New insights in the mechanisms of weight-loss maintenance: Summary from a Pennington symposium

Obesity is a chronic disease that affects more than 650 million adults worldwide. Obesity not only is a significant health concern on its own, but predisposes to cardiometabolic comorbidities, including coronary heart disease, dyslipidemia, hypertension, type 2 diabetes, and some cancers. Lifestyle interventions effectively promote weight loss of 5% to 10%, and pharmacological and surgical interventions even more, with some novel approved drugs inducing up to an average of 25% weight loss. Yet, maintaining weight loss over the long-term remains extremely challenging, and subsequent weight gain is typical. The mechanisms underlying weight regain remain to be fully elucidated. The purpose of this Pennington Biomedical Scientific Symposium was to review and highlight the complex interplay between the physiological, behavioral, and environmental systems controlling energy intake and expenditure. Each of these contributions were further discussed in the context of weight-loss maintenance, and systems-level viewpoints were highlighted to interpret gaps in current approaches. The invited speakers built upon the science of obesity and weight loss to collectively propose future research directions that will aid in revealing the complicated mechanisms involved in the weight-reduced state.

The COVID-19 pandemic and associated increases in experiences of assault violence among black men with low socioeconomic status living in Louisiana

Background

The COVID-19 pandemic has had mental health, social, and economic implications among communities with high levels of social disadvantage; this may have impacted community violence rates. The objective of this study was to characterize overall trends in assault and social disadvantage of patients experiencing assault before and during the COVID-19 pandemic.

Methods

All trauma activations at a level one trauma center serving the entire southeast Louisiana region were included during March–August pre-COVID (2018–2019) and during COVID (2020). ICD-10 E-codes were used to identify trauma intent (assault vs. other). Assaults in this context are defined as physical injuries caused by an act of violence wherein the perpetrator was suspected or confirmed to have intended harm, injury, or death to the victim. Social disadvantage was assessed using the Area Deprivation Index (ADI). Change in the monthly rate of assault-trauma activations was assessed using negative binomial regression with adjustment for race, gender, and injury intent. The study was reviewed and approved by the Louisiana State University Health Sciences Institutional Review Board.

Results

A total of 4,233 trauma activations were included. The majority of activations occurred among men. Assaults increased from 27.5% of all activations pre-Covid to 35.6% during the pandemic. Penetrating trauma similarly increased from 29.5% to 35.7% of all activations. Negative binomial regression demonstrated that in addition to this increase in proportion of assaults relative to all activations, the monthly assault rate also increased by 20% during the pandemic. These increases were driven primarily by increased assaults among Black men. ADI rank did not change between study periods.

Conclusions

Health disparities in violence worsened during the pandemic: increased cases of assault occurred disproportionately among Black men, and assaults persisted in occurring primarily among low-ADI communities where burden had been high pre-pandemic. There is a critical need for resources and support to Black men, to mitigate violence and improve racial heath equity.

PTSD treatment reduces risk of trauma recidivism in a diverse community at a safety-net hospital: A propensity score analysis of data from a level one trauma center

BACKGROUND

Physically-traumatic injuries result in PTSD for approximately 10% of Americans, and this rate is higher among individuals of color and those living in poverty. Individuals of color living in poverty experience lower access to PTSD and other mental health services. Untreated PTSD is associated with increased risk of trauma recidivism, but it is unknown if provision of treatment is actually associated with a subsequent reduction in recidivism risk.

METHODS

For this observational cross-sectional study, data were collected retrospectively from the Trauma Registry of a level one trauma center, safety-net hospital in New Orleans between 2018 and 2020. Receipt of outpatient PTSD treatment at this same hospital was evaluated via chart review of the electronic health record. Propensity score matching was used to balance confounding variables of trauma type (assault vs. non-assault), gender, and race. McNemar test and Cox proportional hazard model were used with the propensity-balanced dataset to assess differences in trauma recidivism according to PTSD treatment status.

RESULTS

Among 5916 trauma activations that occurred in the study period, 92 instances of recidivism occurred. 91 pairs were established after balancing with the propensity score. 1-year recidivism was 2.2% (n = 2) of all treated individuals versus 15.4% (n = 14) of non-treated individuals (p < 0.0001). The marginal risk from the Cox proportional hazard model demonstrated an 82% reduction in risk of recidivism (p = 0.02).

CONCLUSIONS

This study demonstrated that mental health treatment can be used to reduce trauma recidivism. These data were shown among a high-risk population of disproportionately Black men living in a low-income community. Ensuring access to quality mental health care is one way to address the health disparities associated with physically-traumatic injuries.

Development of the PortionSize App for Real-Time Dietary Feedback

Objectives

We developed the PortionSize^TM app (PS app) to provide participants, in real time, an estimate of dietary intake and assistance with following dietary plans and managing body weight. The app provides templates superimposed on user's food images to provide feedback on energy intake (kcal), macronutrients, and food groups. The current pilot study aimed to test the validity of the PS app in a lab-based setting and identify areas for improvement.

