Preeclampsia Onset, Days to Delivery, and Autism Spectrum Disorders in Offspring: Clinical Birth Cohort Study

BACKGROUND

Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring.

OBJECTIVE

This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery.

METHODS

This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery.

RESULTS

Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset.

CONCLUSIONS

Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

Maternal obesity and diabetes during pregnancy and early autism screening score at well-child visits in standard clinical practice

LAY ABSTRACT

Early intervention and treatment can help reduce disability in children diagnosed with autism spectrum disorder. Screening for autism spectrum disorder in young children identifies those at increased likelihood of diagnosis who may need further support. Previous research has reported that exposure to maternal obesity and diabetes during pregnancy is associated with higher likelihood of autism spectrum disorder diagnosis in children. However, little is known about whether these maternal conditions are associated with how very young children score on autism spectrum disorder screening tools. This study examined associations between exposure to maternal obesity and diabetes during pregnancy and offspring scores on the Quantitative Checklist for Autism in Toddlers, an autism spectrum disorder screening questionnaire administered between 18-24 months at well-child visits. A higher score on the Quantitative Checklist for Autism in Toddlers suggests a higher likelihood of autism spectrum disorder; children with scores 3 or greater are referred to developmental pediatricians for evaluation. Our study found that children of mothers with obesity or diabetes during pregnancy had higher scores than children whose mothers did not have these conditions. Associations with maternal obesity and gestational diabetes diagnosed at or before 26 weeks of pregnancy were also present in children who did not have later autism spectrum disorder diagnoses, suggesting that exposure to these conditions during early pregnancy may be associated with a broad range of social and behavioral abilities. Identifying associations between maternal health conditions and early Quantitative Checklist for Autism in Toddlers screening scores could influence future screening and provision of support for children of mothers with these conditions.

Neighborhood Disadvantage and Autism Spectrum Disorder in a Population With Health Insurance

Importance

Family socioeconomic status has been associated with autism spectrum disorder (ASD) diagnoses. Less is known regarding the role of neighborhood disadvantage in the United States, particularly when children have similar access to health insurance.

Objective

To evaluate the association between neighborhood disadvantage and the diagnosis of ASD and potential effect modification by maternal and child demographic characteristics.

Design, Setting, and Participants

This cohort study examined a retrospective birth cohort from Kaiser Permanente Southern California (KPSC), an integrated health care system. Children born in 2001 to 2014 at KPSC were followed up through KPSC membership records. Electronic medical records were used to obtain an ASD diagnosis up to December 31, 2019, or the last follow-up. Data were analyzed from February 2022 to September 2023.

Exposure

Socioeconomic disadvantage at the neighborhood level, an index derived from 7 US census tract characteristics using principal component analysis.

Main Outcomes and Measures

Clinical ASD diagnosis based on electronic medical records. Associations between neighborhood disadvantage and ASD diagnosis were determined by hazard ratios (HRs) from Cox regression models adjusted for birth year, child sex, maternal age at delivery, parity, severe prepregnancy health conditions, maternal race and ethnicity, and maternal education. Effect modification by maternal race and ethnicity, maternal education, and child sex was assessed.

Results

Among 318 372 mothers with singleton deliveries during the study period, 6357 children had ASD diagnoses during follow-up; their median age at diagnosis was 3.53 years (IQR, 2.57-5.34 years). Neighborhood disadvantage was associated with a higher likelihood of ASD diagnosis (HR, 1.07; 95% CI, 1.02-1.11, per IQR = 2.70 increase). Children of mothers from minoritized racial and ethnic groups (African American or Black, Asian or Pacific Islander, Hispanic or Latinx groups) had increased likelihood of ASD diagnosis compared with children of White mothers. There was an interaction between maternal race and ethnicity and neighborhood disadvantage (difference in log-likelihood = 21.88; P < .001 for interaction under χ24); neighborhood disadvantage was only associated with ASD among children of White mothers (HR, 1.17; 95% CI, 1.09-1.26, per IQR = 2.00 increase). Maternal education and child sex did not significantly modify the neighborhood-ASD association.

Conclusions and Relevance

In this study, children residing in more disadvantaged neighborhoods at birth had higher likelihood of ASD diagnosis among a population with health insurance. Future research is warranted to investigate the mechanisms behind the neighborhood-related disparities in ASD diagnosis, alongside efforts to provide resources for early intervention and family support in communities with a higher likelihood of ASD.

Types of diabetes during pregnancy and risk of depression and anxiety in offspring from childhood to young adulthood

AIMS

To assess maternal pre-existing type 1 diabetes (T1D), type 2 diabetes (T2D), gestational diabetes mellitus (GDM) during pregnancy and risk of depression and anxiety from childhood to young adulthood in offspring.

MATERIALS AND METHODS

This birth cohort included singletons born during 1995-2015, followed using electronic medical records through 2020. Cox regression was used to estimate hazard ratio (HR) of depression or anxiety diagnosis during follow-up associated with in-utero exposure to maternal diabetes.

RESULTS

Among 439 590 offspring, 29 891 (6.8%) had depression and 51 918 (11.8%) had anxiety. T1D, followed by T2D and GDM requiring antidiabetes medication were associated with risk of depression and anxiety in offspring. Compared with no diabetes during pregnancy, the adjusted HRs (95% confidence interval) of depression in offspring associated with T1D, T2D or GDM requiring medications were 1.44 (1.09-1.91), 1.30 (1.15-1.47) and 1.18 (1.11-1.26) respectively; conversely, HRs were 0.97 (0.82-1.15) for T2D and 0.99 (0.94-1.04) for GDM without medications. The associations with anxiety followed similar patterns. The significant associations were observed for offspring ages 5-12 and >12-18 years and attenuated for 18-25 years.

CONCLUSION

These data suggest that the severity of diabetes (T1D vs. T2D requiring medications vs. GDM requiring medications) during pregnancy may increase the vulnerability of offspring for depression or anxiety.

Prenatal air pollution, maternal immune activation, and autism spectrum disorder

BACKGROUND

Autism Spectrum Disorder (ASD) risk is highly heritable, with potential additional non-genetic factors, such as prenatal exposure to ambient particulate matter with aerodynamic diameter < 2.5 µm (PM2.5) and maternal immune activation (MIA) conditions. Because these exposures may share common biological effect pathways, we hypothesized that synergistic associations of prenatal air pollution and MIA-related conditions would increase ASD risk in children.

OBJECTIVES

This study examined interactions between MIA-related conditions and prenatal PM2.5 or major PM2.5 components on ASD risk.

METHODS

In a population-based pregnancy cohort of children born between 2001 and 2014 in Southern California, 318,751 mother-child pairs were followed through electronic medical records (EMR); 4,559 children were diagnosed with ASD before age 5. Four broad categories of MIA-related conditions were classified, including infection, hypertension, maternal asthma, and autoimmune conditions. Average exposures to PM2.5 and four PM2.5 components, black carbon (BC), organic matter (OM), nitrate (NO3-), and sulfate (SO42-), were estimated at maternal residential addresses during pregnancy. We estimated the ASD risk associated with MIA-related conditions, air pollution, and their interactions, using Cox regression models to adjust for covariates.

RESULTS

ASD risk was associated with MIA-related conditions [infection (hazard ratio 1.11; 95% confidence interval 1.05-1.18), hypertension (1.30; 1.19-1.42), maternal asthma (1.22; 1.08-1.38), autoimmune disease (1.19; 1.09-1.30)], with higher pregnancy PM2.5 [1.07; 1.03-1.12 per interquartile (3.73 μg/m3) increase] and with all four PM2.5 components. However, there were no interactions of each category of MIA-related conditions with PM2.5 or its components on either multiplicative or additive scales.

CONCLUSIONS

MIA-related conditions and pregnancy PM2.5 were independently associations with ASD risk. There were no statistically significant interactions of MIA conditions and prenatal PM2.5 exposure with ASD risk.

Maternal exposure to aircraft emitted ultrafine particles during pregnancy and likelihood of ASD in children

BACKGROUND

There is increasing evidence for adverse health effects associated with aircraft-emitted particulate matter (PM) exposures, which are largely in the ultrafine (PM0.1) size fraction, but no previous study has examined neurodevelopmental outcomes.

OBJECTIVE

To assess associations between maternal exposure to aircraft ultrafine particles (UFP) during pregnancy and offspring autism spectrum disorder (ASD) diagnosis.

METHODS

This large, representative cohort study included 370,723 singletons born in a single healthcare system. Demographic data, maternal health information, and child's ASD diagnosis by age 5 were extracted from electronic medical records. Aircraft exposure estimates for PM0.1 were generated by the University of California Davis/California Institute of Technology Source Oriented Chemical Transport model. Cox proportional hazard models were used to assess associations between maternal exposure to aircraft PM0·1 in pregnancy and ASD diagnosis, controlling for covariates.

