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Potts BA, Wood GC, Bailey-Davis L. Agreement between parent-report and EMR height, weight, and BMI among rural children. Front Nutr 2024; 11:1279931. [PMID: 38496791 PMCID: PMC10940382 DOI: 10.3389/fnut.2024.1279931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction Remote anthropometric surveillance has emerged as a strategy to accommodate lapses in growth monitoring for pediatricians during coronavirus disease 2019 (COVID-19). The purpose of this investigation was to validate parent-reported anthropometry and inform acceptable remote measurement practices among rural, preschool-aged children. Methods Parent-reported height, weight, body mass index (BMI), BMI z-score, and BMI percentile for their child were collected through surveys with the assessment of their source of home measure. Objective measures were collected by clinic staff at the child's well-child visit (WCV). Agreement was assessed using correlations, alongside an exploration of the time gap (TG) between parent-report and WCV to moderate agreement. Using parent- and objectively reported BMI z-scores, weight classification agreement was evaluated. Correction equations were applied to parent-reported anthropometrics. Results A total of 55 subjects were included in this study. Significant differences were observed between parent- and objectively reported weight in the overall group (-0.24 kg; p = 0.05), as well as height (-1.8 cm; p = 0.01) and BMI (0.4 kg/m2; p = 0.02) in the ≤7d TG + Direct group. Parental reporting of child anthropometry ≤7d from their WCV with direct measurements yielded the strongest correlations [r = 0.99 (weight), r = 0.95 (height), r = 0.82 (BMI), r = 0.71 (BMIz), and r = 0.68 (BMI percentile)] and greatest classification agreement among all metrics [91.67% (weight), 54.17% (height), 83.33% (BMI), 91.67% (BMIz), and 33.33% (BMI percentile)]. Corrections did not remarkably improve correlations. Discussion Remote pediatric anthropometry is a valid supplement for clinical assessment, conditional on direct measurement within 7 days. In rural populations where socioenvironmental barriers exist to care and surveillance, we highlight the utility of telemedicine for providers and researchers.
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Affiliation(s)
| | | | - Lisa Bailey-Davis
- Center for Obesity and Metabolic Research, Geisinger Health System, Danville, PA, United States
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Hoffmann S, Sander L, Rattay P, Blume M, Hövener C, Schneider S, Richter M, Pischke CR, Schüttig W, De Bock F, Spallek J. Do family characteristics contribute to a socioeconomic gradient in overweight in early childhood? - Single mediation analyses of data from German preschool children. Prev Med Rep 2023; 33:102178. [PMID: 37008454 PMCID: PMC10060745 DOI: 10.1016/j.pmedr.2023.102178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Children's overweight is strongly associated with family socioeconomic position (SEP) and family characteristics (FC). There is limited research on the extent to which FC account for a socioeconomic gradient in childhood overweight. This study examined whether FC explain SEP differences in the prevalence of overweight. The study used baseline data of preschool-aged children from the German 'PReschool INtervention Study'. The sample (n = 872, 48% girls) was recruited at kindergartens in Baden-Württemberg, Germany. Data included children's measured weight status and parents' reports on socioeconomic indicators (e.g., school education, vocational education, income) and FC. Variables represent main determinants of overweight (nutrition: sweets consumption in front of TV, soft drink consumption, regular breakfast, child sets table; physical activity: outdoor sports; parental role model). In single mediation analyses indirect effects of SEP on overweight were analysed (OR[95%CI]). Preschool girls and boys with low parental education had higher odds for overweight than children with high parental education. Among boys, low levels of parental education contributed to the odds of overweight via indirect effects by both factors 'sweets consumption in front of TV' (OR = 1.31[1.05-1.59]) and 'no sports' (OR = 1.14[1.01-1.38]). Among girls, FC measured did not explain SEP differences in overweight. Family nutrition and parental/family physical activity contribute to inequalities in overweight among preschool boys, but not girls. Research is needed to identify FC that explain inequalities in overweight for both.
