level socioeconomic status (SES) in the Connecticut Foodborne Diseases Active Surveillance Network site for 2000–2011. Addresses of case-patients were geocoded to census tracts and linked to census tract–level SES data. Higher census tract–level SES was associated with Shiga toxin–producing Escherichia coli, regardless of serotype; hemolytic uremic syndrome; salmonellosis in persons ≥5 years of age; and some Salmonella serotypes. A reverse association was found for salmonellosis in children <5 years of age and for 1 Salmonella serotype. These findings will inform education and prevention efforts as well as further research.     

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.     

Status of Breastfeeding and Child Immunization Outcomes in Clients of the Nurse–Family Partnership

Background The Nurse–Family Partnership (NFP) is a home visiting program serving first-time, low-income mothers, with an area of focus on healthy early childhood development. Previous foundational trials of program effect on breastfeeding and immunizations have shown a mix of neutral and positive results. The present evaluation investigates these effects following program scale-up, using a large contemporary cohort of clients. Methods Nurse–Family Partnership client breastfeeding and immunization status were compared to National Survey of Children’s Health data and National Immunization Survey data, respectively. Sample differences in demographic covariates were adjusted using logistic regression. Results Nurse–Family Partnership clients were significantly more likely to have ever breastfed (adjusted prevalence ratio [aPR: 1.20 (1.17, 1.23)] and maintain breastfeeding at 6 [aPR: 1.17 (1.10, 1.24)] and 12 [aPR: 1.39 (1.25, 1.53)] months, but less likely to exclusively breastfeed at 6 months [aPR: 0.84 (0.70, 0.95)] NFP clients were significantly more likely to be up-to-date on immunizations at 6 [aPR: 1.23 (1.22, 1.25)], 18 [aPR: 1.33 (1.30,1.35)], and 24 [aPR: 1.15 (1.14, 1.16)] months of age than the reference cohort, with no significant difference at 12 months. Discussion Nurse–Family Partnership clients had more beneficial breastfeeding and immunization outcomes than children of mothers with demographically similar profiles. However, exclusive breastfeeding at 6 months lags behind the reference sample and represents a potential area for further improvement.     

Fraction of Gestational Diabetes Mellitus Attributable to Overweight and Obesity by Race/Ethnicity,California, 2007–2009

Objectives. We calculated the racial/ethnic-specific percentages of gestational diabetes mellitus (GDM) attributable to overweight and obesity.Methods. We analyzed 1 228 265 records of women aged 20 years or older with a live, singleton birth in California during 2007 to 2009. Using logistic regression, we estimated the magnitude of the association between prepregnancy body mass index and GDM and calculated the percentages of GDM attributable to overweight and obesity overall and by race/ethnicity.Results. The overall estimated GDM prevalence ranged from 5.4% among White women to 11.9% among Asian/Pacific Islander women. The adjusted percentages of GDM deliveries attributable to overweight and obesity were 17.8% among Asians/Pacific Islander, 41.2% among White, 44.2% among Hispanic, 51.2% among Black, and 57.8% among American Indian women. Select Asian subgroups, such as Vietnamese (13.0%), Asian Indian (14.0%), and Filipino (14.2%), had the highest GDM prevalence, but the lowest percentage attributable to obesity.Conclusions. Elevated prepregnancy body mass index contributed to GDM in all racial/ethnic groups, which suggests that decreasing overweight and obesity among women of reproductive age could reduce GDM, associated delivery complications, and future risk of diabetes in both the mother and offspring.Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy. GDM is associated with increased maternal and infant complications, including infant macrosomia, birth trauma, hypoglycemia, and cesarean section.1–4 Offspring of mothers with GDM are at increased risk for metabolic syndrome and type 2 diabetes in adulthood.5 GDM prevalence estimates range from 1% to 14% of all pregnancies in the United States, depending on the population studied and the diagnostic tests employed.6 Although some women diagnosed with GDM have abnormal glycemia that persists, most women will revert to normal carbohydrate metabolism after delivery.7 Women with a history of GDM are at increased risk of GDM in future pregnancies,8 and more than 50% will develop type 2 diabetes later in life.9Previous studies have shown that GDM prevalence estimates differ vastly by race/ethnicity. American Indians, Hispanics, and Asians have the highest estimates of GDM,10,11 and these differences have not been fully explained by prepregnancy body mass index (BMI).12,13 California is the most populous state in the United States, with an estimated 39.1 million residents in 2010. Its population is diverse, with an estimated 42% White, 37% Hispanic, 12% Asian, 6% Black, 2% multiracial, 0.6% American Indian, and 0.4% Native Hawaiian/Pacific Islander. Recent trends in the racial/ethnic composition of California’s population predicts a continuing decline in the White population and an increase in the Hispanic population through 2020, when Hispanics are projected to become the largest racial/ethnic group in California.14 In addition, California records more than 500 000 births in a given year, half of which are to Hispanic women. In California, during the next 10 years, births to Black women will likely decrease by almost 4%, and births to Asian, American Indian, and Pacific Islander women will likely increase by 6%, 6%, and 16%, respectively.8 Hispanic women are expected to have the largest numerical increase in births during the next 10 years.15In a recent study of diabetes during pregnancy in California, it was reported that prevalence of maternal diabetes had risen from 4.6% of births in 1999 to 6.5% in 2005, with preexisting diabetes increasing by 28% and GDM increasing by 44%.16 The authors suggested that the increase in GDM might be attributable to recent increases in overweight and obesity among women of reproductive age. The purpose of the present study was to estimate the contribution of BMI to GDM risk across different racial/ethnic groups by calculating the race/ethnicity-specific percentages of GDM attributable to prepregnancy overweight and obesity among women giving birth in California during 2007 to 2009.     