Methods

During a lab visit, adults (4 male, 11 female), aged 18–65, BMI 18.5–45 kg/m², majority (93%) White, were trained and used the PS app to assess dietary intake of foods provided, which were also covertly weighed. Participants (n = 14) provided qualitative feedback on PS app usability. Bland-Altman analysis was performed to determine if bias was introduced by increasing energy per food item. Qualitative methods were used to evaluate open-ended responses on PS app desirability.

Results

Across all 69 food items, mean (± SD) energy between PS (162 ± 167 kcal) estimates and weighed food (143 ± 126 kcal) were not statistically different (P = 0.10). The Bland-Altman plot indicated agreement in energy intake between PS estimates and weighed values for lower energy foods, and the PS app overestimated energy intake for higher energy foods (Adj R² = 0.20, P = < 0.001). Beverages (soda and tea), condiments (salad dressing and butter), and specific foods items (apples, chicken, pizza, carrots, and cookies) had the largest error (>30% difference in kcal between PS estimated and weighed foods). These foods have previously been identified as problematic in food intake estimation research. The most frequently mentioned difficulties with the PS app were the food search (7/14), food list options (4/14), and difficulties with PS templates (6/14). Consequently, improvements to the PS app included a new feature for estimating weight of packaged food, new methods for volume estimation of beverages, an updated method for manually entering foods not captured in real-time, an improved food search, updates to the PS food database, and changes to app training instructions.

Conclusions

This pilot study demonstrates promise for the PS app to measure average energy intake. Areas of further app development were identified and actioned and are undergoing additional validity testing.

Funding Sources

R01DK124558, T32 DK64584, P30 DK072476, U54 GM104940.

A Novel Method to Assess Dietary Intake and Obtain Real-Time Dietary Adherence Data: A Pilot Study

Objectives

We developed the PortionSize^TM app (PS) to estimate food intake and dietary adherence based on images of meals captured before and after eating occurs. The PS app provides real-time feedback to users about their dietary intake (energy, nutrients, and food groups) and adherence to specific diets. This pilot study provided initial tests of the validity of the PS app at assessing energy and nutrient intake from simulated meals in a laboratory setting. We also explored participants’ satisfaction with the PS app.

Methods

Fifteen adult participants (aged 18–65 years) were trained to use the app. Participants then used the app to estimate food intake during simulated meals, where participants were provided with a plate of food to represent food provision as well as a plate of leftovers. The amount of food provided as food provision and waste was covertly weighed. Participants completed a six-point user satisfaction survey ranked from 1 (‘extremely dissatisfied’) to six ‘very much satisfied’. Dependent t-tests were performed to compare intake of energy, macronutrients, and food groups (fruits, vegetables, grain, dairy, and protein) from the 15 meals, where intake was estimated with the PS app and compared to directly weighed food. Alpha was set at 0.05.

Results

Of the 15 participants, 73.3% (11) were female, and the mean (± SD) age and body mass index of the participants was 28.0 ± 12.2 years and 24.1 ± 6.6 kg/m², respectively. Energy intake estimated by PS at the meal level (742.9 ± 328.2 kcal) was similar to directly weighed values (659.3 ± 190.7 kcal) and the difference (83.5 ± 287.5 kcal) was not significant (P > .05). No significant differences were found between the two methods (PS and weigh back) for macronutrients (protein, total fat, and carbohydrate), and four food group servings (all P values > .05) except total grains (P value < .05). About 71% of the participants rated the app as a five or six in terms of satisfaction and ease of using the PS app.

Conclusions

Results from this pilot provide preliminary support for the validity of, and user satisfaction with, the PS app. The pilot study identified ways to improve PS. Larger validation studies and further app refinement are ongoing.

Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases; Nutrition Obesity Research Center: PBRC; Louisiana Clinical and Translational Science Center.

Assessing initial validity of the PortionSize app to estimate dietary intake among adults: A pilot and feasibility study (Preprint)

Background

Accurately assessing dietary intake can promote improved nutrition. The PortionSize app (Pennington Biomedical Research Center) was designed to quantify and provide real-time feedback on the intake of energy, food groups, saturated fat, and added sugar.

Objective

This study aimed to assess the preliminary feasibility and validity of estimating food intake via the PortionSize app among adults.

Methods

A total of 15 adults (aged 18-65 years) were recruited and trained to quantify the food intake from a simulated meal by using PortionSize. Trained personnel prepared 15 simulated meals and covertly weighed (weigh back) the amount of food provided to participants as well as food waste. Equivalence tests (±25% bounds) were performed to compare PortionSize to the weigh back method.

Results

Participants were aged a mean of 28 (SD 12) years, and 11 were female. The mean energy intake estimated with PortionSize was 742.9 (SD 328.2) kcal, and that estimated via weigh back was 659.3 (SD 190.7) kcal (energy intake difference: mean 83.5, SD 287.5 kcal). The methods were not equivalent in estimating energy intake (P=.18), and PortionSize overestimated energy intake by 83.5 kcal (12.7%) at the meal level. Estimates of portion sizes (gram weight; P=.01), total sugar (P=.049), fruit servings (P=.01), and dairy servings (P=.047) from PortionSize were equivalent to those estimated via weigh back. PortionSize was not equivalent to weigh back with regard to estimates for carbohydrate (P=.10), fat (P=.32), vegetable (P=.37), grain (P=.31), and protein servings (P=.87).

