Childhood stunting is highly clustered in Northern Province of Rwanda: A spatial analysis of a population-based study

Background

In Northern Province, Rwanda, stunting is common among children aged under 5 years. However, previous studies on spatial analysis of childhood stunting in Rwanda did not assess its randomness and clustering, and none were conducted in Northern Province. We conducted a spatial-pattern analysis of childhood undernutrition to identify stunting clusters and hotspots for targeted interventions in Northern Province.

Methods

Using a household population-based questionnaire survey of the characteristics and causes of undernutrition in households with biological mothers of children aged 1-36 months, we collected anthropometric measurements of the children and their mothers and captured the coordinates of the households. Descriptive statistics were computed for the sociodemographic characteristics and anthropometric measurements. Spatial patterns of childhood stunting were determined using global and local Moran's I and Getis-Ord Gi* statistics, and the corresponding maps were produced.

Results

The z-scores of the three anthropometric measurements were normally distributed, but the z-scores of height-for-age were generally lower than those of weight-for-age and weight-for-height, prompting us to focus on height-for-age for the spatial analysis. The estimated incidence of stunting among 601 children aged 1-36 months was 27.1 %. The sample points were interpolated to the administrative level of the sector. The global Moran's I was positive and significant (Moran's I = 0.403, p < 0.001, z-score = 7.813), indicating clustering of childhood stunting across different sectors of Northern Province. The local Moran's I and hotspot analysis based on the Getis-Ord Gi* statistic showed statistically significant hotspots, which were strongest within Musanze district, followed by Gakenke and Gicumbi districts.

Conclusion

Childhood stunting in Northern Province showed statistically significant hotspots in Musanze, Gakenke, and Gicumbi districts. Factors associated with such clusters and hotspots should be assessed to identify possible geographically targeted interventions.

A randomized, controlled trial of a Nordic, protein-reduced complementary diet in infants: effects on body composition, growth, biomarkers and dietary intake at 12 and 18 months

BACKGROUND

High intake of protein and low intake of plant-based foods during complementary feeding (CF) can contribute to negative long-term health effects.

OBJECTIVES

To investigate the effects of a protein-reduced, Nordic complementary diet on body composition, growth, biomarkers and dietary intake, compared to current Swedish dietary recommendations for infants at 12 and 18 months.

DESIGN

Healthy, term infants (n=250) were randomly allocated to either a Nordic group (NG) or a conventional group (CG). From 4-6 months, NG participants received repeated exposures of Nordic taste portions. From 6 months to 18 months, NG was supplied with Nordic homemade baby food recipes, protein-reduced baby food products and parental support. CG followed the current Swedish dietary recommendations. Measurements of body composition, anthropometry, biomarkers and dietary intake were collected from baseline and at 12 and 18 months.

RESULTS

Of the 250 infants, 82% (n=206) completed the study. There were no group differences in body composition or growth. In NG, protein intake, blood urea nitrogen (BUN) and plasma insulin-like growth factor 1 (IGF-1) were lower compared to CG at 12 and 18 months. Infants in NG consumed 42-45% more fruits and vegetables compared to CG at 12 and 18 months, which was reflected in a higher plasma folate at 12 and 18 months. There were no between-group differences in energy intake (EI) or iron status.

CONCLUSIONS

Introduction of a predominantly plant-based, protein-reduced diet as part of complementary feeding is feasible and can increase fruit and vegetable intake.

CLINICAL TRIAL REGISTRY

OTIS; ClinicalTrials.gov registration number NCT02634749.

The incidence of childhood-onset type 1 diabetes, time trends and association with the population composition in Sweden: a 40 year follow-up

AIMS/HYPOTHESIS

During the 1980s and 1990s, the incidence of childhood-onset type 1 diabetes more than doubled in Sweden, followed by a plateau. In the present 40 year follow-up, we investigated if the incidence remained stable and whether this could be explained by increased migration from countries reporting lower incidences.

METHODS

We used 23,143 incident cases of childhood-onset type 1 diabetes reported between 1978 and 2019 to the nationwide, population-based Swedish Childhood Diabetes Registry and population data from Statistics Sweden. Generalised additive models and ANOVA were applied to analyse the effects of onset age, sex, time trends and parental country of birth and interaction effects between these factors.

RESULTS

The flattening of the incidence increase seems to remain over the period 2005-2019. When comparing the incidence of type 1 diabetes for all children in Sweden with that for children with both parents born in Sweden, the trends were parallel but at a higher level for the latter. A comparison of the incidence trends between individuals with Swedish backgrounds (high diabetes trait) and Asian backgrounds (low diabetes trait) showed that the Asian subpopulation had a stable increase in incidence over time.

CONCLUSIONS/INTERPRETATION

In Sweden, the increase in incidence of childhood-onset type 1 diabetes in the late 20th century has been approaching a more stable albeit high level over the last two decades. Increased immigration from countries with lower incidences of childhood-onset type 1 diabetes does not provide a complete explanation for the observed levelling off.