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Affiliation(s)
- Stephanie Hoffmann
- Department of Public Health, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Lydia Sander
- Department of Public Health, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Petra Rattay
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Miriam Blume
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Claudia Hövener
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Sven Schneider
- Center for Preventive Medicine and Digital Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Richter
- Department of Sport and Health Sciences, Technical University of Munich (TUM), Munich, Germany
| | - Claudia R. Pischke
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Wiebke Schüttig
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Freia De Bock
- Child Health Services Unit, Clinic of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, Heinrich-Heine University Düsseldorf, Germany
| | - Jacob Spallek
- Department of Public Health, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
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Arons A, Pomeranz J, Hamad R. Identifying Novel Predictors of State Legislative Action to Address Obesity. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:E9-E18. [PMID: 31415263 PMCID: PMC7012724 DOI: 10.1097/phh.0000000000001039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is wide variation in the number and types of obesity policies enacted across states, and prior studies suggest that partisan factors may not fully explain this variation. In this exploratory analysis, we examined the association of a broad array of state-level factors with the number and types of obesity policies across states. DESIGN We analyzed 32 predictor variables across 7 categories of state-level characteristics. We abstracted data from 1652 state obesity policies introduced during 2009-2014. We used multilevel regression models and principal component analysis to examine the association between state-level characteristics and policy outcomes. MAIN OUTCOME MEASURES Our outcome measures included whether bills involved topics that were public health-oriented or business interest-oriented, whether bills were enacted into law, and the number of introduced bills and enacted laws per state. RESULTS Numerous state-level characteristics were associated with obesity-related bill introduction and law enactment, and different state characteristics were associated with public health-oriented versus business interest-oriented policies. For example, state-level demographics, economic factors, policy environment, public programs, and the prevalence of obesity's downstream consequences were associated with the number of public health laws whereas obesity prevalence and policy environment were associated with the number of business interest laws. CONCLUSIONS Our results support the hypothesis that a variety of factors contribute to a complex state obesity policymaking environment, highlighting the need for future research to disentangle these key predictors.
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Affiliation(s)
- Abigail Arons
- Departments of Medicine and Pediatrics, University of California Los Angeles, Los Angeles, California (Dr Arons); Department of Public Health Policy and Management, College of Global Public Health, New York University, New York, New York (Dr Pomeranz); and Philip R. Lee Institute for Health Policy Studies, Department of Family and Community Medicine, University of California San Francisco, San Francisco, California (Dr Hamad)
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Faith MS, Cochran WC, Diewald L, Hoffer K, Moore R, Berkowitz RI, Hauer CA, Stettler-Davis N, Tripicchio G, Rukstalis MR. Group lifestyle modification vs. lifestyle newsletters for early childhood obesity: Pilot study in rural primary care. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.jbct.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Zou Y, Ma Y, Wu Z, Liu Y, Xu M, Qiu G, Vos H, Jia P, Wang L. Neighbourhood residential density and childhood obesity. Obes Rev 2021; 22 Suppl 1:e13037. [PMID: 32406192 PMCID: PMC7988655 DOI: 10.1111/obr.13037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 02/01/2023]
Abstract
Residential density is considered an important attribute of the built environment that may be relevant to childhood obesity. However, findings remain inconclusive, and there are no reviews yet on the association between residential density and childhood obesity. This study aimed to systematically review the associations between residential density and weight-related behaviours and outcomes. A comprehensive literature search was conducted using the Cochrane Library, PubMed and Web of Science for articles published before 1 January 2019. A total of 35 studies conducted in 14 countries were identified, including 33 cross-sectional studies, one longitudinal study and one containing both study designs. Residential density was measured by Geographic Information Systems in 28 studies within a varied radius from 0.25 to 2 km around the individual residence. Our study found a general positive association between residential density and physical activity (PA); no significant associations were observed. This study provided evidence for a supportive role of residential density in promoting PA among children. However, it remained difficult to draw a conclusion between residential density and childhood obesity. Future longitudinal studies are warranted to confirm this association.
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Affiliation(s)
- Yuxuan Zou
- School of Geographical Sciences, Guangzhou University, Guangzhou, China.,International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China
| | - Yanan Ma
- School of Public Health, China Medical University, Shenyang, China.,Institute of Health Sciences, China Medical University, Shenyang, China
| | - Zhifeng Wu
- School of Geographical Sciences, Guangzhou University, Guangzhou, China
| | - Yang Liu
- Institute of Health Sciences, China Medical University, Shenyang, China
| | - Min Xu
- International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China.,State Key Laboratory of Remote Sensing Science, Aerospace Information Research Institute, Chinese Academy of Sciences, Beijing, China
| | - Ge Qiu
- International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China.,West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Heleen Vos
- International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China.,Faculty of Geo-information Science and Earth Observation, University of Twente, Enschede, the Netherlands
| | - Peng Jia
- International Institute of Spatial Lifecourse Epidemiology (ISLE), Hong Kong, China.,Faculty of Geo-information Science and Earth Observation, University of Twente, Enschede, the Netherlands.,Department of Land Surveying and Geo-Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Limin Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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The impact of state policies for school-based BMI/fitness assessments on children's BMI outcomes in rural versus urban schools: Evidence from a natural experiment. Prev Med 2020; 141:106257. [PMID: 33031869 PMCID: PMC8880824 DOI: 10.1016/j.ypmed.2020.106257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/22/2022]
Abstract
Childhood obesity remains a public health crisis because of its alarming prevalence and potential for costly long-term health consequences, especially among rural children. Schools are considered natural loci for policies to combat obesity because children spend most of their active hours and consume a substantial share of their calories, at school. Recent state policy efforts have involved measuring children's BMI and/or fitness to notify parents or inform surveillance efforts, but the empirical evidence to date is far from definitive. This study leverages plausibly exogenous assignment of military families as a natural experiment to assess the association of such polices with children's BMI and obesogenic behaviors. The sample is stratified by urbanicity because of the likely differences in obesity prevalence and in environments necessary to support healthy lifestyles. Data were collected in 2013-2014 and analyzed in 2018-9. The policies were associated with lower odds of overweight (OR: 0.422; CI: 0.251-0.708) and at-risk of overweight (OR: 0.360; CI: 0.161-0.801) among children in rural, but not urban, schools. The policies were also associated with greater activity levels and less frequent intake of unhealthy foods, particularly among children attending rural schools. Results were robust to stratification based on urbanicity of the installation versus school, omission of family covariates, and other sensitivity analyses. Falsification checks on children's height, parental BMI outcomes, home food environments and neighborhood environments indicate findings are not driven by selection. BMI assessment policies were associated with children's BMI outcomes and health behaviors in rural, but not urban schools.
