The milk study protocol: A longitudinal, prospective cohort study of the relationship between human milk metabolic hormone concentration, maternal body composition, and early growth and satiety development in Samoan infants aged 1-4 months

BACKGROUND

Current research suggests that energy transfer through human milk influences infant nutritional development and initiates metabolic programming, influencing eating patterns into adulthood. To date, this research has predominantly been conducted among women in high income settings and/or among undernourished women. We will investigate the relationship between maternal body composition, metabolic hormones in human milk, and infant satiety to explore mechanisms of developmental satiety programming and implications for early infant growth and body composition in Samoans; a population at high risk and prevalence for overweight and obesity. Our aims are (1) to examine how maternal body composition influences metabolic hormone transfer from mother to infant through human milk, and (2) to examine the influences of maternal metabolic hormone transfer and infant feeding patterns on early infant growth and satiety.

METHODS

We will examine temporal changes in hormone transfers to infants through human milk in a prospective longitudinal cohort of n = 80 Samoan mother-infant dyads. Data will be collected at three time points (1, 3, & 4 months postpartum). At each study visit we will collect human milk and fingerpick blood samples from breastfeeding mother-infant dyads to measure the hormones leptin, ghrelin, and adiponectin. Additionally, we will obtain body composition measurements from the dyad, observe breastfeeding behavior, conduct semi-structured interviews, and use questionnaires to document infant hunger and feeding cues and satiety responsiveness. Descriptive statistics, univariate and multivariate analyses will be conducted to address each aim.

DISCUSSION

This research is designed to advance our understanding of variation in the developmental programming of satiety and implications for early infant growth and body composition. The use of a prospective longitudinal cohort alongside data collection that utilizes a mixed methods approach will allow us to capture a more accurate representation on both biological and cultural variables at play in a population at high risk of overweight and obesity.

Screening for Hypertension in adolescents living with HIV: Protocol for a cluster randomized trial to improve guideline adherence

BACKGROUND

Although AIDS-related deaths have reduced with increased access to antiretroviral care, cardiovascular disease-related morbidities among persons living with HIV are rising. Contributing to this is the higher incidence of Hypertension among Persons Living with HIV. The duration of exposure to the virus and antiretroviral drugs plays a vital role in the pathogenesis, putting perinatally infected children and adolescents at higher risk than behaviorally-infected ones, supporting the calls for increased surveillance of Hypertension among them. Despite the availability of guidelines to support this surveillance, the blood pressure (BP) of adolescents living with HIV (ADLHIV) is not checked during clinical visits. This study aims to assess the effect of a theory-based intervention on healthcare workers' adherence to the guidelines for hypertension screening among adolescents.

METHODS

A multi-facility cluster-randomized study will be conducted. The clusters will be 20 antiretroviral therapy sites in the Greater Accra Region of Ghana with the highest adolescent caseload. Data will be extracted from the folders of adolescents (10-17 years) who received care in these facilities six months before the study. The ART staff of intervention facilities will receive a multicomponent theory of planned behaviour-based intervention. This will include orientation on hypertension risk among ADLHIV, provision of job aids and pediatric sphygmomanometers. Six months after the intervention, the outcome measure will be the change from baseline in the proportion of ADLHIV whose BP was checked during clinical visits. The calculated sample size is 400 folders.

IMPLICATIONS OF FINDINGS

This study will generate evidence on the effectiveness of a multicomponent theory-based intervention for improving the implementation of clinical practice guidelines.

TRIAL REGISTRATION

PACTR202205641023383.