Conclusions

Due to power limitations, the equivalence tests had large equivalence bounds. Though preliminary, the results of this small pilot study warrant the further adaptation, development, and validation of PortionSize as a means to estimate energy intake and provide users with real-time and actionable dietary feedback.

Social support modifies the negative effects of acculturation on obesity and central obesity in Mexican men

Background: This study examined the moderating role of social support in the acculturation-obesity/central obesity relationship in Mexican American (MA) men and women. Methods: Data from NHANES 1999-2008 were used. Acculturation derived from language use, country of birth and length of residence in the U.S. Social support assessed emotional and financial support. BMI (≥30) and waist circumference (≥88 cm for women; ≥102 cm for men) measured obesity and central obesity, respectively. Weighted multivariate logistic regression models were used to describe associations. Results: Compared to less acculturation, more acculturation was associated with higher odds of obesity (ORs 2.48; 95% CI 1.06-5.83) and central obesity (2.90; 1.39-6.08) among MA men with low/no social support, but not among MA men reporting high social support. The modifying effects was not observed among women. Conclusion: Higher amounts of social support appeared to attenuate the risk of obesity/central obesity associated with acculturation. Interventions enhancing social support maybe effective among acculturated MAs, particularly among men.

Implementing Policy, Systems, and Environmental Change Through Community Coalitions and Extension Partnerships to Address Obesity in Rural Louisiana

Community coalitions and agents funded by the Louisiana State University Agricultural Center's Healthy Communities program implemented multilevel obesity prevention interventions in 3 rural parishes (ie, counties) with an obesity prevalence of 40% or higher. The Healthy Communities coalitions appraised local health concerns through needs assessments and community forums. On the basis of local needs and the evidence base, the coalitions identified and implemented policy, systems, and environmental (PSE) strategies and supporting education to promote healthy behavior change among residents, overcoming barriers in the process. Interventions varied by parish but included Complete Streets implementation plans, healthy retail initiatives, play space improvements, downtown beautification projects, and Smarter Lunchrooms.

Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana

BACKGROUND

Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost.

OBJECTIVE

To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy.

MATERIALS AND METHODS

This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses.

RESULTS

After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62).

CONCLUSION

Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.

Description and Evaluation of Changes to the Rural Nutrition Environment After Implementation of Community-led Policy, System, and Environment Change Strategies (P04-163-19)

Objectives

To assess the nutrition environment in three rural Louisiana parishes (counties) with high rates of poverty (range 25%-41.7%), obesity (>40%), and chronic diseases and to better understand the local nutrition environment in rural, low-income, food insecure areas and to evaluate policy, systems, and environmental (PSE) change strategies aimed at improving the rural food environment.

Methods

Healthy Access, Behaviors, Communities was a community-participatory, multi-level approach to obesity prevention in Louisiana. This evaluation used a descriptive, mixed methods design that focused on 1st and 3rd year project data. Nutrition environments were assessed using the reduced Nutrition Environment Measurement Survey (NEMS) for food stores and restaurants. Pre and post NEMS scores were compared to determine if PSE interventions were effective in improving the nutrition environment.

Results

Overall, 48 food stores and 39 restaurants were assessed at baseline, while 45 food stores and 36 restaurants were assessed at follow-up. Different numbers between baseline and follow-up assessments are due to store closures/openings. Except for the grocery store and fast food environments in Madison parish, the food environments were poor across the targeted parishes, with NEMS scores indicating a lack of healthy grocery items (stores) or a lack of healthy menu options (restaurants). With few exceptions, average NEMS scores generally increased slightly over the assessments, which is a positive trend; however, these positive changes did not result in the food retail environment moving from unhealthy to healthy. Five stores were targeted by the coalition to implement PSE changes. Of the partner stores, the average number of healthy foods available increased in all categories, except skim or low-fat milk, from baseline to post-intervention.

Conclusions

Findings from baseline indicate that the nutrition environment in these poor, rural parishes can present challenges to individuals attempting to meet preventative health recommendations. PSE interventions can improve the nutrition environment in these locations.

Funding Sources

Centers for Disease Control High Obesity 1416 Cooperative agreement.

Knowledge of hepatitis C status moderates the relationship between history of drug treatment and sterile syringe use

High-risk injection related behavior including use of non-sterile syringes is associated with negative health outcomes among people who inject drugs (PWID). Drug treatment programs have been reported to curb hepatitis C (HCV) transmission. This study aims to assess the role of drug treatment programs and knowledge of HCV status, and how they influence current injection-related risk. Data were collected in 2012 by the New Orleans arm of the CDC funded National HIV Behavioral Surveillance. Respondent driven sampling was used to recruit a sample of PWID. The analytic sample consisted of 473 participants. Univariate, bivariate, and linear regression analyses were performed. Findings indicated that history of drug treatment is associated with sterile syringe use among PWID. Further, knowledge of HCV status modifies the relationship between history of drug treatment and sterile syringe use in this sample. These findings highlight the importance of scaling up prevention efforts by expanding testing, counselling, and treatment for HCV among PWID who enter drug treatment facilities.