RESULTS

Over the course of follow-up, 4,554 children (1.4 %) were diagnosed with ASD. Increased risk of ASD was associated with maternal exposure to aircraft PM0.1 [hazard ratio, HR: 1.02, (95 % confidence interval (CI): 1.01-1.03) per IQR = 0.02 µg/m3 increase during pregnancy. Associations were robust to adjustment for total PM0.1 and fine particulate matter (PM2.5), near-roadway air pollution, and other covariates. Noise adjustment modestly attenuated estimates of UFP effects, which remained statistically significant.

DISCUSSION

The results strengthen the emerging evidence that maternal particulate matter exposure during pregnancy is associated with offspring ASD diagnosis and identify aircraft-derived PM0.1 as novel targets for further study and potential regulation.

Associations of Autism Spectrum Disorder with PM2.5 Components: A Comparative Study Using Two Different Exposure Models

This retrospective cohort study examined associations of autism spectrum disorder (ASD) with prenatal exposure to major fine particulate matter (PM2.5) components estimated using two independent exposure models. The cohort included 318 750 mother-child pairs with singleton deliveries in Kaiser Permanente Southern California hospitals from 2001 to 2014 and followed until age five. ASD cases during follow-up (N = 4559) were identified by ICD codes. Prenatal exposures to PM2.5, elemental (EC) and black carbon (BC), organic matter (OM), nitrate (NO3-), and sulfate (SO42-) were constructed using (i) a source-oriented chemical transport model and (ii) a hybrid model. Exposures were assigned to each maternal address during the entire pregnancy, first, second, and third trimester. In single-pollutant models, ASD was associated with pregnancy-average PM2.5, EC/BC, OM, and SO42- exposures from both exposure models, after adjustment for covariates. The direction of effect estimates was consistent for EC/BC and OM and least consistent for NO3-. EC/BC, OM, and SO42- were generally robust to adjustment for other components and for PM2.5. EC/BC and OM effect estimates were generally larger and more consistent in the first and second trimester and SO42- in the third trimester. Future PM2.5 composition health effect studies might consider using multiple exposure models and a weight of evidence approach when interpreting effect estimates.

Prenatal exposure to tailpipe and non-tailpipe tracers of particulate matter pollution and autism spectrum disorders

BACKGROUND

Traffic-related air pollution exposure is associated with increased risk of autism spectrum disorder (ASD). It is unknown whether carbonaceous material from vehicular tailpipe emissions or redox-active non-tailpipe metals, eg. from tire and brake wear, are responsible. We assessed ASD associations with fine particulate matter (PM_2.5) tracers of tailpipe (elemental carbon [EC] and organic carbon [OC]) and non-tailpipe (copper [Cu]; iron [Fe] and manganese [Mn]) sources during pregnancy in a large cohort.

METHODS

This retrospective cohort study included 318,750 children born in Kaiser Permanente Southern California (KPSC) hospitals during 2001-2014, followed until age 5. ASD cases were identified by ICD codes. Monthly estimates of PM_2.5 and PM_2.5 constituents EC, OC, Cu, Fe, and Mn with 4 km spatial resolution were obtained from a source-oriented chemical transport model. These exposures and NO₂ were assigned to each maternal address during pregnancy, and associations with ASD were assessed using Cox regression models adjusted for covariates. PM constituent effect estimates were adjusted for PM_2.5 and NO₂ to assess independent effects. To distinguish ASD risk associated with non-tailpipe from tailpipe sources, the associations with Cu, Fe, and Mn were adjusted for EC and OC, and vice versa.

RESULTS

There were 4559 children diagnosed with ASD. In single-pollutant models, increased ASD risk was associated with gestational exposures to tracers of both tailpipe and non-tailpipe emissions. The ASD hazard ratios (HRs) per inter-quartile increment of exposure) for EC, OC, Cu, Fe, and Mn were 1.11 (95% CI: 1.06-1.16), 1.09 (95% CI: 1.04-1.15), 1.09 (95% CI: 1.04-1.13), 1.14 (95% CI: 1.09-1.20), and 1.17 (95% CI: 1.12-1.22), respectively. Estimated effects of Cu, Fe, and Mn (reflecting non-tailpipe sources) were largely unchanged in two-pollutant models adjusting for PM_2.5, NO₂, EC or OC. In contrast, ASD associations with EC and OC were markedly attenuated by adjustment for non-tailpipe sources.

CONCLUSION

Results suggest that non-tailpipe emissions may contribute to ASD. Implications are that reducing tailpipe emissions, especially from vehicles with internal combustion engines, may not eliminate ASD associations with traffic-related air pollution.

Maternal obesity, diabetes, preeclampsia, and asthma during pregnancy and likelihood of autism spectrum disorder with gastrointestinal disturbances in offspring

LAY ABSTRACT

Autism spectrum disorder is heterogeneous and often accompanied by co-occurring conditions. Previous studies have shown that maternal health conditions during pregnancy including obesity, diabetes, preeclampsia, and asthma were associated with increased likelihood of autism. However, little has been done examining the likelihood associated with autism with co-occurring conditions. This study assessed these maternal health conditions in relationship to autism and gastrointestinal disturbances, a common co-occurring condition in children diagnosed with autism. Data included 308,536 mother-child pairs from one integrated health care system with comprehensive electronic medical records. Among the study cohort, 5,131 (1.7%) children had a diagnosis of autism by age 5. Gastrointestinal disturbances were present in 35.4% of children diagnosed with autism and 25.1% of children without autism diagnoses. Our results showed that each of the four maternal health conditions during pregnancy was associated with increased likelihood of gastrointestinal disturbances, autism without gastrointestinal disturbances, and autism with gastrointestinal disturbances. For all four maternal health conditions, the association was greatest for likelihood of autism with gastrointestinal disturbances. Given that children diagnosed with autism are more likely to have gastrointestinal disturbances and over 80% of gastrointestinal disturbances in this cohort were diagnosed prior to autism diagnosis, this study suggests that there may be common biological pathways between autism and gastrointestinal disturbances impacted by these maternal exposures. Future studies are warranted to assess associations between different exposures and autism with other co-occurring conditions to increase our understanding of autism heterogeneity.

Ambient Air Pollutant Exposures and COVID-19 Severity and Mortality in a Cohort of Patients with COVID-19 in Southern California

Rationale: Ecological studies have shown air pollution associations with coronavirus disease (COVID-19) outcomes. However, few cohort studies have been conducted. Objectives: To conduct a cohort study investigating the association between air pollution and COVID-19 severity using individual-level data from the electronic medical record. Methods: This cohort included all individuals who received diagnoses of COVID-19 from Kaiser Permanente Southern California between March 1 and August 31, 2020. One-year and 1-month averaged ambient air pollutant (particulate matter ⩽2.5 μm in aerodynamic diameter [PM_2.5], NO₂, and O₃) exposures before COVID-19 diagnosis were estimated on the basis of residential address history. Outcomes included COVID-19-related hospitalizations, intensive respiratory support (IRS), and ICU admissions within 30 days and mortality within 60 days after COVID-19 diagnosis. Covariates included socioeconomic characteristics and comorbidities. Measurements and Main Results: Among 74,915 individuals (mean age, 42.5 years; 54% women; 66% Hispanic), rates of hospitalization, IRS, ICU admission, and mortality were 6.3%, 2.4%, 1.5%, and 1.5%, respectively. Using multipollutant models adjusted for covariates, 1-year PM_2.5 and 1-month NO₂ average exposures were associated with COVID-19 severity. The odds ratios associated with a 1-SD increase in 1-year PM_2.5 (SD, 1.5 μg/m³) were 1.24 (95% confidence interval [CI], 1.16-1.32) for COVID-19-related hospitalization, 1.33 (95% CI, 1.20-1.47) for IRS, and 1.32 (95% CI, 1.16-1.51) for ICU admission; the corresponding odds ratios associated with 1-month NO₂ (SD, 3.3 ppb) were 1.12 (95% CI, 1.06-1.17) for hospitalization, 1.18 (95% CI, 1.10-1.27) for IRS, and 1.21 (95% CI, 1.11-1.33) for ICU admission. The hazard ratios for mortality were 1.14 (95% CI, 1.02-1.27) for 1-year PM_2.5 and 1.07 (95% CI, 0.98-1.16) for 1-month NO₂. No significant interactions with age, sex or ethnicity were observed. Conclusions: Ambient PM_2.5 and NO₂ exposures may affect COVID-19 severity and mortality.

Ambient air pollution and COVID-19 incidence during four 2020-2021 case surges

BACKGROUND

Air pollution exposure may make people more vulnerable to COVID-19 infection. However, previous studies in this area mostly focused on infection before May 2020 and long-term exposure.