Differential Trends in Weight-Related Health Behaviors Among American Young Adults by Gender, Race/Ethnicity, and Socioeconomic Status: 1984�C2006

Objectives. We investigated temporal patterns from 1984 to 2006 in 6 weight-related health behaviors by using longitudinal data for multiple cohorts of young adults (aged 19–26 years) from the nationally representative Monitoring the Future Study.Methods. We used growth curve models to examine historical trends in 6 health behaviors: frequency of eating breakfast, eating green vegetables, eating fruit, exercising, watching television, and sleeping 7 hours each night. Variations across gender, race/ethnicity, and socioeconomic status were investigated.Results. Frequency of exercising was consistently lower among young adult women than young adult men over this 23-year period. Compared with White women, Hispanic women, and women from other race/ethnic groups, Black women showed declines in the frequency of exercise since 1984. In general, young adult women showed a marked increase in the frequency of eating breakfast over this period, although Black women did not show any net gains.Conclusions. Social disparities in body weight may increase because Black women, Hispanic women, and men with lower socioeconomic status show declining trends in positive weight-related health behaviors compared with White young adults with higher socioeconomic status.As the prevalence of obesity and overweight rises in the United States,^1–5 researchers continue to investigate a range of mechanisms by which people attain excessive body weight.^6–10 Agreement is growing that the source of the obesity epidemic lies in an environment that produces an energy gap,^11–15 where energy intake exceeds energy expenditure even by as little as 100 excess calories per day.^12,13 Yet, it is unclear whether this 100-calorie excess is a function of increased intake or decreased output (or some combination of both) in American activity and consumption behaviors over time.Limited data exist on trends in energy intake and energy expenditure among Americans over the past 3 decades, but the data that are available are nonetheless consistent with the rise in obesity observed over the same period. Between 1977 and 1996, Americans increased their total energy consumption by about 200 kcal/day.¹⁶ This was largely a result of increased consumption of snacks and soft drinks, particularly among young adults,^16,17 while vegetable and fruit consumption remained low.^18–21 These consumption behaviors have all been linked to excess weight gain.^22–25 The increased availability of inexpensive, energy-dense food and beverages^26–30 coupled with a lack of access to fresh fruits and vegetables^31,32 are some of the environmental factors that may contribute to these trends. The US population has also adopted an increasingly sedentary lifestyle^33–36 in an environment that is associated with a reduction in energy expenditure, including car-dependent neighborhoods that discourage walking and biking^37–41 and limited physical activity in schools.^28,42 On average, American youth spend over 30 hours per week watching television,⁴³ which is positively associated with being overweight, either through sedentary activity or through exposure to the marketing of poor-quality foods.^43–46 Modern lifestyles are increasingly characterized by skipping breakfast and sleeping less,^36,47–49 which have also been linked to energy imbalance.^50–56These reported trends in health behaviors, however, are based on data from repeated cross-sectional surveys^18,21,57 that were often conducted up to 5 years or more apart,^16,21,57 the results of which are typically reported in aggregate across a time span of 4 to 7 years.^20,57 Moreover, published articles frequently focus on trends in only 1 health behavior (e.g., fruit and vegetable consumption^18,20) and not the relative practice of energy consumption and expenditure behaviors among individuals over time. As a result, more detailed trends in health behaviors, particularly as they illustrate subtle changes in the balance of energy intake and output occurring annually among American young adults over the last quarter century, are poorly understood.Also, differences in these behaviors and their trends by gender, socioeconomic status (SES), and racial/ethnic background are not well described at a population level, even though well-documented health disparities in obesity by social position exist.^4,58–61 Using data from the National Health and Nutrition Examination Survey (1988–2002), one study found that non-Hispanic Blacks, persons in poverty, and those with less than a high school education were less likely to meet US Department of Agriculture fruit and vegetable guidelines than were non-Hispanic Whites and socioeconomically advantaged individuals.⁵⁷ However, these results were based on 2 cross-sectional data sets collected 5 years apart. Delva et al.¹⁰ used repeat cross-sectional data collected annually from secondary school students between 1986 and 2003 to report declining trends in the proportion of adolescents who ate breakfast or exercised regularly, with a lower prevalence among women, racial/ethnic minorities, and those with low SES. Trends in the frequency of these behaviors beyond the secondary school setting, however, remain largely undocumented.The purpose of our study was, first, to investigate long-term patterns in weight-related health behaviors among young adults (aged 19–26 years) over the past 23 years (1984–2006) and, second, to assess how these patterns varied by social position (race/ethnicity, gender, and SES). Analyses were based on longitudinal data for multiple cohorts of individuals with frequent repeat measures to better track historical changes in weight-related health behaviors over time. By focusing on young adults, we aimed to better understand how weight-related health behaviors have changed in this early period of the adult life course, when many adult health behavior patterns show their formative roots. The transition to adulthood (sometimes referred to as emerging or early adulthood) is a period when individuals are on their own typically for the first time, when life plans are put into action, and when distinctive life paths become more manifest.⁶² We hypothesized that the frequency of healthy behaviors would generally decline among young adults over this period, and that the rate of decline would be greater among those in disadvantaged social positions (women, Blacks, Hispanics, and those of lower SES).     