The adiposity of children is associated with their lifestyle behaviours: a cluster analysis of school-aged children from 12 nations

BACKGROUND

The relationship between children's adiposity and lifestyle behaviour patterns is an area of growing interest.

OBJECTIVES

The objectives of this study are to identify clusters of children based on lifestyle behaviours and compare children's adiposity among clusters.

METHODS

Cross-sectional data from the International Study of Childhood Obesity, Lifestyle and the Environment were used.

PARTICIPANTS

the participants were children (9-11 years) from 12 nations (n = 5710).

MEASURES

24-h accelerometry and self-reported diet and screen time were clustering input variables. Objectively measured adiposity indicators were waist-to-height ratio, percent body fat and body mass index z-scores.

ANALYSIS

sex-stratified analyses were performed on the global sample and repeated on a site-wise basis. Cluster analysis (using isometric log ratios for compositional data) was used to identify common lifestyle behaviour patterns. Site representation and adiposity were compared across clusters using linear models.

RESULTS

Four clusters emerged: (1) Junk Food Screenies, (2) Actives, (3) Sitters and (4) All-Rounders. Countries were represented differently among clusters. Chinese children were over-represented in Sitters and Colombian children in Actives. Adiposity varied across clusters, being highest in Sitters and lowest in Actives.

CONCLUSIONS

Children from different sites clustered into groups of similar lifestyle behaviours. Cluster membership was linked with differing adiposity. Findings support the implementation of activity interventions in all countries, targeting both physical activity and sedentary time.

Role of Age and Acculturation in Diet Quality Among Mexican Americans - Findings From the National Health and Nutrition Examination Survey, 1999-2012

Age and acculturation may play a role in diet quality among Mexican Americans. This study examined diet quality in Mexican Americans by age and whether acculturation influences diet quality across different age groups, using data from the National Health and Nutrition Examination Survey (NHANES). Diet quality, measured by the Healthy Eating Index 2010, improved with age except in categories of dairy, sodium, and refined grains. More acculturation was associated with lower scores in overall diet quality and categories of vegetables, fruits, and sodium and empty calories across almost all ages, but higher scores in grain categories, especially in younger groups. A diet rich in fruits and vegetables but low in fat and sodium should be promoted among more acculturated Mexican Americans, and whole-grain foods should be promoted among young but less acculturated Mexican Americans.

A population-based approach to define body-composition phenotypes

BACKGROUND

Abnormal body compositions such as high adiposity (HA), low muscle mass (LM), or a combination of the 2 [high adiposity with low muscle mass (HA-LM)] are relevant phenotypes, but data on their prevalence and impact on health are still limited. This is largely because of a lack of a consensus definition for these conditions. Of particular interest is the HA-LM phenotype, also termed "sarcopenic obesity," which may confer greater health risk.

OBJECTIVE

We propose a new approach for operationalizing abnormal body-composition phenotypes in a representative adult population.

DESIGN

Whole-body dual-energy X-ray absorptiometry data obtained from the 1999-2004 NHANES were analyzed for 13,236 subjects aged ≥18 y (maximum weight and height of 136 kg and 1.96 m, respectively). Sex- and body mass index (BMI)-specific decile groups of appendicular skeletal muscle index (ASMI; kg/m²) and fat mass index (FMI; kg/m²) were developed. Cutoffs for HA and LM were incorporated into a diagnostic framework to characterize 4 specific body-composition phenotypes-low adiposity with high muscle mass, high adiposity with high muscle mass, low adiposity with low muscle mass, and HA-LM-and a subclassification of the phenotypes into classes I, II, and III.

RESULTS

Abnormal phenotypes were prevalent across the age spectrum and BMI categories. The association between ASMI or FMI and age was modified by sex and BMI. The prevalence of HA-LM in the whole sample was 10.3% in women and 15.2% in men. The prevalence of all subclasses of HA-LM in obese women and men was 14.7% and 22.9%, respectively. HA-LM class III was more prevalent in obese men (2.3%) than in obese women (0.3%).

CONCLUSIONS

We developed sex- and BMI-specific reference curves to harmonize the classification of body-composition phenotypes. The application of this classification will be particularly useful in the identification of cases of sarcopenic obesity. The association of these phenotypes with metabolic deregulation and increased disease risk awaits verification.

Association of metabolic risk with longitudinal physical activity and fitness: coronary artery risk development in young adults (CARDIA)

BACKGROUND

Despite established relationships between physical activity (PA) or physical fitness (fitness) and metabolic risk, the prospective association is not well understood. The purpose of this study was to determine whether metabolic risk in young adults is associated with 20-year PA or fitness trajectories.