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Schaeffer AJ, Cartwright PC, Lau GA, Ebert MD, Fino NF, Nkoy FL, Hess R. Utilization of Radiographic Imaging for Infant Hydronephrosis over the First 12 Months of Life. Adv Urol 2020; 2020:2108362. [PMID: 32802050 PMCID: PMC7414334 DOI: 10.1155/2020/2108362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The workup and surveillance strategies for infant hydronephrosis (HN) vary, although this could be due to grade-dependent differences in imaging intensity. We aimed to describe the frequency of imaging studies for HN within the first year of life, stratified by initial HN grade, within a large regional healthcare system. Study Design and Data Source. Retrospective cohort using Intermountain Healthcare Data Warehouse. Inclusion criteria: (1) birth between 1/1/2005 and 12/31/2013, (2) CPT code for HN, and (3) ultrasound (U/S) confirmed HN within four months of birth. Data Collection. Grade of HN on initial postnatal U/S; number of HN-associated radiologic studies (renal U/Ss, voiding cystourethrograms (VCUGs), and diuretic renal scans); demographic and medical variables. Primary Outcome. Sum of radiologic studies within the first year of life or prior to pyeloplasty. Statistical Analysis. Multivariate poisson regression to analyze association between the primary outcome and the initial HN grade. RESULTS Of 1,380 subjects (993 males and 387 females), 990 (72%), 230 (17%), and 160 (12%) had mild, moderate, and severe HN, respectively. Compared with those with mild HN, patients with moderate (RR: 1.57; 95% CI: 1.42-1.73) and severe (RR: 2.09; 95% CI: 1.88-2.32) HN had a significantly higher rate of imaging use over 12 months (or prior to surgery) after controlling for potential confounders. CONCLUSIONS In a large regional healthcare system, imaging use for HN is proportional to its initial grade. This suggests that within our system, clinicians treating this condition are using a risk-stratified approach to imaging.
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Affiliation(s)
- Anthony J. Schaeffer
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Patrick C. Cartwright
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Glen A. Lau
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Mark D. Ebert
- Intermountain Pediatric Imaging SLC, UT/Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Nora F. Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rachel Hess
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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Kaiser ML, Hand MD, Pence EK. Individual and Community Engagement in Response to Environmental Challenges Experienced in Four Low-Income Urban Neighborhoods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061831. [PMID: 32178263 PMCID: PMC7142717 DOI: 10.3390/ijerph17061831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 11/16/2022]
Abstract
Low-income urban communities, and the individuals that live within them, continue to face disproportionate interconnected social, economic, and environmental challenges related to their built, natural, and social environments. The aim of our phenomenological research study was to elevate the experiences of residents living in low-income urban neighborhoods in terms of their communities' environmental challenges. Our objectives were to (1) identify challenges across neighborhoods, (2) identify ways individuals and communities are addressing those challenges, and (3) assess the individual and collective efficacy and engagement of communities to lead environmental improvements in neighborhoods. This study brings forward the voices that are often ignored or misunderstood in these communities and uses an ecological-social perspective. We conducted focus groups (N = 68) in four low-income urban neighborhoods across two Ohio cities in the United States. Participants described five key challenges in their communities: Pollution, abandoned buildings with associated crime, low food access and health concerns, trash and illegal dumping, and lack of trees. We assessed engagement and efficacy using two frameworks focused on individual and community readiness to engage in and lead community change. Policymakers should acknowledge the valuable contributions and leadership capacity of residents in low-income communities to implement environmental initiatives.