Maternal responsiveness and toddler body mass index z-score: Prospective analysis of maternal and child mealtime interactions

Responsive feeding, where parents are guided by children's hunger and satiation cues and provide appropriate structure and support for eating, is believed to promote healthier weight status. However, few studies have assessed prospective associations between observed parental feeding and toddler growth. We characterized toddler growth from 18 to 36 months and, in a subset of families, examined whether observed maternal responsiveness to toddler satiation cues and encouraging prompts to eat at 18 and 24 months were associated with toddler body mass index z-score (BMIz) from 18 to 36 months. Participants included 163 toddlers and their mothers with overweight/obesity who had participated in a lifestyle intervention during pregnancy. Anthropometrics were measured at 18, 24, and 36 months. In a subsample, mealtime interactions were recorded in families' homes at 18 (n = 77) and 24 (n = 75) months. On average, toddler BMIz remained stable from 18 to 36 months with 31.3% (n = 51) categorized with a healthy weight, 56.4% (n = 92) with at risk for overweight and 12.3% (n = 20) with overweight. Fewer maternal prompts to eat at 18 months was associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p = .002). Higher child weight status at 12 months was also associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p < .001). Neither 24-month maternal prompts nor 18 or 24 month responsiveness to satiation cues were associated with toddler BMIz. In this diverse sample, weight status was relatively stable from 18 to 36 months. Maternal prompts to eat measured earlier in toddlerhood and prior child weight status were associated with toddler BMIz.

Consensus-building during the Becoming Breastfeeding Friendly (BBF) initiative in Samoa: A qualitative content analysis

The Becoming Breastfeeding Friendly (BBF) initiative provides countries with an evidence-based toolbox to improve the national breastfeeding environment by assessing and developing a plan to effectively scale up well-coordinated national policies and programs. BBF is carried out by a multi-institutional, intersectoral committee of experts, convening across five committee meetings designed to produce policy recommendations that can be implemented in the country's context. Samoa successfully completed the BBF initiative in 2018, resulting in the institution of breastfeeding policy in hospitals and the establishment of lactation rooms within government ministries. An important step in informing the success of future breastfeeding scale-up initiatives is understanding how consensus is built. This study aimed to investigate how the BBF Samoa committee built consensus. We conducted a content analysis of audio recordings of three BBF Samoa meetings (meetings 1, 2 and 4), meeting minutes, and meeting notes using an a priori operational consensus-building framework. We used a combination of deductive and inductive approaches to: a) evaluate the data against existing, a priori criteria for consensus-building and b) identify emergent ways in which the BBF Samoa committee may have achieved consensus. We identified 6 themes, 2 meta-subthemes, and 16 subthemes. The 6 themes, largely defined by the a priori framework, represented key components of successful consensus-building. The 2 meta-subthemes described two overarching methods of consensus-building: "process-led" (i.e., inherent to the BBF process itself) and "organic" (unique/specific to the committee). Lastly, the 16 subthemes described more specific ways that the committee reached consensus. The detailed manualization of the BBF process, its reliance on data, and its transparent and engaged committee process were key for reaching consensus on BBF scores and recommendations in Samoa. Our study contributes to the understanding of how effective breastfeeding policy recommendations are made, using a methodology that can be applied beyond the topic of breastfeeding.

Regional Research-Practice-Policy Partnerships in Response to Climate-Related Disparities: Promoting Health Equity in the Pacific

Although climate change poses a threat to health and well-being globally, a regional approach to addressing climate-related health equity may be more suitable, appropriate, and appealing to under-resourced communities and countries. In support of this argument, this commentary describes an approach by a network of researchers, practitioners, and policymakers dedicated to promoting climate-related health equity in Small Island Developing States and low- and middle-income countries in the Pacific. We identify three primary sets of needs related to developing a regional capacity to address physical and mental health disparities through research, training, and assistance in policy and practice implementation: (1) limited healthcare facilities and qualified medical and mental health providers; (2) addressing the social impacts related to the cooccurrence of natural hazards, disease outbreaks, and complex emergencies; and (3) building the response capacity and resilience to climate-related extreme weather events and natural hazards.