METHODS

Young adults were from the Coronary Artery Risk Development in Young Adults (CARDIA) study, baseline ages 18-30 years (n=4161). PA was determined from a self-reported questionnaire administered at baseline and at follow-up exams at years 2, 5, 7, 10, 15, and 20. Fitness (seconds) was estimated from a graded exercise treadmill test at baseline and years 7 and 20. Baseline metabolic risk was calculated using age-adjusted principal components analysis (elevated=top 10% of first factor), for each sex-race group, from mean arterial pressure, glucose, waist circumference, triglycerides, and high-density lipoprotein cholesterol. Repeated measures general linear modeling estimated PA and fitness trajectories over 20 years, separately in sex-race groups, adjusting for age and smoking status.

RESULTS

PA was significantly lower among those with elevated metabolic risk compared with normal risk at baseline and each subsequent time point (black and white men, white women; all P<0.0001; black women P=0.27). Significant and consistent results were also found with fitness trajectories for all sex-race groups (P<0.0001). Despite these lower PA and fitness levels at baseline in young adults with elevated metabolic compared with normal risk, 20-year trajectories declined at similar rates.

CONCLUSION

Elevated metabolic risk is associated with lower levels of PA and fitness in early adulthood, and these differences persist over 20 years.

Impact of small group size on neighbourhood influences in multilevel models

BACKGROUND

Given the growing availability of multilevel data from national surveys, researchers interested in contextual effects may find themselves with a small number of individuals per group. Although there is a growing body of literature on sample size in multilevel modelling, few have explored the impact of group sizes of less than five.

METHODS

In a simulated analysis of real data, the impact of a group size of less than five was examined on both a continuous and dichotomous outcome in a simple two-level multilevel model. Models with group sizes one to five were compared with models with complete data. Four different linear and logistic models were examined: empty models; models with a group-level covariate; models with an individual-level covariate and models with an aggregated group-level covariate. The study evaluated further whether the impact of small group size differed depending on the total number of groups.

RESULTS

When the number of groups was large (N=459), neither fixed nor random components were affected by small group size, even when 90% of tracts had only one individual per tract and even when an aggregated group-level covariate was examined. As the number of groups decreased, the SE estimates of both fixed and random effects were inflated. Furthermore, group-level variance estimates were more affected than were fixed components.

CONCLUSIONS

Datasets in which there is a small to moderate number of groups, with the majority of very small group size (n<5), size may fail to find or even consider a group-level effect when one may exist and also may be underpowered to detect fixed effects.

Predicting adult body mass index-specific metabolic risk from childhood

BACKGROUND

Metabolic risk varies within adult body mass index (BMI) categories; however, the development of BMI-specific metabolic risk from childhood is unknown.

METHODS

The sample included 895 adults (20-38 years of age; 43% male, 34% black) from the Bogalusa Heart Study (1995-2002), who had been measured as children (5-18 years of age) in 1981-1982. Adult metabolic risk was assessed using two definitions: Cardiometabolic risk factor clustering (RFC) included two or more abnormal risk factors [blood pressure, high-density lipoprotein cholesterol (HDL-C), triglycerides, and fasting glucose] and insulin resistance (IR), comprising the top quartile of the homeostasis model of insulin resistance (HOMA-IR) distribution. Logistic regression, within BMI categories, was used to predict adult metabolic risk from childhood mean arterial pressure (MAP), HDL-C, low-density lipoprotein cholesterol (LDL-C), glucose, and triglycerides. Covariates included childhood age, race, sex, adult BMI, and length of follow-up.

RESULTS

The prevalence of the adult abnormal metabolic risk profile varied by definitions of metabolic risk (normal weight, 5%-9%; overweight, 15%-23%; and obese, 40%-53%). The adult abnormal profile was associated with higher childhood LDL-C [IR, odds ratio (OR), 1.95; 95% confidence interval (CI), 1.06-3.58) and insulin (IR, OR, 1.69; CI, 1.10-2.58) in normal-weight adults; lower childhood HDL-C in overweight adults (RFC, OR, 0.61; CI, 0.40-0.94); and higher childhood MAP (RFC, OR, 1.75; CI, 1.24-2.47) and glucose (IR, OR,1.38; CI, 1.06-1.81) in obese adults.

CONCLUSIONS

Some childhood metabolic risk factors are moderately associated with adult BMI-specific metabolic risk profiles. The ability to identify children with high future adult cardiovascular risk may initiate early treatment options.

The pediatric obesity epidemic continues unabated in Bogalusa, Louisiana

OBJECTIVES

To examine 35-year trends in the prevalence of overweight and obesity among children and adolescents from Bogalusa, Louisiana.

PATIENTS AND METHODS

Height and weight were measured for 11653 children and adolescents between 5 and 17 years of age in 8 cross-sectional surveys. The Bogalusa Heart Study contributed data from 1973-1994, and routine school screening provided 2008-2009 data. Trends in mean BMI, mean gender-specific BMI-for-age z scores, prevalence of overweight/obesity (BMI > or = 85th percentile), and prevalence of obesity (BMI > or = 95th percentile) according to age, race, and gender were examined.

RESULTS

Since 1973-1974, the proportion of children and adolescents aged 5 to 17 years who are overweight (overweight plus obese) has more than tripled, from 14.2% to 48.4% in 2008-2009. Similarly, the proportion of obese children and adolescents has increased more than fivefold from 5.6% in 1973-1974 to 30.8% in 2008-2009. The prevalence of overweight or obesity, and secular changes, were similar among black and white boys and girls.