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9
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Davidson K, Vidgen H, Denney-Wilson E, Daniels L. How is children's weight status assessed for early identification of overweight and obesity? - Narrative review of programs for weight status assessment. J Child Health Care 2018; 22:486-500. [PMID: 29439599 DOI: 10.1177/1367493518759238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Assessment of a child's weight status is the first step in the management of childhood overweight and obesity. We reviewed routine assessment programs to inform early and routine identification of childhood overweight and obesity to address this global health issue. Twelve electronic databases were searched (Scopus, Web of Science, Wiley, ScienceDirect, PsycINFO, PsycARTICLES, PsycEXTRA, CINAHL, Primary Search, MEDLINE, ERIC, Academic Search Elite) for universal programs for weight status assessment of children aged 4-12 in Organization for Economic Co-operation and Development - countries, which included more than one assessment and parents receiving feedback. Of 1638 papers found via database searches, and 18 additional records identified through other sources, 26 were included. Reference to five countries' programs for weight status assessment was found in the results: Australia, Sweden, the Netherlands, the United Kingdom and the United States. All of these programs were implemented in a school setting. Lack of services, stakeholder collaboration, parental awareness and engagement and government funding need to be improved for this health check to be undertaken as a part of an ongoing program. This review is about the implementation of similar programs. Early identification of risk for overweight and obesity allows families that require help to connect with available health services.
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Affiliation(s)
- Kamila Davidson
- 1 School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Vidgen
- 1 School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Lynne Daniels
- 1 School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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Ogden CL, Fryar CD, Hales CM, Carroll MD, Aoki Y, Freedman DS. Differences in Obesity Prevalence by Demographics and Urbanization in US Children and Adolescents, 2013-2016. JAMA 2018; 319:2410-2418. [PMID: 29922826 PMCID: PMC6393914 DOI: 10.1001/jama.2018.5158] [Citation(s) in RCA: 324] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Differences in childhood obesity by demographics and urbanization have been reported. OBJECTIVE To present data on obesity and severe obesity among US youth by demographics and urbanization and to investigate trends by urbanization. DESIGN, SETTING, AND PARTICIPANTS Measured weight and height among youth aged 2 to 19 years in the 2001-2016 National Health and Nutrition Examination Surveys, which are serial, cross-sectional, nationally representative surveys of the civilian, noninstitutionalized population. EXPOSURES Sex, age, race and Hispanic origin, education of household head, and urbanization, as assessed by metropolitan statistical areas (MSAs; large: ≥ 1 million population). MAIN OUTCOMES AND MEASURES Prevalence of obesity (body mass index [BMI] ≥95th percentile of US Centers for Disease Control and Prevention [CDC] growth charts) and severe obesity (BMI ≥120% of 95th percentile) by subgroups in 2013-2016 and trends by urbanization between 2001-2004 and 2013-2016. RESULTS Complete data on weight, height, and urbanization were available for 6863 children and adolescents (mean age, 11 years; female, 49%). In 2013-2016, the prevalence among youth aged 2 to 19 years was 17.8% (95% CI, 16.1%-19.6%) for obesity and 5.8% (95% CI, 4.8%-6.9%) for severe obesity. Prevalence of obesity in large MSAs (17.1% [95% CI, 14.9%-19.5%]), medium or small MSAs (17.2% [95% CI, 14.5%-20.2%]) and non-MSAs (21.7% [95% CI, 16.1%-28.1%]) were not significantly different from each other (range of pairwise comparisons P = .09-.96). Severe obesity was significantly higher in non-MSAs (9.4% [95% CI, 5.7%-14.4%]) compared with large MSAs (5.1% [95% CI, 4.1%-6.2%]; P = .02). In adjusted analyses, obesity and severe obesity significantly increased with greater age and lower education of household head, and severe obesity increased with lower level of urbanization. Compared with non-Hispanic white youth, obesity and severe obesity prevalence were significantly higher among non-Hispanic black and Hispanic youth. Severe obesity, but not obesity, was significantly lower among non-Hispanic Asian youth than among non-Hispanic white youth. There were no significant linear or quadratic trends in obesity or severe obesity prevalence from 2001-2004 to 2013-2016 for any urbanization category (P range = .07-.83). CONCLUSIONS AND RELEVANCE In 2013-2016, there were differences in the prevalence of obesity and severe obesity by age, race and Hispanic origin, and household education, and severe obesity was inversely associated with urbanization. Demographics were not related to the urbanization findings.