OBJECTIVE

To assess both long-term and short-term exposure to air pollution and COVID-19 incidence across four case surges from 03/1/2020 to 02/28/2021.

METHODS

The cohort included 4.6 million members from a large integrated health care system in southern California with comprehensive electronic medical records (EMR). COVID-19 cases were identified from EMR. Incidence of COVID-19 was computed at the census tract-level among members. Prior 1-month and 1-year averaged air pollutant levels (PM_2.5, NO₂, and O₃) at the census tract-level were estimated based on hourly and daily air quality data. Data analyses were conducted by each wave: 3/1/2020-5/31/2020, 6/1/202-9/30/2020, 10/1/2020-12/31/2020, and 1/1/2021-2/28/2021 and pooled across waves using meta-analysis. Generalized linear mixed effects models with Poisson distribution and spatial autocorrelation were used with adjustment for meteorological factors and census tract-level social and health characteristics. Results were expressed as relative risk (RR) per 1 standard deviation.

RESULTS

The cohort included 446,440 COVID-19 cases covering 4609 census tracts. The pooled RRs (95% CI) of COVID-19 incidence associated with 1-year exposures to PM_2.5, NO₂, and O₃ were 1.11 (1.04, 1.18) per 2.3 μg/m³,1.09 (1.02, 1.17) per 3.2 ppb, and 1.06 (1.00, 1.12) per 5.5 ppb respectively. The corresponding RRs (95% CI) associated with prior 1-month exposures were 1.11 (1.03, 1.20) per 5.2 μg/m³ for PM_2.5, 1.09 (1.01, 1.17) per 6.0 ppb for NO₂ and 0.96 (0.85, 1.08) per 12.0 ppb for O₃.

CONCLUSION

Long-term PM_2.5 and NO₂ exposures were associated with increased risk of COVID-19 incidence across all case surges before February 2021. Short-term PM_2.5 and NO₂ exposures were also associated. Our findings suggest that air pollution may play a role in increasing the risk of COVID-19 infection.

Human Serum Albumin Cys34 Adducts in Newborn Dried Blood Spots: Associations With Air Pollution Exposure During Pregnancy

Background: Increasing evidence suggests that exposure to air pollution during pregnancy is associated with adverse pregnancy outcomes. However, biomarkers associated with air pollution exposure are widely lacking and often transient. In addition, ascertaining biospecimens during pregnacy to assess the prenatal environment remains largely infeasible.

Objectives: To address these challenges, we investigated relationships between air pollution exposure during pregnancy and human serum albumin Cys³⁴ (HSA-Cys³⁴) adducts in newborn dried blood spots (DBS) samples, which captures an integration of perinatal exposures to small reactive molecules in circulating blood.

Methods: Newborn DBS were obtained from a state archive for a cohort of 120 children born at one Kaiser Permanente Southern California (KPSC) hospitals in 2007. These children were selected to maximize the range of residential air pollution exposure during the entire pregnancy to PM_2.5, PM₁₀, NO₂, O₃, based on monthly estimates interpolated from regulatory monitoring sites. HSA-Cys³⁴ adducts were selected based on previously reported relationships with air pollution exposure and oxidative stress.

Results: Six adducts measured in newborn DBS samples were associated with air pollution exposures during pregnancy; these included direct oxidation products, adducts formed with small thiol compounds, and adducts formed with reactive aldehydes. Two general trends were identified: Exposure to air pollution late in pregnancy (i.e., in the last 30 days) was associated with increased oxidative stress, and exposure to air pollution earlier in pregnancy (i.e., not in the last 30 days) was associated with decreased oxidative stress around the time of birth.

Discussion: Air pollution exposure occurring during pregnancy can alter biology and leave measurable impacts on the developing infant captured in the newborn DBS adductome, which represents a promising tool for investigating adverse birth outcomes in population-based studies.

Prenatal Exposure to Air Pollution and Autism Spectrum Disorder: Sensitive Windows of Exposure and Sex Differences

BACKGROUND

Studies have shown that air pollution exposures during pregnancy are associated with an increased risk of autism spectrum disorder (ASD) in children, and the risk appears to be greater for boys. However, studies assessing gestational windows of susceptibility have been mostly limited by trimesters.

OBJECTIVE

We identified sensitive windows of exposure to regional air pollution and risk of ASD and examined sex differences in a large birth cohort.

METHODS

This population-based retrospective cohort study included 294,937 mother-child pairs with singleton deliveries in Kaiser Permanente Southern California (KPSC) hospitals from 2001 to 2014. Children were followed using electronic medical records until clinical ASD diagnosis, non-KPSC membership, death, or 31 December 2019, whichever came first. Weekly mean fine particulate matter [PM with an aerodynamic diameter of ≤2.5μm (PM2.5)], nitrogen dioxide (NO2), and ozone (O3) pregnancy exposures were estimated using spatiotemporal prediction models. Cox proportional hazard models with distributed lags were used to estimate weekly pollutant exposure associations with ASD risk for the entire cohort, and separately for boys and for girls. Models were adjusted for child sex (for full cohort), maternal race/ethnicity, maternal age at delivery, parity, maternal education, maternal comorbidities, medical center, census tract median household income, birth year, and season.

RESULTS

There were 5,694 ASD diagnoses (4,636 boys, 1,058 girls). Sensitive PM2.5 exposure windows associated with ASD were found early in pregnancy, statistically significant throughout the first two trimesters [1-27 wk of gestation, cumulative hazard ratio (HR)=1.14 [95% confidence interval (CI): 1.06, 1.23] per interquartile range (IQR) (7.4-μg/m3) increase]. O3 exposure during 34-37 wk of gestation was associated with increased risk [HR=1.06 (95% CI: 1.01, 1.11) per IQR (17.4 ppb) increase] but with reduced risk during 20-28 wk of gestation [HR=0.93 (95% CI: 0.89, 0.98)]. No associations were observed with NO2. Sex-stratified early gestational PM2.5 associations were stronger among boys [boys HR=1.16 (95% CI: 1.08, 1.26); girls HR=1.06 (95% CI: 0.89, 1.26)]. O3 associations in later gestation were observed only in boys [boys HR=1.10 (95% CI: 1.04, 1.16); girls HR=0.94 (95% CI: 0.84, 1.05)].

CONCLUSIONS

Exposures to PM2.5 in the first two gestational trimesters were associated with increased ASD risk in children, with stronger associations observed for boys. The role of O3 exposure on ASD risk merits further investigation. https://doi.org/10.1289/EHP9509.

In utero exposure to near-roadway air pollution and autism spectrum disorder in children

IMPORTANCE

Previous studies have reported associations between in utero exposure to regional air pollution and autism spectrum disorders (ASD). In utero exposure to components of near-roadway air pollution (NRAP) has been linked to adverse neurodevelopment in animal models, but few studies have investigated NRAP association with ASD risk.

OBJECTIVE

To identify ASD risk associated with in utero exposure to NRAP in a large, representative birth cohort.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective pregnancy cohort study included 314,391 mother-child pairs of singletons born between 2001 and 2014 at Kaiser Permanente Southern California (KPSC) hospitals. Maternal and child data were extracted from KPSC electronic medical records. Children were followed until: clinical diagnosis of ASD, non-KPSC membership, death, or December 31, 2019, whichever came first. Exposure to the complex NRAP mixture during pregnancy was assessed using line-source dispersion models to estimate fresh vehicle emissions from freeway and non-freeway sources at maternal addresses during pregnancy. Vehicular traffic load exposure was characterized using advanced telematic models combining traditional traffic counts and travel-demand models with cell phone and vehicle GPS data. Cox proportional-hazard models estimated hazard ratios (HR) of ASD associated with near-roadway traffic load and dispersion-modeled NRAP during pregnancy, adjusted for covariates. Non-freeway NRAP was analyzed using quintile distribution due to nonlinear associations with ASD.

EXPOSURES

Average NRAP and traffic load exposure during pregnancy at maternal residential addresses.

MAIN OUTCOMES

Clinical diagnosis of ASD.

RESULTS

A total of 6,291 children (5,114 boys, 1,177 girls) were diagnosed with ASD. The risk of ASD was associated with pregnancy-average exposure to total NRAP [HR(95% CI): 1.03(1.00,1.05) per 5 ppb increase in dispersion-modeled NOx] and to non-freeway NRAP [HR(95% CI) comparing the highest to the lowest quintile: 1.19(1.11, 1.27)]. Total NRAP had a stronger association in boys than in girls, but the association with non-freeway NRAP did not differ by sex. The association of freeway NRAP with ASD risk was not statistically significant. Non-freeway traffic load exposure demonstrated associations with ASD consistent with those of NRAP and ASD.