CONCLUSIONS

In semirural Bogalusa, the childhood obesity epidemic has not plateaued, and nearly half of the children are now overweight or obese.

Quality of care for HIV infection provided by Ryan White Program-supported versus Non-Ryan White Program-supported facilities

BACKGROUND

The Ryan White HIV/AIDS Care Act (now the Treatment Modernization Act; Ryan White Program, or RWP) is a source of federal public funding for HIV care in the United States. The Health Services and Resources Administration requires that facilities or providers who receive RWP funds ensure that HIV health services are accessible and delivered according to established HIV-related treatment guidelines. We used data from population-based samples of persons in care for HIV infection in three states to compare the quality of HIV care in facilities supported by the RWP, with facilities not supported by the RWP.

METHODOLOGY/PRINCIPAL FINDINGS

Within each area (King County in Washington State; southern Louisiana; and Michigan), a probability sample of patients receiving care for HIV infection in 1998 was drawn. Based on medical records abstraction, information was collected on prescription of antiretroviral therapy according to treatment recommendations, prescription of prophylactic therapy, and provision of recommended vaccinations and screening tests. We calculated population-level estimates of the extent to which HIV care was provided according to then-current treatment guidelines in RWP-supported and non-RWP-supported facilities. For all treatment outcomes analyzed, the compliance with care guidelines was at least as good for patients who received care at RWP-supported (vs non-RWP supported) facilities. For some outcomes in some states, delivery of recommended care was significantly more common for patients receiving care in RWP-supported facilities: for example, in Louisiana, patients receiving care in RWP-supported facilities were more likely to receive indicated prophylaxis for Pneumocystis jirovecii pneumonia and Mycobacterium avium complex, and in all three states, women receiving care in RWP-supported facilities were more likely to have received an annual Pap smear.

CONCLUSIONS/SIGNIFICANCE

The quality of HIV care provided in 1998 to patients in RWP-supported facilities was of equivalent or better quality than in non-RWP supported facilities; however, there were significant opportunities for improvement in all facility types. Data from population-based clinical outcomes surveillance data can be used as part of a broader strategy to evaluate the quality of publicly-supported HIV care.

Use of tissue culture cell lines to evaluate HIV antiviral resistance

Most current assays of HIV antiviral resistance are based on either sequencing of viral genes (genotypic assays) or amplification and insertion of these genes into standardized virus backbones and culture. These latter are called phenotypic assays. But the only generally accepted phenotypic assay is based upon culture of intact patient virus, performed in phytohemagglutinin-activated peripheral blood mononuclear cells (PHA blasts) in the presence of differing drug concentrations. However, PHA blast culture is difficult and not always reproducible. Therefore we have sought cell lines that may produce more predictable results, yet faithfully mirror results in PHA blasts. We have compared 10 different cell lines for receptor and coreceptor expression, growth of laboratory-adapted strains of HIV, growth by direct inoculation of PBMC from infected patients, and in assays of antiviral drug effects. One of these cell lines, C8166-R5, is statistically not inferior to CD8-depleted PHA blasts for culturing HIV from the peripheral blood cells of patients. The effective concentrations of antiviral drugs of all classes were similar when assayed in C8166-R5 or PHA blasts. Known drug-resistant isolates grown in C8166-R5 demonstrated the predicted effects. We followed a patient longitudinally and demonstrated that resistance testing in C8166-R5 was predictive of clinical outcome. These experiments represent the first steps in developing a clinically useful phenotypic drug resistance assay based upon culturing the patient's own virus.

The New Orleans HIV outpatient program patient experience with Hurricane Katrina

In an effort to understand better the experience of New Orleans HIV Outpatient Program patients surviving Hurricane Katrina, a survey was conducted on a convenience sample of 175 subjects who had returned to the clinic between January and April 2006. Although 90% of patients eventually evacuated, only 43% left the city prior to Hurricane Katrina. Twenty-six percent were exposed to flood waters, and some stayed in shelters, usually longer than two weeks. Antiretroviral treatment interruption was common and in most persons was due to running out of medications. The New Orleans experience with Hurricane Katrina may help other HIV clinics planning for disasters.

Six months later: The effect of Hurricane Katrina on health care for persons living with HIV/AIDS in New Orleans

Nearly 13,000 Louisiana residents with HIV/AIDS were estimated to be living in areas affected by Hurricane Katrina. Although minimal general outpatient primary care services were available within a few weeks following the hurricane in New Orleans, access to antiretroviral medications was an early problem. The largest HIV care provider, the Medical Center of Louisiana at New Orleans HIV Outpatient Program (HOP), was able to assist in obtaining medications mid-October and opened an HIV clinic the first week of November in a temporary location. Services have slowly expanded in the five months since the HOP clinic opened but remain limited. Six months following the hurricane, microbiologic studies are still unable to be performed in clinic and uninsured patients must travel at least 70 miles for subspecialty care. The authors suggest recommendations for disaster planning for other centers caring for persons with HIV/AIDS based on the New Orleans experience.