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Affiliation(s)
- Cynthia L Ogden
- National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Cheryl D Fryar
- National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Craig M Hales
- National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, Maryland
- US Public Health Service, Rockville, Maryland
| | - Margaret D Carroll
- National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Yutaka Aoki
- National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - David S Freedman
- National Center for Chronic Disease Prevention and Health Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
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Shapiro M, Reid A, Olsen B, Taasan M, McNamara J, Nguyen M. Topiramate, zonisamide and weight loss in children and adolescents prescribed psychiatric medications: A medical record review. Int J Psychiatry Med 2017; 51:56-68. [PMID: 26681236 DOI: 10.1177/0091217415621266] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Childhood obesity is a growing epidemic that is contributed to by the use of psychopharmacological agents, such as antipsychotics. This study represents a preliminary investigation into the effectiveness of two anticonvulsants that were hypothesized to reduce weight in a pediatric sample seeking treatment at a psychiatric clinic. METHODS The electronic medical records of a university-based child and adolescent psychiatric clinic were reviewed for patients who were first prescribed either topiramate or zonisamide between 1 July 2011 and 30 June 2013. Based on inclusionary criteria, the review identified 47 children or adolescents. RESULTS Multilevel modeling was utilized for study analyses. Including the full sample and controlling for confounders, anticonvulsant dosage was uniquely associated with an average reduction in body mass index of 1.3 (dosages above 200 mg) to 4.1 (dosages below 50 mg) every six months of treatment. Exlucing patients whose baseline body mass index was below 25.0 and controlling for confounders, anticonvulsant dosage was uniquely associated with an average reduction in body mass index of 3.2 (dosages above 200 mg) to 6.1 (dosages below 50 mg) every six months of treatment. Weight reduction was not statistically different between topiramate or zonisamide. Anticonvulsants were associated with an increase in body mass index, yet the benefits of the two anticonvulsants on weight loss remained despite the counteractive effects of antipsychotics. CONCLUSIONS Results provide preliminary evidence that topiramate and zonisamide may be utilized for weight loss in a pediatric psychopharmacological treatment seeking sample, even if antipsychotics are also prescribed. A randomized controlled trial investigating the impact of topiramate and zonisamide on weight reduction is warranted.
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Affiliation(s)
- Michael Shapiro
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Adam Reid
- Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA Division of Clinical & Health Psychology, Department of Psychology, University of Florida, Gainesville, FL, USA
| | - Brian Olsen
- Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Michael Taasan
- Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Joseph McNamara
- Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Mathew Nguyen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Florida, Gainesville, FL, USA
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Construct Validity of an Obesity Risk Screening Tool in Two Age Groups. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14040419. [PMID: 28420116 PMCID: PMC5409620 DOI: 10.3390/ijerph14040419] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/04/2017] [Accepted: 04/09/2017] [Indexed: 11/17/2022]
Abstract
Home environment influences child health, but the impact varies as children move into adolescence. The Family Nutrition and Physical Activity (FNPA) screening tool has been used to evaluate home environments, but studies have not compared the utility of the tool in different age groups. The purpose of this study was to examine the efficacy of the FNPA tool in first and tenth grade samples. Parents of first grade (n = 250) and tenth grade (n = 99) students completed the FNPA and results were linked to body mass index (BMI) data. FNPA scores were examined by gender, income, race, and school-level socioeconomic status (SES). Correlations examined associations between FNPA scores and several BMI indicators. Logistic and linear regression analyses evaluated the construct validity of the FNPA in both groups. Mean FNPA score differed by age group, by SES in both age groups, and by race in the first grade sample only. Correlations between FNPA score and BMI indicators were higher in the first grade sample, but SES was significantly associated with BMI only in tenth graders. The FNPA has stronger utility in younger children, while school SES is a stronger predictor of adolescent weight status.
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Lilly CL, Umer A, Cottrell L, Pyles L, Neal W. Examination of cardiovascular risk factors and rurality in Appalachian children. Rural Remote Health 2017; 17:4200. [PMID: 28320207 DOI: 10.22605/rrh4200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTOIN The prevalence of childhood cardiovascular disease (CVD) risk factors often increases in more rural geographic regions in the USA. However, research on the topic often has conflicting results. Researchers note differences in definitions of rurality and other factors that would lead to differences in inference, including appropriate use of statistical clustering analysis, representative data, and inclusion of individual-level covariates. The present study's objective was to examine CVD risk factors during childhood by geographic distribution in the US Appalachian region as a first step towards understanding the health disparities in this area. METHODS Rurality and CVD risk factors (including blood pressure, body-mass index (BMI), and cholesterol) were examined in a large, representative sample of fifth-grade students (<i>N=</i>73 014) from an Appalachian state in the USA. A six-category Rural-Urban Continuum Codes classification system was used to define rurality regions. Mixed modeling analysis was used to appropriately cluster individuals within 725 unique zip codes in each of these six regions, and allowed for including several individual-level socioeconomic factors as covariates. RESULTS Rural areas had better outcomes for certain CVD risk factors (lowest low-density lipoprotein cholesterol (LDL-C), and blood pressure (BP) and highest high-density lipoprotein cholesterol (HDL-C)) whereas mid-sized metro and town areas presented with the worst CVD risk factors (highest BMI% above ideal, mean diastolic BP, LDL-C, total cholesterol, triglyceride levels and lowest HDL-C) outcomes in children and adolescence in this Appalachian state. CONCLUSIONS Counter to the study hypothesis, mid-sized metro areas presented with the worst CVD risk factors outcomes in children and adolescence in the Appalachian state. This data contradicts previous literature suggesting a straightforward link between rurality and cardiovascular risk factors. Future research should include a longitudinal design and explore some of the mechanisms between cardiovascular risk factors and rurality.