CONCLUSIONS

In utero exposure to near-roadway air pollution, particularly from non-freeway sources, may increase ASD risk in children.

Near-roadway air pollution associated with COVID-19 severity and mortality - Multiethnic cohort study in Southern California

BACKGROUND

Air pollution exposure has been associated with increased risk of COVID-19 incidence and mortality by ecological analyses. Few studies have investigated the specific effect of traffic-related air pollution on COVID-19 severity.

OBJECTIVE

To investigate the associations of near-roadway air pollution (NRAP) exposure with COVID-19 severity and mortality using individual-level exposure and outcome data.

METHODS

The retrospective cohort includes 75,010 individuals (mean age 42.5 years, 54% female, 66% Hispanic) diagnosed with COVID-19 at Kaiser Permanente Southern California between 3/1/2020-8/31/2020. NRAP exposures from both freeways and non-freeways during 1-year prior to the COVID-19 diagnosis date were estimated based on residential address history using the CALINE4 line source dispersion model. Primary outcomes include COVID-19 severity defined as COVID-19-related hospitalizations, intensive respiratory support (IRS), intensive care unit (ICU) admissions within 30 days, and mortality within 60 days after COVID-19 diagnosis. Covariates including socio-characteristics and comorbidities were adjusted for in the analysis.

RESULT

One standard deviation (SD) increase in 1-year-averaged non-freeway NRAP (0.5 ppb NO_x) was associated with increased odds of COVID-19-related IRS and ICU admission [OR (95% CI): 1.07 (1.01, 1.13) and 1.11 (1.04, 1.19) respectively] and increased risk of mortality (HR = 1.10, 95% CI = 1.03, 1.18). The associations of non-freeway NRAP with COVID-19 outcomes were largely independent of the effect of regional fine particulate matter and nitrogen dioxide exposures. These associations were generally consistent across age, sex, and race/ethnicity subgroups. The associations of freeway and total NRAP with COVID-19 severity and mortality were not statistically significant.

CONCLUSIONS

Data from this multiethnic cohort suggested that NRAP, particularly non-freeway exposure in Southern California, may be associated with increased risk of COVID-19 severity and mortality among COVID-19 infected patients. Future studies are needed to assess the impact of emerging COVID-19 variants and chemical components from freeway and non-freeway NRAP.

Asthma Disease Status, COPD, and COVID-19 Severity in a Large Multiethnic Population

Background

Current studies of asthma history on coronavirus disease 2019 (COVID-19) outcomes are limited and lack consideration of disease status.

Objective

To conduct a population-based study to assess asthma disease status and chronic obstructive pulmonary disease (COPD) in relation to COVID-19 severity.

Methods

Patients diagnosed with COVID-19 (n = 61,338) in a large, diverse integrated health care system were identified. Asthma/COPD history, medication use, and covariates were extracted from electronic medical records. Asthma patients were categorized into those with and without clinical visits for asthma 12 or fewer months prior to COVID-19 diagnosis and labeled as active and inactive asthma, respectively. Primary outcomes included COVID-19–related hospitalizations, intensive respiratory support (IRS), and intensive care unit admissions within 30 days, and mortality within 60 days after COVID-19 diagnosis. Logistic and Cox regression were used to relate COVID-19 outcomes to asthma/COPD history.

Results

The cohort was 53.9% female and 66% Hispanic and had a mean age of 43.9 years. Patients with active asthma had increased odds of hospitalization, IRS, and intensive care unit admission (odds ratio 1.47-1.66; P < .05) compared with patients without asthma or COPD. No increased risks were observed for patients with inactive asthma. Chronic obstructive pulmonary disease was associated with increased risks of hospitalization, IRS, and mortality (odds ratio and hazard ratio 1.27-1.67; P < .05). Among active asthma patients, those using asthma medications had greater than 25% lower odds for COVID-19 outcomes than those without medication.

Conclusions

Patients with asthma who required clinical care 12 or fewer months prior to COVID-19 or individuals with COPD history are at increased risk for severe COVID-19 outcomes. Proper medication treatment for asthma may lower this risk.

Types of diabetes during pregnancy and longitudinal BMI in offspring from birth to age 10 years

OBJECTIVE

To examine longitudinal BMI trajectory from birth to age 10 years in a clinical cohort after exposure to maternal pre-existing type 1 (T1D), type 2 (T2D), gestational diabetes managed with or without anti-diabetes medication, and no diabetes during pregnancy.

METHODS

Data included 218 227 singleton children born in 2008-2015 from a population-based integrated healthcare system; 537 exposed to maternal T1D, 7836 to T2D, 6982 to medicated GDM and 12 576 to unmedicated GDM. Differences in BMI over time among groups were assessed by non-linear mixed-effects models adjusting for covariates.

RESULTS

Children's BMI was significantly lower 6-months after birth for all diabetes exposed groups compared to no diabetes. Beginning at approximately age 2.5 years, BMI was significantly higher for T1D, T2D and medicated GDM groups compared to the no diabetes group. At age 3, the growth pattern started separating with highest BMI in T1D and T2D groups, followed by medicated GDM, unmedicated GDM, and the no diabetes groups. By age 7, BMI was significantly higher for the unmedicated GDM group compared to the no diabetes group. Adjusted BMI was generally comparable between T1D and T2D groups for all ages. Starting at age 5, T1D, T2D and medicated GDM groups had BMI greater than one SD over the BMI in the no diabetes group.

CONCLUSION

In a clinical cohort with standard diabetes management approaches, a hierarchical BMI growth pattern exists in offspring exposed to different types of diabetes during pregnancy after adjusting for important covariates, starting as early as age 3 years.

Liver Fat Reduction After Gastric Banding and Associations with Changes in Insulin Sensitivity and β-Cell Function

OBJECTIVE

The aim of this study was to examine the relationship between changes in liver fat and changes in insulin sensitivity and β-cell function 2 years after gastric banding surgery.

METHODS

Data included 23 adults with the surgery who had prediabetes or type 2 diabetes for less than 1 year and BMI 30 to 40 kg/m² at baseline. Body adiposity measures including liver fat content (LFC), insulin sensitivity (M/I), and β-cell responses (acute, steady-state, and arginine-stimulated maximum C-peptide) were assessed at baseline and 2 years after surgery. Regression models were used to assess associations adjusted for age and sex.

RESULTS

Two years after surgery, all measures of body adiposity, LFC, fasting and 2-hour glucose, and hemoglobin A1c significantly decreased; M/I significantly increased; and β-cell responses adjusted for M/I did not change significantly. Among adiposity measures, reduction in LFC had the strongest association with M/I increase (r = -0.61, P = 0.003). Among β-cell measures, change in LFC was associated with change in acute C-peptide response to arginine at maximal glycemic potentiation adjusted for M/I (r = 0.66, P = 0.007). Significant reductions in glycemic measures and increase in M/I were observed in individuals with LFC loss >2.5%.

CONCLUSIONS

Reduction in LFC after gastric banding surgery appears to be an important factor associated with long-term improvements in insulin sensitivity and glycemic profiles in adults with obesity and prediabetes or early type 2 diabetes.

BMI growth trajectory from ages 2 to 6 years and its association with maternal obesity, diabetes during pregnancy, gestational weight gain, and breastfeeding

OBJECTIVE

To identify latent BMI growth trajectories from ages 2 to 6 years and examine their independent associations with maternal prepregnancy obesity or overweight, pre-existing type 1 (T1D) or type 2 diabetes (T2D) or gestational diabetes (GDM) with or without requiring antidiabetic medications during pregnancy, excessive gestational weight gain (EGWG), and breastfeeding ≤ 6 months.

RESEARCH DESIGN AND METHOD

Data included 71 892 children born at Kaiser Permanente Southern California hospitals in 2007 to 2011 with complete information on maternal risk factors. Group-based trajectory modelling was used to identify latent BMI trajectory groups. Logistic regression was used to assess independent associations adjusted for covariates.

RESULTS

Three distinct BMI trajectory groups were identified: Group 1 (59% of the cohort) had stable low BMI, Group 2 (35% of the cohort) had stable median BMI, and Group 3 (6% of the cohort) had high and increasing BMI over time. Relative to Groups 1 and 2 combined, the adjusted odds ratio (OR) (95% CI) of being in Group 3 associated with maternal exposures were 5.6 (5.1-6.2) for prepregnancy obesity, 2.4 (2.2-2.7) for prepregnancy overweight, 2.1 (1.2-3.7) for T1D, 1.6 (1.4-1.8) for T2D, 1.4 (1.3-1.6) for GDM requiring medication treatment, 1.1 (1.0-1.3) for GDM not requiring medication, 1.3 (1.2-1.4) for EGWG, and 1.2 (1.2-1.3) for breastfeeding ≤ 6 months.