Electrocardiographic findings in 888 patients > or =90 years of age

The oldest old are the fastest growing component of many national populations. No large-scale analysis of electrocardiographic findings in this group exists to date. This study cataloged the frequencies of specific electrocardiographic (ECG) findings in the target population and compared the frequencies of these findings by gender and race. The electrocardiograms of 888 subjects aged > or =90 years presenting for any reason were retrospectively analyzed using standard criteria for 128 separate ECG findings. Left ventricular enlargement (28%), first-degree atrioventricular block (16%), and atrial fibrillation (15%) were the most common abnormalities found in the population as a whole. In contrast to previous studies, which demonstrated a predominance of left-axis deviation, 91% of the electrocardiograms analyzed in our study demonstrated a mean frontal QRS axis ranging from -30 degrees to +90 degrees . Sinus rhythm was observed in 79% of the population. More Caucasians than African-Americans had atrial fibrillation (19% vs 12%, p = 0.004). Women had more normal ECG results than men (6% vs 2%, p = 0.02), and more women demonstrated complete right bundle branch block (13% vs 7%, p = 0.002). In conclusion, few patients aged > or =90 years who have their electrocardiograms recorded at hospitals have completely normal ECG results. The frequencies of some ECG findings in the target population vary by gender and race.

A two-stage sampling method for clinical surveillance of individuals in care for HIV infection in the United States

OBJECTIVES

The goals of this study were two-fold: (1) to describe methods for drawing a population-based sample of individuals in care for HIV infection and (2) to compare data from the sample with data from existing surveillance systems that describe care for HIV.

METHODS

The authors implemented a two-stage sampling method, using local HIV/AIDS surveillance data as a sampling frame of HIV care providers in three states. At selected providers, medical records of a random sample of patients were abstracted.

RESULTS

The medical records of a number of patients, ranging from 253 to 374 individuals per state, were abstracted. The demographics of sampled individuals and of individuals reported to the local HIV/AIDS surveillance program were similar; however, differences existed in the proportion of individuals receiving HIV care consistent with treatment guidelines between the sample and a contemporary facility-based supplemental surveillance project. The median design effect for outcomes collected in the sample was 1.8 (range=0.5-29.6).

CONCLUSIONS

This survey method is feasible for collecting population-based data on patients in care for HIV. Sample size and some design elements should be changed in future studies to increase precision of estimates and usefulness of data for local planning and evaluation.

CDC HIV prevention indicators: monitoring and evaluating HIV prevention in the USA

OBJECTIVE

This study selected and field tested indicators to track changes in HIV prevention effectiveness in the USA.

METHODS

During 1996-1999, the Centers for Disease Control and Prevention held two 2 day expert consultations with more than 80 national, state and local experts. A consensus-driven, evidence-based approach was used to select 70 indicators, which had to be derived from existing data, available in more than 25 states, and meaningful to state health officials in monitoring HIV. A literature review was performed for each indicator to determine general relevance, validity, and reliability. Two field tests in five US sites determined accessibility, feasibility, and usefulness.

RESULTS

The final 37 core indicators represent four categories: biological, behavioral, services, and socio-political. Specific indicators reflect the epidemic and associated risk factors for men who have sex with men, injection drug users, heterosexuals at high risk, and childbearing women.

CONCLUSIONS

Despite limitations, the indicators sparked the regular, proactive integration and review of monitoring data, facilitating a more effective use of data in HIV prevention community planning.

Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994

OBJECTIVES

The purposes of this study were to report the neurodevelopmental, neurosensory, and functional outcomes of 1151 extremely low birth weight (401-1000 g) survivors cared for in the 12 participating centers of the National Institute of Child Health and Human Development Neonatal Research Network, and to identify medical, social, and environmental factors associated with these outcomes.

STUDY DESIGN

A multicenter cohort study in which surviving extremely low birth weight infants born in 1993 and 1994 underwent neurodevelopmental, neurosensory, and functional assessment at 18 to 22 months' corrected age. Data regarding pregnancy and neonatal outcome were collected prospectively. Socioeconomic status and a detailed interim medical history were obtained at the time of the assessment. Logistic regression models were used to identify maternal and neonatal risk factors for poor neurodevelopmental outcome.

RESULTS

Of the 1480 infants alive at 18 months of age, 1151 (78%) were evaluated. Study characteristics included a mean birth weight of 796 +/- 135 g, mean gestation (best obstetric dates) 26 +/- 2 weeks, and 47% male. Birth weight distributions of infants included 15 infants at 401 to 500 g; 94 at 501 to 600 g; 208 at 601 to 700 g; 237 at 701 to 800 g; 290 at 801 to 900 g; and 307 at 901 to 1000 g. Twenty-five percent of the children had an abnormal neurologic examination, 37% had a Bayley II Mental Developmental Index <70, 29% had a Psychomotor Developmental Index <70, 9% had vision impairment, and 11% had hearing impairment. Neurologic, developmental, neurosensory, and functional morbidities increased with decreasing birth weight. Factors significantly associated with increased neurodevelopmental morbidity included chronic lung disease, grades 3 to 4 intraventricular hemorrhage/periventricular leukomalacia, steroids for chronic lung disease, necrotizing enterocolitis, and male gender. Factors significantly associated with decreased morbidity included increased birth weight, female gender, higher maternal education, and white race.