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Affiliation(s)
| | - Amna Umer
- West Virginia University, Morgantown, West Virginia, USA.
| | | | - Lee Pyles
- West Virginia University, Morgantown, West Virginia, USA.
| | - William Neal
- West Virginia University, Morgantown, West Virginia, USA.
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Peyer K, Welk GJ, Bailey-Davis L, Chen S. Relationships between County Health Rankings and child overweight and obesity prevalence: a serial cross-sectional analysis. BMC Public Health 2016; 16:404. [PMID: 27180170 PMCID: PMC4894376 DOI: 10.1186/s12889-016-3091-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/11/2016] [Indexed: 11/23/2022] Open
Abstract
Background The County Health Rankings (CHR) system provides health rankings for U.S. counties. These factors may have utility for evaluating and predicting health outcomes. This study examined the association between CHR factors and the prevalence of child overweight/obesity (OWOB) in the state of Pennsylvania over 3 years. Methods The prevalence of childhood OWOB was obtained for all Pennsylvania school districts for the 2009-10 through 2011-12 school years. Correlational and inferential statistical analyses were used to examine the associations between the prevalence of OWOB in grades K-6 (OWOB1) and 7-12 (OWOB2) and z-score for the overall CHR Health Factors rank, as well as for individual predictive factors (Health Behaviors, Clinical Care, Social and Economic Factors and Physical Environment). Results Low to moderate correlations (0.29–0.43) were found between OWOB1 and CHR factors. Weaker and less consistent correlations were found for adolescents. There was a significantly higher prevalence of OWOB in counties with poorer CHR scores. Conclusions County-level adult indicators of health are significantly associated with levels of child obesity. Future studies should examine the relationship between CHR and other health outcomes.
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Affiliation(s)
- Karissa Peyer
- Iowa State University, 283 Forker Building, Ames, IA, 50011, USA.
| | - Greg J Welk
- Iowa State University, 283 Forker Building, Ames, IA, 50011, USA
| | - Lisa Bailey-Davis
- Geisinger Health System, 100 N. Academy Ave., MC 44-00, Danville, PA, 17822, USA
| | - Senlin Chen
- Iowa State University, 283 Forker Building, Ames, IA, 50011, USA
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15
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Moreno-Black G, Stockard J. Two Worlds of Obesity: Ethnic Differences in Child Overweight/Obesity Prevalence and Trajectories. J Racial Ethn Health Disparities 2015; 3:331-9. [PMID: 27271074 DOI: 10.1007/s40615-015-0150-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 06/17/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Research on childhood obesity has examined the prevalence of overweight and obesity during childhood and developmental trajectories. This study focuses on the extent to which Hispanic and non-Hispanic white elementary students differ in prevalence of overweight and obesity by grade level, time, gender, and school setting. It also focuses on comparison of the trajectories in weight status for the Hispanic and non-Hispanic white students. METHODS BMI values were examined both using standard scores (z-scores) and as categorical variables. Cross-sectional data from 4 years were used to examine prevalence, and panel data across 2-year periods examined trajectories. Descriptive statistics and mixed models, controlling for school setting, were used. RESULTS Hispanic students began first grade with higher prevalence of obesity and overweight, and the differences were larger in higher grades and later years. The majority of students had stable weight status over the 2-year periods of the trajectory analysis, but Hispanic students began the panel with higher BMI-Z values and were more likely to increase and less likely to decrease BMI-Z. CONCLUSIONS The findings suggest that the degree of childhood overweight/obesity, especially among Hispanics, is substantial and will likely have profound impacts on adult obesity and other associated health issues in the future. Findings confirm the need for early childhood interventions to influence BMI.
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Affiliation(s)
| | - Jean Stockard
- Department of Planning, Public Policy and Management, University of Oregon, Eugene, Oregon, USA
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16
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Early detection for cases of enterovirus- and influenza-like illness through a newly established school-based syndromic surveillance system in Taipei, January 2010 ~ August 2011. PLoS One 2015; 10:e0122865. [PMID: 25875080 PMCID: PMC4398411 DOI: 10.1371/journal.pone.0122865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 02/16/2015] [Indexed: 11/19/2022] Open
Abstract
School children may transmit pathogens with cluster cases occurring on campuses and in families. In response to the 2009 influenza A (H1N1) pandemic, Taipei City Government officials developed a School-based Infectious Disease Syndromic Surveillance System (SID-SSS). Teachers and nurses from preschools to universities in all 12 districts within Taipei are required to daily report cases of symptomatic children or sick leave requests through the SID-SSS. The pre-diagnosis at schools is submitted firstly as common pediatric disease syndrome-groups and re-submitted after confirmation by physicians. We retrieved these data from January 2010 to August 2011 for spatio-temporal analysis and evaluated the temporal trends with cases obtained from both the Emergency Department-based Syndromic Surveillance System (ED-SSS) and the Longitudinal Health Insurance Database 2005 (LHID2005). Through the SID-SSS, enterovirus-like illness (EVI) and influenza-like illness (ILI) were the two most reported syndrome groups (77.6% and 15.8% among a total of 19,334 cases, respectively). The pre-diagnosis judgments made by school teachers and nurses showed high consistency with physicians' clinical diagnoses for EVI (97.8%) and ILI (98.9%). Most importantly, the SID-SSS had better timeliness with earlier peaks of EVI and ILI than those in the ED-SSS. Furthermore, both of the syndrome groups in these two surveillance systems had the best correlation reaching 0.98 and 0.95, respectively (p<0.01). Spatio-temporal analysis observed the patterns of EVI and ILI both diffuse from the northern suburban districts to central Taipei, with ILI spreading faster. This novel system can identify early suspected cases of two important pediatric infections occurring at schools, and clusters from schools/families. It was also cost-effective (95.5% of the operation cost reduced and 59.7% processing time saved). The timely surveillance of mild EVI and ILI cases integrated with spatial analysis may help public health decision-makers with where to target for enhancing surveillance and prevention measures to minimize severe cases.