Maternal urinary concentrations of organophosphate ester metabolites: associations with gestational weight gain, early life anthropometry, and infant eating behaviors among mothers-infant pairs in Rhode Island

BACKGROUND

Organophosphate esters (OPEs)-used as flame retardants and plasticizers-are associated with adverse pregnancy outcomes such as reduced fecundity and live births and increased preterm delivery. OPEs may interfere with growth and metabolism via endocrine-disruption, but few studies have investigated endocrine-related outcomes. The objective of this pilot study (n = 56 mother-infant pairs) was to evaluate associations of OPEs with gestational weight gain (GWG), gestational age at delivery, infant anthropometry, and infant feeding behaviors.

METHODS

We quantified OPE metabolites (bis-2-chloroethyl phosphate [BCEP], bis (1,3-dichloro-2-propyl) phosphate [BDCPP], diphenyl phosphate [DPHP]) in pooled maternal spot urine collected throughout pregnancy (~ 12, 28, and 35 weeks' gestation). We obtained maternal sociodemographic characteristics from questionnaires administered at enrollment and perinatal characteristics from medical record abstraction. Trained research assistants measured infant weight, length, head and abdominal circumferences, and skinfold thicknesses at birth and 6 weeks postpartum. Mothers reported infant feeding behavior via the Baby Eating Behavior Questionnaire (BEBQ). Using multiple linear regression, we assessed associations of log2-transformed maternal urinary OPE metabolites with GWG, gestational age at delivery, infant anthropometry at birth, weekly growth rate, and BEBQ scores at 6 weeks postpartum. We used linear mixed effects (LME) models to analyze overall infant anthropometry during the first 6 weeks of life. Additionally, we considered effect modification by infant sex.

RESULTS

We observed weak positive associations between all OPE metabolites and GWG. In LME models, BDCPP was associated with increased infant length (β = 0.44 cm, 95%CI = 0.01, 0.87) and weight in males (β = 0.14 kg, 95%CI = 0.03, 0.24). BDCPP was also associated with increased food responsiveness (β = 0.23, 95%CI = 0.06, 0.40). DPHP was inversely associated with infant abdominal circumference (β = - 0.50 cm, 95%CI = - 0.86, - 0.14) and female weight (β = - 0.19 kg, 95%CI = - 0.36, - 0.02), but positively associated with weekly growth in iliac skinfold thickness (β = 0.10 mm/wk., 95%CI = 0.02, 0.19). Further, DPHP was weakly associated with increased feeding speed. BCEP was associated with greater infant thigh skinfold thickness (β = 0.34 mm, 95%CI = 0.16, 0.52) and subscapular skinfold thickness in males (β = 0.14 mm, 95%CI = 0.002, 0.28).

CONCLUSIONS

Collectively, these findings suggest that select OPEs may affect infant anthropometry and feeding behavior, with the most compelling evidence for BDCPP and DPHP.

An Exploratory Study of the Gaps and Barriers to Nutrition Education for Pregnant Women in Tamale, Ghana

Objectives

Nutrition education (NE) remains a popular intervention to improve maternal health literacy (MHL), with the promise of behavior change and improved maternal and child health outcomes. However, there continue to be gaps and barriers that impede the delivery of NE to women, and/or affect maternal compliance to NE guidelines. This is the first phase of a larger project that examines the role of NE on MHL and pregnancy outcomes. Specifically, this phase aimed to identify the gaps in, and barriers to current NE delivered at hospitals to women in Tamale, Ghana.

Methods

A series of focus group discussions were used to engage health providers and pregnant women. Field observations of the antenatal care (ANC) process and informal interviews with focal personnel were also employed. Data were thematized using recurrent themes from field notes and audio loggings.