CONCLUSION

Child's high and increasing BMI trajectory was strongly associated with maternal prepregnancy obesity and overweight, modestly associated with maternal T1D, T2D, and GDM requiring medication treatment and EGWG, and slightly associated with breastfeeding ≤ 6 months. GDM not requiring medication treatment during pregnancy had little association.

Gestational diabetes mellitus, prenatal air pollution exposure, and autism spectrum disorder

BACKGROUND

Ambient air pollution and maternal diabetes may affect common biological pathways underlying adverse neurodevelopmental effects. However, joint effects of maternal diabetes and air pollution on autism spectrum disorder (ASD) have not been studied.

OBJECTIVE

We evaluated whether prenatal and early-life air pollution exposure interacts with maternal diabetes status to affect ASD risk.

METHODS

This retrospective cohort study included 246,420 singleton children born in Kaiser Permanente Southern California hospitals in 1999-2009. Children were followed from birth until age 5, during which 2471 ASD cases were diagnosed. Ozone (O₃), particulate matter < 2.5 μm (PM_2.5) and <10 μm in aerodynamic diameter, and nitrogen dioxide measured at regulatory air monitoring stations were interpolated to estimate exposures during preconception and each pregnancy trimester, and first year of life at each child's birth address. Hazard ratios (HRs) for ASD were estimated adjusting for birth year, KPSC service areas, and relevant maternal and child characteristics. For each exposure window, interactions were tested between pollutants and a 4-category maternal diabetes variable (none, GDM ≥ 24 and <24 weeks' gestation, and pre-existing type 2 diabetes). For an exposure window with statistically significant global interaction between pollutant and diabetes (p < 0.05), pollutant-associated HRs were estimated separately for each category of maternal diabetes.

RESULTS

There were associations of ASD with preconception, first and third trimesters, and first year of life PM_2.5, but not with other pollutants. There were, however, interactions of maternal diabetes with first trimester and first year of life O₃. Increased ASD risk was associated with first trimester O₃ among mothers with GDM < 24 weeks' gestation [adjusted HR 1.50 per 15.7 ppb O₃ (95% CI: 1.08-2.09)]. No O₃ associations with ASD were observed in other categories of maternal diabetes.

CONCLUSIONS

GDM onset early in pregnancy may increase children's susceptibility to prenatal O₃-associated ASD risk. These novel findings merit further investigation.

Sex-specific associations of autism spectrum disorder with residential air pollution exposure in a large Southern California pregnancy cohort

Autism spectrum disorder (ASD) affects more boys than girls. Recent animal studies found that early life exposure to ambient particles caused autism-like behaviors only in males. However, there has been little study of sex-specificity of effects on ASD in humans. We evaluated ASD risk associated with prenatal and first year of life exposures to particulate matter less than 2.5 μm in aerodynamic diameter (PM2.5) by child sex. This retrospective cohort study included 246,420 singleton children born in Kaiser Permanente Southern California (KPSC) hospitals between 1999 and 2009. The cohort was followed from birth through age five to identify 2471 ASD cases from the electronic medical record. Ambient PM2.5 and other regional air pollution measurements (PM less than 10 μm, ozone, nitrogen dioxide) from regulatory air monitoring stations were interpolated to estimate exposure during each trimester and first year of life at each geocoded birth address. Hazard ratios (HRs) were estimated using Cox regression models to adjust for birth year, KPSC medical center service areas, and relevant maternal and child characteristics. Adjusted HRs per 6.5 μg/m3 PM2.5 were elevated during entire pregnancy [1.17 (95% confidence interval (CI), 1.04-1.33)]; first trimester [1.10 (95% CI, 1.02-1.19)]; third trimester [1.08 (1.00-1.18)]; and first year of life [1.21 (95% CI, 1.05-1.40)]. Only the first trimester association remained robust to adjustment for other exposure windows, and was specific to boys only (HR = 1.18; 95% CI, 1.08-1.27); there was no association in girls (HR = 0.90; 95% CI, 0.76-1.07; interaction p-value 0.03). There were no statistically significant associations with other pollutants. PM2.5-associated ASD risk was stronger in boys, consistent with findings from recent animal studies. Further studies are needed to better understand these sexually dimorphic neurodevelopmental associations.

Associations of gestational diabetes mellitus with residential air pollution exposure in a large Southern California pregnancy cohort

BACKGROUND

Studies of effects of air pollution on gestational diabetes mellitus (GDM) have not been consistent, and there has been little investigation of effects of exposure preceding pregnancy. In previous studies, the temporal relationship between exposure and GDM onset has been difficult to establish.

METHODS

Data were obtained for 239,574 pregnancies between 1999 and 2009 in a population-based health care system with comprehensive electronic medical records. Concentrations of ambient nitrogen dioxide (NO₂), particulate matter (PM) ≤2.5 μm in aerodynamic diameter (PM_2.5) and ≤10 μm (PM₁₀), and ozone (O₃) during preconception and the first trimester of pregnancy at the residential birth address were estimated from regulatory air monitoring stations. Odds ratios (ORs) of GDM diagnosed in the second and third trimesters in association with pollutant exposure were estimated using generalized estimating equation models adjusted for birth year, medical center service areas, maternal age, race/ethnicity, education, census-tract household income, and parity.

RESULTS

In single-pollutant models, preconception NO₂ was associated with increased risk of GDM (OR = 1.10 per 10.4 ppb, 95% confidence interval [CI]: 1.07, 1.13). First trimester NO₂ was weakly associated with GDM, and this was not statistically significant (OR = 1.02 per 10.4 ppb, 95% CI: 0.99, 1.05). Preconception NO₂ associations were robust in multi-pollutant models adjusted for first trimester NO₂ with another co-pollutant from both exposure windows. In single-pollutant models, preconception PM_2.5 and PM₁₀ associations were associated with increased risk of GDM (OR = 1.04 per 6.5 μg/m³, 95% CI: 1.01, 1.06; OR = 1.03 per 16.1 μg/m³, 95% CI: 1.00, 1.06, respectively), but these effect estimates were not robust to adjustment for other pollutants. In single-pollutant models, preconception and first trimester O₃ were associated with reduced risk of GDM (OR = 0.94 per 15.7 ppb, 95% CI: 0.92, 0.95; OR = 0.95 per 15.7 ppb, 95% CI: 0.94, 0.97), associations that were robust to adjustment for co-pollutants.

CONCLUSIONS

Maternal exposure to NO₂ during the preconception trimester may increase risk of GDM.

Hemoglobin A1c Levels During Pregnancy and Risk of Autism Spectrum Disorders in Offspring

This cohort study uses electronic medical record (EMR) data to examine the association between maternal hemoglobin A_1c levels during pregnancy and risk of autism spectrum disorder in offspring.

Attention-Deficit Hyperactivity Disorder Risk: Interaction Between Parental Age and Maternal History of Attention-Deficit Hyperactivity Disorder

OBJECTIVE

To assess the interaction between maternal attention-deficit/hyperactivity disorder (ADHD) history and young parental age on child's ADHD risk.

METHODS

The study included 321,272 singleton children born between 1995 and 2012 from hospitals within a single integrated health care organization. The children were prospectively followed up through electronic medical record systems from birth until the first date of the following: date of clinical diagnosis of ADHD, last date of continuous health plan membership, death due to any cause, or December 31, 2017. Risks of ADHD associated with a maternal history of ADHD before pregnancy and young parental age were assessed by using Cox regression adjusting for potential confounders.

RESULTS

The children were followed up for a median (interquartile range) of 8.9 (6.2, 13.6) years from birth. Among them, 5.1% had ADHD diagnosis, 1.8% had a maternal history of ADHD before the pregnancy, and 4.4% had mothers <20 years and 2.3% had fathers <20 years at date of birth. The hazard ratio (HR) of ADHD in children associated with parental age <20 years varied by maternal history of ADHD (p < 0.005 for both multiplicative and additive interactions). For children without a maternal history of ADHD, the HR associated with at least 1 parent <20 years was 1.14 (95% confidence interval 1.04-1.24). However, for children with a maternal history of ADHD, the HR associated with at least 1 parent <20 years was 1.92 (95% confidence interval 1.31-2.82).

CONCLUSION

High ADHD risk in offspring associated with young parenthood was predominantly observed among children with a maternal history of ADHD.

Breastfeeding Persistence at 6 Months: Trends and Disparities from 2008 to 2015

OBJECTIVE

To assess trends and disparities in breastfeeding by maternal characteristics (race and ethnicity, age at delivery, obesity, parity, and level of education) and the relative importance among these for breastfeeding at 6 months.