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Looney SM, Raynor HA. Examining the effect of three low-intensity pediatric obesity interventions: a pilot randomized controlled trial. Clin Pediatr (Phila) 2014; 53:1367-74. [PMID: 25006118 DOI: 10.1177/0009922814541803] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Primary care is an ideal setting to treat pediatric obesity. Effective, low-intensity (≤25 contact hours over 6 months) interventions that reduce standardized body mass index (z-BMI) and can be delivered by primary care providers are needed. OBJECTIVE This pilot randomized controlled trial investigated the effect of 3 low-intensity (≤25 contact hours over 6 months) pediatric obesity treatments on z-BMI. METHODS Twenty-two families (children 8.0 ± 1.8 years, z-BMI of 2.34 ± 0.48) were randomized into 1 of 3, 6-month, low-intensity conditions: newsletter (N), newsletter and growth monitoring (N + GM), or newsletter and growth monitoring plus family-based behavioral counseling (N + GM + BC). Anthropometrics and child eating and leisure-time behaviors were measured. RESULTS Mixed-factor analyses of variance found a significant (P < .05) main effect of time for z-BMI and servings per day of sugar sweetened beverages, with both decreasing over time. CONCLUSION Low-intensity obesity treatments can reduce z-BMI and may be more feasible in primary care.
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Affiliation(s)
- Shannon M Looney
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA University of Tennessee, Knoxville, TN, USA
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18
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Pudrovska T, Reither EN, Logan ES, Sherman-Wilkins KJ. Gender and reinforcing associations between socioeconomic disadvantage and body mass over the life course. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2014; 55:283-301. [PMID: 25138198 PMCID: PMC4198174 DOI: 10.1177/0022146514544525] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Using the 1957-1993 data from the Wisconsin Longitudinal Study, we explore reciprocal associations between socioeconomic status (SES) and body mass in the 1939 birth cohort of non-Hispanic white men and women. We integrate the fundamental cause theory, the gender relations theory, and the life course perspective to analyze gender differences in (a) the ways that early socioeconomic disadvantage launches bidirectional associations of body mass and SES and (b) the extent to which these mutually reinforcing effects generate socioeconomic disparities in midlife body mass. Using structural equation modeling, we find that socioeconomic disadvantage at age 18 is related to higher body mass index and a greater risk of obesity at age 54, and that this relationship is significantly stronger for women than men. Moreover, women are more adversely affected by two mechanisms underlying the focal association: the obesogenic effect of socioeconomic disadvantage and the SES-impeding effect of obesity. These patterns were also replicated in propensity score-matching models. We conclude that gender and SES act synergistically over the life course to shape reciprocal chains of two disadvantaged statuses: heavier body mass and lower SES.
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Affiliation(s)
| | | | - Ellis S Logan
- Pennsylvania State University, University Park, PA, USA
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19
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Helton JJ, Liechty JM. Obesity prevalence among youth investigated for maltreatment in the United States. CHILD ABUSE & NEGLECT 2014; 38:768-775. [PMID: 24035366 DOI: 10.1016/j.chiabu.2013.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 06/02/2023]
Abstract
The objective of this study is to determine the prevalence and correlates of obesity among youth investigated for maltreatment in the United States. Participants were drawn from the National Survey of Child and Adolescent Well-Being II, a national probability study of 5,873 children aged birth to 17 years under investigation for maltreatment in 2008. From child weight reported by caregivers, we estimated obesity (weight-for-age ≥95th percentile) prevalence among children aged 2 through 17 (n=2,948). Sex-specific logistic regression models by developmental age were used to identify obesity risk factors, including child age, race/ethnicity, and maltreatment type. Obesity prevalence was 25.4% and was higher among boys than girls (30.0% vs. 20.8%). African American adolescent boys had a lower risk for obesity than white boys (OR=0.28, 95% CI [0.08, 0.94]). Compared with girls aged 2-5 with a neglect allegation, girls with a sexual abuse allegation were at greater risk for obesity (OR=3.54, 95% CI [1.01, 12.41]). Compared with adolescent boys with a neglect allegation, boys with a physical abuse allegation had a lower risk for obesity (OR=0.24, 95% CI [0.06, 0.99]). Adolescent girls with a prior family history of investigation were at greater risk for obesity than those without a history of investigation (OR=3.97, 95% CI [1.58, 10.02]). Youth investigated for maltreatment have high obesity rates compared with national peers. Opportunities to modify and evaluate related child welfare policies and health care practices should be pursued.