Results

Preliminary analysis of discussions with 33 health providers and 13 pregnant women identified 3 thematic areas describing gaps and challenges to successful delivery and implementation of NE: 1) Sociocultural: Women's adherence to NE advice was affected by constrained autonomy resulting from patriarchal norms including spousal control, polygamy, coercion, and financial abuse. Food insecurity resulting from low socioeconomic status and a lack of social safety nets also impacted maternal ability to access and comply with NE 2) Communication: Midwives were cited as the most common sources of information for women at ANC sessions, yet owing to dissatisfaction with the hospital set up, some mothers preferred and continued to seek health information from traditional birth attendants. Also, more emphasis was placed on anemia prevention at ANC visits compared to other salient topics like weight gain during pregnancy. 3) Administrative: Lack of professional language translation, health professional workload and inadequate health worker retraining also affected the quality of NE.

Conclusions

Attention should be paid especially to the sociocultural factors plaguing vulnerable women in low-middle income settings like Tamale when designing NE interventions. The study investigators will continue to engage community members in exploring ways of incorporating these in the design of a NE intervention for pregnant women in the area.

Funding Sources

N/A.

A-48 The Role of Processing Speed in Verbal and Nonverbal Learning within a Clinical Sample of Older Adults

Objective

Prior research revealed that processing speed predicts nonverbal learning in healthy older adults (Tam & Schmitter-Edgecombe, 2013). This study aims to examine the role of processing speed in both verbal and nonverbal learning in a clinical sample. We expect that processing speed will lend the most variance to the initial learning trials.

Method

Records from 718 patients were reviewed (mean age = 74). Hierarchical regression analyses were conducted using Brief Visuospatial Memory Test –Revised (BVMT-R) and Hopkins Verbal Learning Test –Revised (HVLT-R) learning trials as outcome variables. Demographics were entered in a first step followed by BVMT-R copy or Wechsler Adult Intelligence Scale (WAIS-IV) Digit Span –longest digit span forward raw score, to account for visuoconstruction or simple auditory attention for nonverbal and verbal learning outcomes respectively. A processing speed composite of sample-standardized raw scores was entered in a final step.

Results

Processing speed accounted for 5.4% of the variance in BVMT-R trial 1, 7.5% of the variance in trial 2, and 8.5% of the variance in trial 3, all p < .001. Processing speed accounted for 6.6% of the variance in HVLT-R trial 1, 11.1% of the variance in trial 2, and 11.5% of the variance in trial 3, all p < .001.

Conclusions

Processing speed significantly predicted all verbal and nonverbal learning trials. Contrary to our hypotheses, processing speed actually had a greater contribution during subsequent learning trials. These findings have implications for evaluating memory performance in patients with syndromes where processing speed is typically affected (e.g., cerebrovascular disease, Parkinson’s disease).

C-03 The sensitivity and specificity of the Montreal Cognitive Assessment is Age Dependent for Amyloid Positivity in a Mixed Clinical Sample

Objective

The Montreal Cognitive Assessment (MoCA) is a widely-used screening tool for neurodegenerative disorders. Despite widespread use, there have been few investigations into correlations between MoCA and biomarkers of Alzheimer's disease pathology. This study examined the relationship between MoCA performance and the presence of amyloid as detected by positron emission tomography (PET).

Methods

Sensitivity and specificity for the total MoCA score were determined for 76 individuals (26 amyloid-negative, 50 amyloid- positive) who were between the ages of 55 and 90 and diagnosed with MCI or mild dementia with a CDR score of 0-1 and were participating in a longitudinal, observational study at the Cleveland Clinic Lou Ruvo Center for Brain Health. All individuals underwent an amyloid PET scan and cognitive screening.

Results

Sensitivity and specificity for the total score were determined using amyloid positivity as the standard. A cutpoint of 25 yielded the best balance between sensitivity and specificity (74% and 74%, respectively). A total score of 27 was required to achieve 90% sensitivity to identify amyloid positive individuals (i.e. only a 10% risk that individuals with a score of 28-30 have a positive scan). A score of 26 was required in individuals over the age of 75.

Conclusions

With the emergence of new diagnostic biomarkers, there is need to define the utility of affordable, widely-available screening tools. In this mixed clinical sample, the MoCA score showed good sensitivity for detecting amyloid pathology but with low specificity. Thus a total MoCA score of 28 is needed to confidently rule out risk for AD pathology.