STUDY DESIGN

This retrospective birth cohort study included 195 861 live singleton children born at 32-42 weeks of gestation from 2008 to 2015 within a single integrated healthcare system. All children had healthcare coverage during the first year of life. Maternal characteristics and breastfeeding status at 6 months of age were extracted from electronic medical records. Trends over time of any breastfeeding ≥6 months were evaluated for the 5 maternal characteristics. Robust Poisson regression models were used to estimate breastfeeding rate differences associated with each of the 5 characteristics. The relative importance among them associated with breastfeeding ≥6 months was assessed by comparing model quasi-likelihood information criteria.

RESULTS

Rates of breastfeeding ≥6 months significantly increased overall and among groups defined by the maternal characteristics. However, there was little improvement over time in closing disparities associated with maternal race and ethnicity, age at delivery, prepregnancy obesity status, and level of education. Education level contributed to the greatest disparity in breastfeeding ≥6 months. Maternal age was the second factor, followed by prepregnancy obesity and maternal race and ethnicity.

CONCLUSIONS

Breastfeeding outreach programs focusing on women with less than a college education, women <25 years old, and women from non-Hispanic black or Hispanic race and ethnicity may help to reduce disparities and improve breastfeeding persistence rates within integrated healthcare systems.

Maternal Gestational Diabetes Mellitus, Type 1 Diabetes, and Type 2 Diabetes During Pregnancy and Risk of ADHD in Offspring

OBJECTIVE

To examine the relative importance of maternal preexisting type 1 diabetes (T1D), preexisting type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) on risk of attention deficit/hyperactivity disorder (ADHD) in offspring.

RESEARCH DESIGN AND METHODS

This retrospective birth cohort study included 333,182 singletons born in 1995-2012 within Kaiser Permanente Southern California hospitals. Children were prospectively followed through electronic medical records from age 4 years. Relative risks of ADHD associated with diabetes exposures in utero were estimated by hazard ratios (HRs) using Cox regression with adjustment for potential confounders. For GDM, timing of exposure was evaluated by gestational age at diagnosis and severity was assessed by the need for antidiabetes medication treatment during pregnancy.

RESULTS

A total of 37,878 (11.4%) children were exposed to diabetes (522 exposed to T1D, 7,822 T2D, and 29,534 GDM). During a median of 4.9 years (interquartile range 2.2, 9.6) of follow-up after age 4 years, 17,415 (5.2%) children were diagnosed with ADHD. ADHD risk was not associated with GDM taken as a whole (P = 0.50) or with gestational age at GDM diagnosis (P = 0.16). However, the risk was significantly greater for the GDM requiring versus not requiring antidiabetes medications (P < 0.001). Compared with children unexposed to diabetes, the adjusted HRs for ADHD in children were 1.57 (95% CI 1.09-2.25) for exposure to T1D, 1.43 (1.29-1.60) for T2D, 1.26 (1.14-1.41) for GDM requiring antidiabetes medications, and 0.93 (0.86-1.01) for GDM not requiring medications.

CONCLUSIONS

The hierarchy of risks suggests that severity of maternal diabetes (T1D vs. T2D vs. GDM requiring antidiabetes medications) influences the risk of ADHD in offspring of mothers with diabetes.

Maternal Type 1 Diabetes and Risk of Autism in Offspring

This cohort study uses electronic health record data to examine associations between maternal diabetes (preexisting type 1, type 2, and gestational) and autism spectrum disorder in children.

Maternal obesity, gestational diabetes, breastfeeding and childhood overweight at age 2 years

BACKGROUND

Maternal obesity, excessive gestational weight gain (EGWG), gestational diabetes mellitus (GDM) and breastfeeding are four important factors associated with childhood obesity.

OBJECTIVES

The objective of the study was to assess the interplay among these four factors and their independent contributions to childhood overweight in a cohort with standard clinical care.

METHODS

The cohort included 15 710 mother-offspring pairs delivered in 2011. Logistic regression was used to assess associations between maternal exposures and childhood overweight (body mass index >85th percentile) at age 2 years.

RESULTS

Mothers with pre-pregnancy obesity or overweight were more likely to have EGWG, GDM and less likely to breastfeed ≥6 months. Mothers with GDM had 40-49% lower EGWG rates and similar breastfeeding rates compared with mothers without GDM. Analysis adjusted for exposures and covariates revealed an adjusted odds ratio (95% confidence interval) associated with childhood overweight at age 2 years of 2.34 (2.09-2.62), 1.50 (1.34-1.68), 1.23 (1.12-1.35), 0.95 (0.83-1.10) and 0.76 (0.69-0.83) for maternal obesity, overweight, EGWG, GDM and breastfeeding ≥6 months vs. <6 months, respectively.

CONCLUSIONS

In this large clinical cohort, GDM was not associated with, but maternal pre-pregnancy obesity or overweight and EGWG were independently associated with an increased risk, and breastfeeding ≥6 months was associated with a decreased risk of childhood overweight at age 2 years.

Association of maternal diabetes with autism in offspring

IMPORTANCE

Information about the association of maternal diabetes and autism spectrum disorders (ASDs) in offspring is limited, with no report on the importance of timing of exposure during gestation.

OBJECTIVE

To assess ASD risk associated with intrauterine exposure to preexisting type 2 diabetes and gestational diabetes mellitus (GDM) by gestational age at GDM diagnosis.

DESIGN, SETTING, AND PATIENTS

Retrospective longitudinal cohort study including 322 323 singleton children born in 1995-2009 at Kaiser Permanente Southern California (KPSC) hospitals. Children were tracked from birth until the first of the following: date of clinical diagnosis of ASD, last date of continuous KPSC health plan membership, death due to any cause, or December 31, 2012. Relative risks of ASD were estimated by hazard ratios (HRs) using Cox regression models adjusted for birth year.

EXPOSURES

Maternal preexisting type 2 diabetes (n = 6496), GDM diagnosed at 26 weeks' gestation or earlier (n = 7456) or after 26 weeks' gestation (n = 17 579), or no diabetes (n = 290 792) during the index pregnancy.

MAIN OUTCOMES AND MEASURES

Clinical diagnosis of ASD in offspring.

RESULTS

During follow-up, 3388 children were diagnosed as having ASD (115 exposed to preexisting type 2 diabetes, 130 exposed to GDM at ≤26 weeks, 180 exposed to GDM at >26 weeks, and 2963 unexposed). Unadjusted annual ASD incidences were 3.26, 3.02, 1.77, and 1.77 per 1000 among children of mothers with preexisting type 2 diabetes, GDM diagnosed at 26 weeks or earlier, GDM diagnosed after 26 weeks, and no diabetes, respectively. The birth year-adjusted HRs were 1.59 (95% CI, 1.29-1.95) for preexisting type 2 diabetes, 1.63 (95% CI, 1.35-1.97) for GDM diagnosed at 26 weeks or earlier, and 0.98 (95% CI, 0.84-1.15) for GDM diagnosed after 26 weeks relative to no exposure. After adjustment for maternal age, parity, education, household income, race/ethnicity, history of comorbidity, and sex of the child, maternal preexisting type 2 diabetes was not significantly associated with risk of ASD in offspring (HR, 1.21; 95% CI, 0.97-1.52), but GDM diagnosed at 26 weeks or earlier remained so (HR, 1.42; 95% CI, 1.15-1.74). Antidiabetic medication exposure was not independently associated with ASD risk. Adjustment for a mother or older sibling with ASD in the full cohort and for maternal smoking, prepregnancy body mass index, and gestational weight gain in the subset with available data (n = 68 512) did not affect the results.

CONCLUSIONS AND RELEVANCE

In this large, multiethnic clinical cohort of singleton children born at 28 to 44 weeks' gestation, exposure to maternal GDM diagnosed by 26 weeks' gestation was associated with risk of ASD in offspring.

Racial and ethnic disparities in extremes of fetal growth after gestational diabetes mellitus

AIMS/HYPOTHESIS

The aim of this study was to assess and compare risks of having large- or small-for gestational age (LGA and SGA, respectively) infants born to women with gestational diabetes mellitus (GDM) from ten racial/ethnic groups.

METHODS

LGA and SGA were defined as birthweight >90th and <10th percentile, respectively, specific to each racial/ethnic population and infant sex. Risks of LGA and SGA were compared among a retrospective cohort of 29,544 GDM deliveries from Hispanic, non-Hispanic white (NHW), non-Hispanic black (NHB), Filipino, Chinese, Asian Indian, Vietnamese, Korean, Japanese and Pacific Islander (PI) groups of women.