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Affiliation(s)
- Jesse J Helton
- School of Social Work and Children and Family Research Center, University of Illinois, Urbana, IL, USA
| | - Janet M Liechty
- School of Social Work and College of Medicine, University of Illinois, Urbana, IL, USA
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Schwartz BS, Bailey-Davis L, Bandeen-Roche K, Pollak J, Hirsch AG, Nau C, Liu AY, Glass TA. Attention deficit disorder, stimulant use, and childhood body mass index trajectory. Pediatrics 2014; 133:668-76. [PMID: 24639278 PMCID: PMC3966507 DOI: 10.1542/peds.2013-3427] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Childhood attention-deficit/hyperactivity disorder (ADHD) has been associated with childhood and adult obesity, and stimulant use with delayed childhood growth, but the independent influences are unclear. No longitudinal studies have examined associations of ADHD diagnosis and stimulant use on BMI trajectories throughout childhood and adolescence. METHODS We used longitudinal electronic health record data from the Geisinger Health System on 163,820 children ages 3 to 18 years in Pennsylvania. Random effects linear regression models were used to model BMI trajectories with increasing age in relation to ADHD diagnosis, age at first stimulant use, and stimulant use duration, while controlling for confounding variables. RESULTS Mean (SD) age at first BMI was 8.9 (5.0) years, and children provided a mean (SD) of 3.2 (2.4) annual BMI measurements. On average, BMI trajectories showed a curvilinear relation with age. There were consistent associations of unmedicated ADHD with higher BMIs during childhood compared with those without ADHD or stimulants. Younger age at first stimulant use and longer duration of stimulant use were each associated with slower BMI growth earlier in childhood but a more rapid rebound to higher BMIs in late adolescence. CONCLUSIONS The study provides the first longitudinal evidence that ADHD during childhood not treated with stimulants was associated with higher childhood BMIs. In contrast, ADHD treated with stimulants was associated with slower early BMI growth but a rebound later in adolescence to levels above children without a history of ADHD or stimulant use. The findings have important clinical and neurobiological implications.
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Affiliation(s)
- Brian S. Schwartz
- Departments of Environmental Health Sciences,,Epidemiology,,Center for Health Research, Geisinger Health System, Danville, Pennsylvania
| | - Lisa Bailey-Davis
- Center for Health Research, Geisinger Health System, Danville, Pennsylvania
| | | | | | | | - Claudia Nau
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and
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Ramos MM, Fullerton L, Sapien R, Greenberg C, Bauer-Creegan J. Rural-urban disparities in school nursing: implications for continuing education and rural school health. J Rural Health 2014; 30:265-74. [PMID: 24612383 DOI: 10.1111/jrh.12058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexico's rural school nurse workforce. METHODS We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). FINDINGS Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. CONCLUSIONS Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health.
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Affiliation(s)
- Mary M Ramos
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico
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Parsons WG, Garcia GM, Hoffman PK. Evaluating school wellness policy in curbing childhood obesity in Anchorage, Alaska. J Sch Nurs 2013; 30:324-31. [PMID: 24316497 DOI: 10.1177/1059840513513155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In 2006, the Anchorage School District implemented a school wellness policy to address the problem of obesity among its elementary-aged students. We assessed whether the addition of this policy is effective in protecting or preventing students from becoming overweight/obese over time. The methods involved following two cohorts of students for 5 years, a cohort not exposed and a cohort exposed to the policy. The results show that exposure to the policy does not significantly protect or prevent students from becoming overweight/obese. However, we found that regardless of being exposed to the policy, boys (odds ratio [OR] = 1.12), ethnic minorities, (OR = 1.18), and students from low socioeconomic backgrounds (OR = 1.44) were more likely to remain or become overweight/obese. Our findings suggest that factors outside the school may be impacting students' overweight/obese status. Efforts to curb the problem of childhood obesity should extend to the children's communities and homes.
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Affiliation(s)
| | - Gabriel M Garcia
- Department of Health Sciences, University of Alaska Anchorage, Anchorage, AK, USA
| | - Pamela K Hoffman
- Department of Family Medicine & Community Health University of Minnesota, University of Minnesota, Minneapolis, MN, USA
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