C-02 An Unbiased Biomarker Approach to Neuropsychological, Behavioral, and Psychiatric Symptoms in a Mixed Clinical Sample

Objective

Suspected Non-Alzheimer’s Pathology (SNAPs) are individuals who present with a cognitive syndrome meeting clinical criteria for Alzheimer’s disease (AD) but are found to lack underlying AD pathology. Current clinical criteria for AD lack specificity in predicting underlying neurodegenerative pathology. With the advent of amyloid positron emission tomography (PET) the presence of amyloid pathology can now be identified in vivo. Using a biomarker-based approach, we aimed to characterize the neuropsychological, behavioral, and psychiatric profile of SNAPs in contrast to those with AD pathology (APs).

Method

76 individuals (26 amyloid-negative [SNAPs], 50 amyloid- positive [APs]) completed neuropsychological testing and a PET amyloid scan as a part of a longitudinal observational study at the Cleveland Clinic LRCBH. Individuals meeting NIA-A criteria for MCI or mild AD with a Clinical Dementia Rating score of .05 -1 were included. Amyloid status was determined via clinical read of two clinicians trained in reading amyloid scans (neuroradiologist and neuropsychiatrist). Independent samples t tests assessed group differences between SNAPs and APs across cognitive, behavioral, and psychiatric measures.

Results

Mini-Mental State Examination scores were equivalent between SNAPs and APs. SNAPs performed significantly better on measures of verbal and nonverbal memory, set-shifting, and semantic fluency, as well as aspects of processing speed and working memory (all p’s < .05). Additionally, SNAPs endorsed more RBD symptoms (p < .05). No significant group differences were observed across neuropsychiatric or functional measures.

Conclusion(s)

Differences in an individual’s neuropsychological, behavioral, and psychiatric profile in consideration with a biomarker approach may provide key insights and afford greater diagnostic clarity.

Perceived Barriers to Physical Activity Among Low-Income Latina Women at Risk for Type 2 Diabetes

Purpose

The purpose of this study was to examine perceived barriers to physical activity among low-income Latina women who were at risk for type 2 diabetes, as well as the demographic factors that influence these perceived barriers.

Methods

Recruited in the waiting room of a community health center in a low-income neighborhood (n = 160), Latina women between the ages of 18 and 49 years completed a survey to assess demographic characteristics and perceived barriers to physical inactivity. Descriptive statistics, chi-square tests, and multivariate regression analyses were conducted to identify barriers to physical activity and the associations between demographic factors and perceived barriers.

Results

The most commonly perceived barriers to physical activity in the study sample were lack of willpower and lack of energy. After adjusting for other characteristics, overweight/obese participants were more likely than women of normal weight to report social influence and fear of injury as important barriers to exercise. In addition, women whose preferred language was Spanish were more likely than women whose preferred language was English to perceive lack of time, and social influence as important barriers.

Conclusions

The effective encouragement of physical activity among Latina women at risk for type 2 diabetes must address the perceived barriers of lack of willpower and lack of energy. Although all women at risk for type 2 diabetes could benefit from counseling and other strategies to encourage physical activity, these efforts should be targeted toward Spanish-speaking overweight/obese women, who are more likely to perceive barriers to exercise.

Trends in the Prevalence of Overweight and Obesity among Chinese School-Age Children and Adolescents from 2010 to 2015

BACKGROUND

In China, recent rapid economic growth has been associated with increasing prevalence of childhood obesity. This study aimed to provide the most updated prevalence and trends in overweight and obesity among school-age children and adolescents in Shanghai, China, in 2010-2015.

METHODS

Annual physical examination data were collected from 66,410, 43,812, 104,887, 113,667, 119,401, and 109,068 school children and adolescents aged 6-17 in Minhang District, Shanghai, in 2010-2015. The outcome of interest was the prevalence of overweight and obesity based on the body mass index (BMI) criteria from the International Obesity Task Force.