CONCLUSION

ELBW infants are at significant risk of neurologic abnormalities, developmental delays, and functional delays at 18 to 22 months' corrected age.

Postglacial migration and the loss of allozyme variation in northern populations of Asclepias exaltata (Asclepiadaceae)

The recent Wisconsin glaciation has provided opportunities for examining the effects of postglacial recolonization on the population genetics of plant and animal communities. In this study allozyme Variation was examined in 19 populations of the herbaceous perennial Asclepias exaltata occurring in previously glaciated regions of North America. These northern populations of A. exaltata possess significantly fewer polymorphic loci (46.31 ± 2.7; mean ± 1 SD), alleles per polymorphic locus (1.84 ± 0.24), and expected heterozygosity (0.133 ± 0.031) than populations found in the Pleistocene refugium in the southern Appalachians. Population-level allozyme diversity decreased linearly from south to north and from east to west. Nineteen uncommon alleles previously observed in southern Appalachian populations were undetected in the northern region. Seven common alleles exhibited a clinal change in allele frequency. Of these, only Pgd-1a and Mnr-1c were at low-frequency in the southern Appalachians and increased significantly with increasing latitude and longitude, respectively. Despite this loss of allozyme diversity following postglacial migration, northern populations of A. exaltata have higher allozyme diversity and lower population differentiation (G" = 0.1 17) than mean values for other long-lived herbaceous perennials. Increased habitat fragmentation in northern regions and potential habitat loss in the southern Appalachians are likely to reduce the historically rich gene pool that has provided the genetic stock for postglacial recoveries.

The small for gestational age infant: accelerated or delayed pulmonary maturation? Increased or decreased survival?

OBJECTIVE

Small for gestational age (SGA) neonates have been considered to have accelerated pulmonary maturation and thus a lower risk for respiratory distress syndrome (RDS) than appropriate for gestational age (AGA) neonates. This, however, has not been thoroughly examined. Therefore, we compared SGA infants with AGA infants of the same gestational age (GA) with respect to risk of RDS, respiratory failure, or death.

POPULATION

An indigent population born in a large county hospital.

METHODS

Multivariate analyses were performed controlling for GA alone or for GA, race, sex, and congenital anomalies. Because the proper method to identify SGA infants is unclear, we performed separate analyses using different GA estimates (obstetric or pediatric) and intrauterine growth grids (hospital-specific grids or grids for a healthy, geographically-defined population).

RESULTS

SGA infants did not fare better than AGA infants in any analysis. SGA infants had significantly increased risk in some analyses of RDS and in almost all analyses of respiratory failure or death. The risk associated with being SGA was generally comparable to that associated with male sex or White race.

CONCLUSION

The concept that intrauterine growth retardation accelerates lung maturation and improves outcome is not supported in comparisons of SGA and AGA infants of the same GA, sex, and race. This widely accepted concept deserves critical re-evaluation.

How should parents be informed about major procedures? An exploratory trial in the neonatal period

The current doctrine of informed consent in medical practice may require the provision of more information than is understandable or desired by some parents. We conducted an exploratory trial comparing: (1) detailed risk/benefit disclosure provided both verbally and in writing and (2) flexible disclosure consisting of a brief verbal description supplemented with detailed verbal and written disclosure if desired by the mother. Information about mechanical ventilation was presented to 26 mothers of newborns at risk for respiratory failure. Of the 13 mothers in the flexible disclosure group, seven (54%) desired only brief verbal disclosure. Despite poor recall of information, most mothers were satisfied with the information provided. There was no evidence that the detailed disclosure group had greater maternal satisfaction or less maternal anxiety. Flexible disclosure as evaluated in this study had no important disadvantages relative to detailed disclosure. Methods of providing information to better meet the wants and needs of parents deserve further study.

Chronic neuropsychological and neurological impairment following acute exposure to a solvent mixture of toluene and methyl ethyl ketone (MEK)

A 38 year-old laborer experienced solvent intoxication during each of two spray paintings of a dump truck and other heavy equipment in an enclosed, unventilated garage. The paint base consisted primarily of toluene and methyl ethyl ketone. Nausea, headaches, dizziness, respiratory difficulty and other symptoms began after exposures. Over the next several days he developed impaired concentration, memory loss and cerebellar signs including an intention tremor, gait ataxia and dysarthria. MRI of the brain and EGG early in the work-up were normal, although later MRIs demonstrated fluid collection over the left parietal area. Examination by a toxicologist and neurologist revealed likely toxic encephalopathy with dementia and cerebellar ataxia. Three formal neuropsychological assessments over 2 1/2 years quantified cognitive, motor and behavioral changes. Despite similar findings in chronic exposure to these solvents, lasting sequelae following acute exposure have not been widely reported.