Do Differences in Prelacteal Feeding Explain Differences in Subsequent Breastfeeding Between Haiti and the Dominican Republic?

Maternal and Child Health Journal - Although Haiti and the Dominican Republic (DR) share the same island of Hispaniola, exclusive breastfeeding is much higher in Haiti. As prelacteal feeding also...     

Health Insurance and Access to Care for Families with Young Children in California, 2001–2005: Differences by Immigration Status

Objectives To examine differences and trends in health insurance coverage and access to care for California families by immigration status. Methods Cross-sectional data on 37,236 families with young children <18 years of age from the 2001, 2003 and 2005 California Health Interview Survey are used to assess trends in health insurance and access to care for children and their parents by four immigration dyads: (1) both are Citizens; (2) child is a legal resident/citizen, and parent is legal resident (Documented); (3) child is a citizen, and parent is undocumented (Mixed); and (4) both are Undocumented. Results Before and after adjustment for covariates, only children in Undocumented dyads were less likely than Citizen dyads to have insurance (OR = 0.20, CI: 0.16–0.26) and all three measures of access: physician visits (OR = 0.69, CI: 0.52–0.91), dental visits (OR = 0.47, CI: 0.35–0.63), and a regular source of care (OR = 0.51, CI: 0.37–0.69). Parents in all non-Citizen dyads had poorer access than Citizen dyads across all measures, with the exception of dental visits and a regular source for parents in Documented dyads. Children of all dyads except Citizens were more likely to be insured in 2005 vs. 2001. The largest gain was for undocumented dyad children with 2.77 times higher odds (CI: 1.62–4.75) of being insured in 2005 vs. 2001. All children dyads except Mixed were also more likely to have a physician visit. For parents, there was only a decrease in insurance coverage for Citizen dyads (OR = 0.79, CI: 0.67–0.93) and few changes in access. Conclusions While there were relatively few disparities and some improvements in insurance coverage and access for children in California (except for undocumented children), concomitant changes for parents were not observed. Without attention to the family in health care reforms, disparities may not fully resolve for children and may continue or even increase for parents.     

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.     