RESULTS

Unadjusted LGA and SGA risks varied among the ten groups. For LGA, the highest risk was in infants born to NHB women (17.2%), followed by those born to PI (16.2%), Hispanic (14.5%), NHW (13.1%), Asian Indian (12.8%), Filipino (11.6%) and other Asian (9.6-11.1%) women (p < 0.0001). Compared with NHW, the LGA risk was significantly greater for NHB women with GDM (RR 1.25 [95% CI 1.11-1.40]; p = 0.0001 after adjustment for maternal characteristics). Further adjustment for maternal pre-pregnancy BMI and gestational weight gain in the sub-cohort with available data (n = 8,553) greatly attenuated the elevated LGA risk for NHB women. For SGA, the risks ranged from 5.6% to 11.3% (p = 0.003) where most groups (8/10) had risks that were lower than the population-expected 10% and risks were not significantly different from those in NHW women.

CONCLUSIONS/INTERPRETATION

These data suggest that variation in extremes of fetal growth associated with GDM deliveries across race/ethnicity can be explained by maternal characteristics, maternal obesity and gestational weight gain. Women should be advised to target a normal weight and appropriate weight gain for pregnancies; this is particularly important for NHB women.

Recruitment results among families contacted for an obesity prevention intervention: the Obesity Prevention Tailored for Health Study

Background

Overweight and obesity are serious threats to health and increase healthcare utilization and costs. The Obesity Prevention Tailored for Health (OPT) study was designed to test the effectiveness of a family-based intervention targeting diet and physical activity. We describe the results of efforts to recruit parents and children enrolled in a large managed-care organization into the OPT study.

Methods

Parents with 10- to 12-year-old children were randomly selected from the membership of Kaiser Permanente Southern California, a large integrated health plan, and contacted between June 2010 and November 2011. We describe recruitment outcomes and compare characteristics of parents and children who did and did not participate. Information was collected from calls with parents and through the administrative and electronic medical records of the health plan.

Results

Of the 4,730 parents contacted, 16.1% expressed interest in participation (acceptors), 28.8% declined participation (refusers), 4.7% were ineligible, and, even after multiple attempts, we were unable to reach 50.4%. Slightly less than half of the acceptors (n = 361) were ultimately randomized to receive either the OPT program plus usual care or usual care alone (7.6% of all parents initially contacted). There were not any significant differences between acceptors who were or were not randomized. Overall, we found that acceptors were more likely to be female parents, have overweight/obese children, and higher utilization of outpatient visits by parents and children compared with refusers and those we were unable to reach. We found no differences in recruitment outcomes by body mass index or comorbidity score of the parents, level of physical activity of the parents and children, education of the parents, or household income.

Conclusions

Recruiting parents and children into an obesity prevention program in a healthcare setting proved to be challenging and resource-intensive. Barriers and incentives for participation in obesity prevention programs need to be identified and addressed. Concern for the weight of their children may motivate parents to participate in family-based lifestyle interventions; however, the healthcare setting may be more relevant to weight-related treatment than to primary prevention.

Trial registration

Trial Registration Number: ISRCTN06248443, 30 January 2014.

The prevalence of primary pediatric prehypertension and hypertension in a real-world managed care system

To assess the burden associated with hypertension, reliable estimates for the prevalence of pediatric hypertension are vital. For this cross-sectional study of 237,248 youths aged 6 to 17 years without indication of secondary hypertension, blood pressure (BP) was classified according to age, sex, and height using standards from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents as prehypertension with at least 1 BP ≥90th percentile and as hypertension with 3 BPs ≥95th percentile. The prevalence of prehypertension and hypertension were 31.4% and 2.1%, respectively. An additional 21.4% had either 1 (16.6%) or 2 (4.8%) BPs ≥95th percentile. Based on this large population-based study using routinely measured BP from clinical care, a remarkable proportion of youth (6.9%) has hypertension or nearly meets the definition of hypertension with 2 documented BPs in the hypertensive range.

High blood pressure in overweight and obese youth: implications for screening

In the absence of evidence-based guidelines for high blood pressure screening in asymptomatic youth, a reasonable strategy is to screen those who are at high risk. The present study aimed to identify optimal body mass index (BMI) thresholds as a marker for high-risk youth to predict hypertension prevalence. In a cross-sectional study, youth aged 6 to 17 years (n=237,248) enrolled in an integrated prepaid health plan in 2007 to 2009 were classified according to their BMI and hypertension status. In moderately and extremely obese youth, the prevalence of hypertension was 3.8% and 9.2%, respectively, compared with 0.9% in normal weight youth. The adjusted prevalence ratios (95% confidence intervals) of hypertension for normal weight, overweight, moderate obesity, and extreme obesity were 1.00 (Reference), 2.27 (2.08-2.47), 4.43 (4.10-4.79), and 10.76 (9.99-11.59), respectively. The prevalence of hypertension was best predicted by a BMI-for-age ≥94th percentile. These results suggest that all obese youth should be screened for hypertension.

OBAYA (obesity and adverse health outcomes in young adults): feasibility of a population-based multiethnic cohort study using electronic medical records

Background

Although obesity is a risk factor for many chronic diseases, we have only limited knowledge of the magnitude of these associations in young adults. A multiethnic cohort of young adults was established to close current knowledge gaps; cohort demographics, cohort retention, and the potential influence of migration bias were investigated.

Methods

For this population-based cross-sectional study, demographics, and measured weight and height were extracted from electronic medical records of 1,929,470 patients aged 20 to 39 years enrolled in two integrated health plans in California from 2007 to 2009.

Results

The cohort included about 84.4% of Kaiser Permanente California members in this age group who had a medical encounter during the study period and represented about 18.2% of the underlying population in the same age group in California. The age distribution of the cohort was relatively comparable to the underlying population in California Census 2010 population, but the proportion of women and ethnic/racial minorities was slightly higher. The three-year retention rate was 68.4%.

Conclusion

These data suggest the feasibility of our study for medium-term follow-up based on sufficient membership retention rates. While nationwide 6% of young adults are extremely obese, we know little to adequately quantify the health burden attributable to obesity, especially extreme obesity, in this age group. This cohort of young adults provides a unique opportunity to investigate associations of obesity-related factors and risk of cancer in a large multiethnic population.

The prevalence of obesity and obesity-related health conditions in a large, multiethnic cohort of young adults in California

PURPOSE

To identify population groups that are most susceptible to obesity-related health conditions at young age.

METHODS

For this population-based cross-sectional study, measured weight and height, diagnosis, laboratory, and drug prescription information were extracted from electronic medical records of 1,819,205 patients aged 20 to 39 years enrolled in two integrated health plans in California in 2007 through 2009.

RESULTS

Overall, 29.9% of young adults were obese. Extreme obesity (body mass index [BMI] ≥ 40 kg/m(2)) was observed in 6.1% of women and 4.5% of men. The adjusted relative risk (RR) for diabetes, hypertension, dyslipidemia, and the metabolic syndrome increased sharply for those individuals with a BMI of 40 or greater, with the sharpest increase in the adjusted RR for hypertension and the metabolic syndrome. The association between weight class and dyslipidemia, hypertension, and the metabolic syndrome but not diabetes was stronger among 20.0- to 29.9-year-olds compared with 30.0- to 39.9-year-olds (P for interaction < .05). For example, compared with their normal weight counterparts of the same age group, young adults with a BMI of 40.0 to 49.9, 50.0 to 59.9, and 60 or greater kg/m(2) had a RR for hypertension of 11.73, 19.88, and 30.47 (95% confidence interval [CI], 26.39-35.17) at 20 to 29 years old, and 9.31, 12.41, and 15.43 (95% CI, 14.32-16.63) at 30 to 39 years old.

CONCLUSIONS

Although older individuals were more likely to be extremely obese, the association between obesity-related health conditions was stronger in younger individuals. Hispanics and Blacks are also more likely to be obese, including extremely obese, putting them at an elevated risk for premature cardiovascular disease and some cancers relative to non-Hispanic Whites.

Inhibition of polyamine synthesis arrests trichomonad growth and induces destruction of hydrogenosomes

Trichomonad parasites such as Tritrichomonas foetus produce large amounts of putrescine (1,4-diaminobutane), which is transported out of the cell via an antiport mechanism which results in the uptake of a molecule of spermine. The importance of putrescine to the survival of the parasite and its role in the biology of T. foetus was investigated by use of the putrescine analogue 1, 4-diamino-2-butanone (DAB). Growth of T. foetus in vitro was significantly inhibited by 20 mM DAB, which was reversed by the addition of exogenous 40 mM putrescine. High-performance liquid chromatography analysis of 20 mM DAB-treated T. foetus revealed that putrescine, spermidine, and spermine levels were reduced by 89, 52, and 43%, respectively, compared to those in control cells. The DAB treatment induced several ultrastructural alterations, which were primarily observed in the redox organelles termed hydrogenosomes. These organelles were progressively degraded, giving rise to large vesicles that displayed material immunoreactive with an antibody to beta-succinyl-coenzyme A synthetase, a hydrogenosomal enzyme. A protective role for polyamines as stabilizing agents in the trichomonad hydrogenosomal membrane is proposed.