RESULTS

In 2010-2015, the age-adjusted prevalence of overweight and obesity among boys increased from 21.2% to 31.7% and from 10.6% to 16.9% among girls. In 2015, the prevalence of obesity among boys was 9.3% higher than among girls (3.5%). The prevalence for boys was consistently higher than that for girls at each age and across years. The prevalence of overweight and obesity was highest at 11 years: 37.3% for boys and 19.8% for girls.

CONCLUSIONS

The prevalence of overweight and obesity among Chinese urban children and adolescents is comparable to that in developed countries and was still increasing in 2010-2015. The prevalence among boys was alarmingly high. The findings highlight the need to develop public intervention strategies targeting urban children to stop the increasing trend in childhood obesity in China.

Hypertensive Disorders of Pregnancy and Offspring Cardiometabolic Health at Midchildhood: Project Viva Findings

BACKGROUND

Exposure to preeclampsia or gestational hypertension is associated with higher offspring systolic blood pressure (SBP), but less is known about associations with other cardiometabolic risk markers.

METHODS AND RESULTS

We studied 1097 children from the Project Viva cohort born 1999-2002. Exposures were preeclampsia or gestational hypertension and mean maternal SBP in each trimester from prenatal records. Outcomes were research measures in midchildhood (mean 8.0 years) of SBP, overall adiposity, and a global cardiometabolic risk score comprising measures of SBP, waist circumference, glycemia, and lipids. We conducted linear regression analyses adjusted for maternal characteristics and offspring sex and age. In adjusted models, maternal preeclampsia or gestational hypertension (n=98, 9.1%) versus normal blood pressure was associated with slightly higher offspring SBP z-score (0.15 units; 95% confidence interval [CI] -0.03, 0.32) but otherwise predicted better cardiometabolic health markers including metabolic risk z-score (-0.23 units; -95% CI 0.44, -0.03) and several of its components as well as lower body mass index z-score (-0.27 units; 95% CI -0.48, -0.06) and lower fat mass index (-0.91 kg/m2; 95% CI -1.35, -0.47). Similarly, higher mean third-trimester maternal SBP was associated with higher offspring SBP z-score (0.09 units per 10 mm Hg; 95% CI 0.02, 0.16) and lower overall and central adiposity but not with biomarkers of metabolic risk. Results for second-trimester SBP were generally similar. First-trimester blood pressure was associated with higher offspring blood pressure but not with other outcomes.

CONCLUSIONS

Higher maternal late-pregnancy SBP and hypertensive disorders of pregnancy were associated with higher offspring SBP but otherwise better cardiometabolic health.

Effect of experimental change in children's sleep duration on television viewing and physical activity

BACKGROUND

Paediatric observational studies demonstrate associations between sleep, television viewing and potential changes in daytime activity levels.

OBJECTIVE(S)

To determine whether experimental changes in sleep lead to changes in children's sedentary and physical activities.

METHODS

Using a within-subject counterbalanced design, 37 children 8-11 years old completed a 3-week study. Children slept their typical amount during a baseline week and were then randomized to increase or decrease mean time in bed by 1.5 h/night for 1 week; the alternate schedule was completed the final week. Children wore actigraphs on their non-dominant wrist and completed 3-d physical activity recalls each week.

RESULTS

Children reported watching more television (p < 0.001) and demonstrated lower daytime actigraph-measured activity counts per epoch (p = 0.03) when sleep was decreased (compared with increased). However, total actigraph-measured activity counts accrued throughout the entire waking period were higher when sleep was decreased (and children were awake for longer) than when it was increased (p < 0.001).

CONCLUSION(S)

Short sleep during childhood may lead to increased television viewing and decreased mean activity levels. Although additional time awake may help to counteract negative effects of short sleep, increases in reported sedentary activities could contribute to weight gain over time.