Maternal Obesity and Risk of Preterm Birth and Low Birthweight in Hawaii PRAMS, 2000–2011

Objective Maternal obesity is a risk factor for preterm birth, a leading cause of infant morbidity and mortality. Native Hawaiian and other Pacific Islanders (NHOPI) have high rates of poor birth outcomes. Despite the high rates of obesity in NHOPI in Hawaii, the association with preterm birth has not been examined in this population. Methods We performed a retrospective cohort study of 20,061 women using data collected by Hawaii’s Pregnancy Risk Assessment Monitoring System (PRAMS) from 2000 to 2011. We investigated the contribution of maternal age, pre-pregnancy BMI, gestational diabetes, hypertension, race, socioeconomic status, and smoking to our primary outcomes of preterm birth and low birthweight using multivariable logistic regression, stratified by NHOPI versus non-NHOPI race. Results Pre-pregnancy obesity was more common in NHOPI than non-NHOPI women (23.9 and 10.5%, respectively; p?<?0.01). Overall, the risk for preterm birth increased with maternal obesity (BMI?≥?30.0; aOR?=?1.24, 95% CI 1.06–1.45, p?<?0.01), compared with normal weight women. Among NHOPI women, the prevalence of preterm birth was elevated compared with non-NHOPI women although the prevalence of low birth weight was lower. After adjusting for confounders, risk for preterm birth and low birth weight were elevated in NHOPI women compared with White women. Maternal obesity did not significantly affect the risk of prematurity within the NHOPI group. Conclusions for Practice Our study demonstrates an association between maternal pre-pregnancy obesity and preterm deliveries in Hawaii. NHOPI have high rates of pre-pregnancy obesity as well as increased risk of both preterm delivery and low birthweight when compared to White women. Further data are needed to assess interactions between race, maternal health, and neonatal morbidity, and to identify ways to improve birth outcomes for minority populations in the state of Hawaii.     

Maternal Morbidity and Perinatal Outcomes Among Foreign-Born Cambodian,Laotian, and Vietnamese Americans in Washington State, 1993–2006

This study examined differences in perinatal outcomes of Southeast Asian (SEA) women compared with non-Hispanic white women in Washington. Using linked birth certificate and hospitalization discharge records for the years 1993–2006, we compared singleton births of Cambodian (3,858), Laotian (2,223), and Vietnamese (12,949) women with a random sample of white women (35,581). Associations between maternal nativity and perinatal outcomes were assessed using multivariable logistic regression. There are clear nativity differences among SEAs for gestational diabetes mellitus, anemia, placenta previa and febrile illness. SEAs had increased risks for these disorders when compared with white women. Compared with infants delivered of white women, infants of SEAs had increased risks for moderate to heavy meconium, birth injury and low birth weight. Differences in nativity among SEAs (populations that are traditionally studied in aggregate) should be considered when designing and carrying out interventions to prevent adverse pregnancy morbidity and outcomes among immigrants.     

Are Racial Differences in Patient–Physician Cancer Communication and Information Explained by Background,Predisposing, and Enabling Factors?

Research shows that African Americans tend to have poorer and less informative patient–physician communication than Whites. We analyzed survey data from 248 African American and 244 White cancer patients to examine whether this disadvantage could be explained by race variability on several other variables commonly reported to affect communication. These variables were organized into background, enabling, and predisposing factors, based on the Precede-Proceed Model. Multivariate regressions were used to test whether race differences in communication and information variables persisted after successively controlling for background, enabling, and predisposing factors. African American patients had higher interpersonal communication barriers than Whites, but this difference did not persist after controlling for background factors. African Americans also had higher unmet information needs and were less likely to receive the name of a cancer expert. These differences persisted after controlling for all other factors. Future research should focus on the informational disadvantages of African American patients and how such disadvantages may affect cancer treatment decisions.     

Skin Carotenoid Status Over Time and Differences by Age and Sex Among Head Start Children (3–5 Years)

ObjectiveExamine differences in skin carotenoid status (SCS) based on time, age, and sex of preschool-aged children enrolled in Head Start (HS) in North Carolina.DesignData were collected using surveys from participating families. preschool-aged children's SCS were measured 3 times over a 6-month period.SettingThree HS centers in North Carolina.ParticipantsOne hundred twelve children aged 3–5 years, enrolled in HS.Main Outcome Measure(s)Differences in SCS assessed using the Veggie Meter (Longevity Link, Salt Lake City, UT) based on time, sex, and age.AnalysisOne-way ANOVA to assess SCS at time 1 between sex and age (n = 112). Repeated measures ANOVA with a Greenhouse-Geisser correction for assessment of SCS over time (n = 45) using Bonferroni correction.ResultsOn average, children were aged 4 years, African American (81.3%), male (57%), and had a mean SCS of 266 (SD = 82.9). Skin carotenoid status (Veggie Meter units) were significantly different over time (P < 0.001). Significant differences were observed between ages (P = 0.01) and sex (P < 0.01).Conclusions and ImplicationsThe Veggie Meter is a promising tool to assess fruit and vegetable intake but needs to be validated in preschool-aged children as it has been in adults. Sex and age are potential confounders which should be assessed in future studies using the Veggie Meter.