Reconstitution of a bacterial/plant polyamine biosynthesis pathway in Saccharomyces cerevisiae

Polyamine synthesis in most organisms is initiated by the decarboxylation of ornithine to form putrescine via ornithine decarboxylase (ODC). Plants, some bacteria and some fungi and protozoa generate putrescine from arginine, via arginine decarboxylase (ADC) and agmatine ureohydrolase (AUH) or agmatine iminohydrolase. A polyamine-requiring strain of Saccharomyces cerevisiae with a mutation in the gene encoding ODC was transformed with plasmids bearing genes encoding Escherichia coli ADC and AUH. Transformants regained the ability to grow in the absence of exogenous polyamines and contained enzyme activities consistent with the presence of both prokaryotic enzymes. Similar results were obtained when a plasmid containing a gene encoding oat (Avena sativa L.) ADC was substituted for the E. coli gene. These data demonstrate the successful complementation of a yeast biosynthetic polyamine synthesis defect by genes encoding an alternative pathway found in bacteria; they also show that plant ADC can substitute for the bacterial enzyme in this pathway. The recombinant yeast provides a tool for the study of the functional properties of these enzymes and for discovery of compounds that specifically inhibit this pathway.

Prevalence of micro- and macroalbuminuria in a Canarian population of type 2 diabetic patients. Relationship with blood pressure, lipid profile, obesity and metabolic control

We performed a cross-sectional study on the prevalence of micro- and macroalbuminuria in a population of 288 Type 2 diabetic patients from Northern Gran Canaria Island (age 59 +/- 9.5, years; 48% male): 179 unselected patients referred by their family physicians, and 109 from our diabetes clinic. Sex, age, duration of diabetes and hypertension, blood pressure, body mass index, waist-hip ratio, HbA1c, creatinine, cholesterol (total and HDL), triglycerides, lipoprotein (a), and the presence of retinopathy, polyneuropathy, and coronary and cerebrovascular disease were assessed. The prevalences of micro- and macroalbuminuria were 28.5% and 11.8%. Among the patients referred by their family physicians, 32.4% were micro- and 6.1% macroalbuminuric. In our diabetes clinic, there were respectively 22% and 21% (with a higher prevalence of macroalbuminuria than in primary care, p < 0.05). Seventy-three percent were hypertensive in both settings. Prevalence was 31.5% for diabetic retinopathy, 21.0% for diabetic polyneuropathy, 8.1% for cerebrovascular disease, and 20.2% for coronary heart disease. The albumin excretion rate was significantly correlated with plasma creatinine levels, diastolic blood pressure, total cholesterol and the presence of coronary heart disease and diabetic retinopathy, but not with age, duration of diabetes or hypertension, body mass index, waist/hip ratio, glycated haemoglobin or triglycerides.

Polyamine biosynthesis in Cryptosporidium parvum and its implications for chemotherapy

This study demonstrates that polyamine biosynthesis in Cryptosporidium parvum occurs via a pathway chiefly found in plants and some bacteria. The lead enzyme of this pathway, arginine decarboxylase (ADC) was sensitive to the specific, irreversible inhibitor DL-alpha-difluoromethyl-arginine (IC50 30 microM), and intracellular growth of C. parvum was significantly reduced by inhibitors of ADC. No activity was detected using ornithine as substrate, and the irreversible inhibitor of ornithine decarboxylase, DL-alpha-difluoromethyl-ornithine, had no effect upon ADC activity or upon growth of the parasite. Back-conversion of spermine to spermidine and putrescine via spermidine:spermine-N1-acetyltransferase (SSAT) was also detected. Compounds such as his(ethyl)norspermine, which have been demonstrated to down-regulate SSAT activity in tumor cells, were synergistic in the inhibition of growth when used in combination with inhibitors of the forward pathway. Thus, C. parvum differs fundamentally in its polyamine metabolism from the majority of eukaryotes, including humans. Such differences indicate that polyamine metabolism may serve as a chemotherapeutic target in this organism.

The contribution of the arginine dihydrolase pathway to energy metabolism by Trichomonas vaginalis

The enzymes of the arginine dihydrolase pathway were measured in Trichomonas vaginalis hydrogenosome-deficient lines MR-5 and MR-100, and the parent strain TV 10-02. The activities and substrate affinities of arginine deiminase, carbamate kinase and ornithine decarboxylase were similar for the hydrogenosome-deficient lines and the parent TV 10-02. The activity of catabolic ornithine carbamyltransferase, however, was found to be 5-7-fold elevated in the hydrogenosome-deficient lines; the apparent K(m) for citrulline was similar for all of the lines. Putrescine biosynthesis by the hydrogenosome-deficient cell lines was found to be significantly higher than the parent. Incubation of strain MR-100 with U-[14C]-arginine resulted in a 5-fold greater amount of 14CO2 liberated compared to the parent strain TV 10-02. Inclusion of the ornithine decarboxylase inhibitor difluoromethylornithine in these incubations reduced the CO2 production of strain TV 10-02 by 42%, but only inhibited the MR-100 strain by 14.5%, indicative that the majority of the CO2 liberated from arginine by this strain is derived from the elevated activity of ornithine carbamyltransferase. Despite the increased flow through the arginine dihydrolase pathway, the energy gain to the parasite is approximately 10% of that from glucose, thus, under the growth conditions used in this study carbohydrate metabolism provides the bulk of the ATP for the parasite.

Higher erythropoietin secretion in response to cobaltous chloride in post-hypoxic than in hypertransfused polycythemic mice

BACKGROUND

We have shown previously that both erythrocyte production rate (EPR) and plasma erythropoietin (EPO) levels in response to hypoxia or to compounds able to stimulate EPO secretion are very much higher in post-hypoxic (PH) than in hypertransfused (HT) polycythemic mice with similar levels of hematocrit. Since it has been demonstrated that cobalt (Co) treatment rises renal EPO-mRNA and increases plasma EPO levels, the present study was conducted to determine whether there is a difference between PH and HT mice in relation to the erythropoietic response to Co and whether the stimulatory effect of Co on EPO secretion can be blunted by polycythemia.

METHODS

Adult female mice of the CF-1 strain were made polycythemic by either exposing them to 270 h of discontinuous hypoxia (18 h/d) in a hypobaric chamber maintained at 456 hPA (PH mice) or by injecting them with 0.8 ml of washed packed red cells on two consecutive days (HT mice). Measurement of the erythrocyte production rate (EPR) was made by RBC-59Fe uptake. Plasma EPO concentration was determined by RIA. Cobalt chloride (CoC12) was dissolved in saline and injected in doses of 4 and 8 umoles/mouse. Recombinant human EPO (HEMAX 4000, Bio Sidus SA, Argentina) was dissolved in PBS + albumin to the desired concentration.

RESULTS

By comparison with the corresponding dose-regression line for rHu-EPO, it was estimated that the responses (EPR) (measured as RBC-59Fe incorporation) of PH mice to sc injections of 4 and 8 umoles of CoC12 were equivalent to 95 and 145 mU of rHu-EPO, respectively. The response of HT mice to 4 umoles of the drug was not detectable. At the upper dose level, the response was equivalent to 52 mU of rHuEPO. Plasma immunoreactive EPO (iEPO) titers 12 h after COC12 (8 umoles) were not significantly different between normocythemic and PH mice. The observed values were significantly higher than those found in HT mice.

DISCUSSION

These findings demonstrate that EPO production in response to COC12 is depressed by polycythemia when induced by transfusion but not when induced by chronic exposure to hypobaric hypoxia. They also confirm, but not explain the nature of the conditioning effect of exposure to hypoxia which makes the mechanism controlling EPO secretion either more sensitive to EPO-secreting stimuli or unable to recognize the polycythemic state.

Congenital adrenal hypoplasia in a male with gonadotropin deficiency

We report the case of a boy with adrenal insufficiency diagnosed at the age of 2.5 months. He required immediate therapy with corticosteroids. His two brothers and a cousin died in infancy with vomiting and dehydration. Aged 17.5 years (bone age 13 years), he showed no signs of puberty, a testicular volume of 2 ml, an infantile penis, and no axillary or pubic hair. There was no evidence of a pubertal growth spurt. The low plasma levels of cortisol, 17-OHP, delta-4-A, LH and FSH did not increase after stimulation with ACTH or LHRH respectively. Urinary testosterone levels before and after HCG were extremely low. These factors strongly suggest the diagnosis of a sex-linked type of adrenal insufficiency (cytomegalic form), associated with gonadotropin deficiency.