Risk of cancer in young and middle-aged adults with childhood-onset type 1 diabetes in Sweden-A prospective cohort study

AIMS/HYPOTHESIS

In persons with type 1 diabetes, the risk of cancer remains controversial. We wanted to examine the excess risk of cancer in a large population-based cohort diagnosed with type 1 diabetes before 15 years of age.

STUDY POPULATION AND METHODS

From 1 July 1977 to 31 December 2013, we prospectively and on a national scale included 18,724 persons (53% men) with childhood-onset type 1 diabetes. For each person with type 1 diabetes, we selected four referents, matched for the date at birth and municipality of living at the time when the case developed diabetes. Cases and referents were linked to national registers of cancer and of the cause of death.

RESULTS

A total of 125 persons (61% women) with diabetes had 135 different cancers, all diagnosed after the diabetes diagnosis. The median duration from diabetes diagnosis to first cancer diagnosis was 19 years (interquartile range 10-26). The median age at cancer diagnosis in the diabetes group was 28 years (interquartile range 20-35). The overall standardized incidence ratio (95%), using the Swedish general population as referents for women with diabetes was 1.28 (1.02, 1.58) and when comparing women with diabetes with matched referents, we found a hazard ratio of 1.42 (1.10, 1.85). No elevated risk was seen for men. Cancers of the breast and testis were the most common types in women and men respectively.

CONCLUSIONS

Women with childhood-onset type 1 diabetes had a small but significantly elevated risk of cancer. No such tendency was seen for men. The reason behind this is unclear.

How children with juvenile idiopathic arthritis view participation and communication in healthcare encounters: a qualitative study

BACKGROUND

Children report that they do not participate in their healthcare as much as they want, despite having the lawful right to form their own views and the right to express those views freely in all matters affecting them. Children and parents appeared to be more satisfied when healthcare professionals (HCP) use a participatory style in healthcare encounters.

AIM

To explore how children, adolescents and young adults with Juvenile Idiopathic Arthritis (JIA) and parents of children with JIA view their participation and communication in healthcare encounters with healthcare professionals.

METHODS

Using a qualitative study design, participatory workshops were held separately for children and young adults with JIA and parents of children with JIA. The workshop data were analysed with Graneheim and Lundman's Qualitative Content Analysis resulting in one main theme and two subthemes.

RESULTS

The theme "Feeling alienated or familiar with healthcare encounters" illuminates how children felt alienated at healthcare encounters if they found the encounters emotionally distressing. Children could withhold information regarding their health and function from both HCPs and their family and friends. The subtheme "Distancing oneself from healthcare" describe why children felt reluctant to engage in the healthcare encounters and experienced difficulty expressing how they really felt. The subtheme "Being a normal event in life" describe how children felt more comfortable over time engaging with HCPs when they knew what would happen, and felt that HCPs gave them the necessary support they needed to participate.

CONCLUSIONS

Children's participation in healthcare encounters varied depending if children felt alienated or familiar to the healthcare situations. Children distance themselves and are reluctant to engage in healthcare encounters if they find them emotionally distressing and feel disregarded. Over time, children can become more familiar and at ease with healthcare situations when they feel safe and experience personal and positive encounters. When the children are prepared for the encounter, provided with the space and support they want and receive tailored help they are more enabled to participate.

Perinatal factors and hospitalisations for severe childhood infections: a population-based cohort study in Sweden

OBJECTIVE

To examine the association between perinatal factors and hospitalisations for sepsis and bacterial meningitis in early childhood (from 28 days to 2 years of age).

DESIGN

A population-based cohort study. The Swedish Medical Birth Register was combined with the National Inpatient Register, the Cause of Death Register, the Total Population Register and the Longitudinal integration database for health insurance and labour market studies. Associations between perinatal factors and hospitalisations were examined using negative binomial regression models.

SETTING

Sweden.

PARTICIPANTS

1 406 547 children born in Sweden between 1997 and 2013.

MAIN OUTCOME MEASURES

Hospital admissions for sepsis and bacterial meningitis recorded between 28 days and 2 years of life.

RESULTS

Gestational age was inversely associated with severe infections, that is, extreme prematurity was strongly associated with an increased risk of sepsis, adjusted incidence rate ratio (aIRR) 10.37 (95% CI 6.78 to 15.86) and meningitis aIRR 6.22 (95% CI 2.28 to 16.94). The presence of congenital malformation was associated with sepsis aIRR 3.89 (95% CI 3.17 to 4.77) and meningitis aIRR 1.69 (95% CI 1.09 to 2.62). Moreover, children born small or large for gestational age were more likely to be hospitalised for sepsis and children exposed to maternal smoking were more likely to be hospitalised for meningitis.

CONCLUSIONS

Prematurity and several other perinatal factors were associated with an increased risk of severe infections in young children. Therefore, clinical guidelines for risk assessment of infections in young children should consider perinatal factors.

Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS)

OBJECTIVE

This study aimed to compare metabolic control measured as hemoglobin A1c (HbA1c), the risk of severe hypoglycemia, and body composition measured as body mass index standard deviation scores (BMI-SDS) in a nationwide sample of children and adolescents with Type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI), respectively.

RESEARCH DESIGN AND METHODS

Longitudinal data from 2011 to 2016 were extracted from the Swedish National Quality Register (SWEDIABKIDS) with both cross-sectional (6 years) and longitudinal (4 years) comparisons. Main end points were changes in HbA1c, BMI-SDS, and incidence of severe hypoglycemia.

RESULTS

Data were available from 35,624 patient-years (54% boys). In general, HbA1c decreased approximately 0.5% (2-5 mmol/mol) from 2011 to 2016 (p_trend  < 0.001) and the use of CSII increased in both sexes and all age groups. Mean HbA1c was 0.1% (0.7-1.5 mmol/mol) lower in the CSII treated group. Teenagers, especially girls, using CSII tended to have higher BMI-SDS. There was no difference in the number of hypoglycemias between CSII and MDI over the years 2011-2016.

CONCLUSIONS

There was a small decrease in HbA1c with CSII treatment but of little clinical relevance. Overall, mean HbA1c decreased in both sexes and all age groups without increasing the episodes of severe hypoglycemia, indicating that other factors than insulin method contributed to a better metabolic control.

How children and adolescents with juvenile idiopathic arthritis participate in their healthcare: health professionals' views

BACKGROUND

The study explores how healthcare professionals view participation of children and adolescents with juvenile idiopathic arthritis, in healthcare encounters.

METHODS

This qualitative study includes focus groups of HCPs from different professions. The interviews were analysed with qualitative content analysis.

RESULTS

The theme "Creating an enabling arena" illuminates how HCPs face possibilities and challenges when enabling children to communicate and participate in clinical encounters. HCPs, parents, and the healthcare system need to adjust to the child. The sub-theme "Bringing different perspectives" describes how children and their parents cooperate and complement each other during healthcare encounters. The sub-theme "Building a safe and comfortable setting" includes how HCPs address the child's self-identified needs and make the child feel comfortable during encounters. The sub-theme "Facilitating methods in a limiting organisation" includes how HCPs' working methods and organization may help or hinder child participation during encounters.

CONCLUSIONS

HCPs encourage children and adolescents to make their views known during healthcare encounters by creating an enabling arena. Collaboration and building good relationships between the child, the parents and the HCPs, before and during the healthcare encounters, can help the child express their wishes and experiences. Clinical examinations and use of technology, such as photos, films and web-bases questionnaires can be a good start for a better child communication in healthcare encounters.IMPLICATIONS FOR REHABILITATIONHealthcare professionals in JIA teams experience that they can facilitate communication and participation with children and adolescents in healthcare encounters.When healthcare professionals enable both children, adolescents and their parents to bring their perspectives, these views complement one another and enrich information during healthcare encounters.Children and adolescents are more empowered to participate, when healthcare professionals create a good relationship with the child and their parents, and strengthen the child's knowledge, confidence and autonomy.

Vitamin D status and cardiometabolic risk markers in young Swedish children: a double-blind randomized clinical trial comparing different doses of vitamin D supplements

BACKGROUND

Observational studies have linked low vitamin D status to unfavorable cardiometabolic risk markers, but double-blinded vitamin D intervention studies in children are scarce.

OBJECTIVES

The aim was to evaluate the effect of different doses of a vitamin D supplement on cardiometabolic risk markers in young healthy Swedish children with fair and dark skin.

METHODS

Cardiometabolic risk markers were analyzed as secondary outcomes of a double-blind, randomized, milk-based vitamin D intervention trial conducted during late fall and winter in 2 areas of Sweden (latitude 63°N and 55°N, respectively) in both fair- and dark-skinned 5- to 7-y-old children. During the 3-mo intervention, 206 children were randomly assigned to a daily milk-based vitamin D3 supplement of either 10 or 25 µg or placebo (2 µg; only at 55°N). Anthropometric measures, blood pressure, serum 25-hydroxyvitamin D [25(OH)D], total cholesterol, HDL cholesterol, apoA-I, apoB, and C-reactive protein (CRP) were analyzed and non-HDL cholesterol calculated at baseline and after the intervention.

RESULTS

At baseline, serum 25(OH)D was negatively associated with systolic and diastolic blood pressure (β = -0.194; 95% CI: -0.153, -0.013; and β = -0.187; 95% CI: -0.150, -0.011, respectively). At follow-up, there was no statistically significant difference in any of the cardiometabolic markers between groups.

CONCLUSIONS

We could not confirm any effect of vitamin D supplementation on serum lipids, blood pressure, or CRP in healthy 5- to 7-y-old children. The study was registered at clinicaltrials.gov (NCT01741324).

Effectiveness of vitamin D supplementation in Swedish children may be negatively impacted by BMI and serum fructose

In regions where sunlight exposure is limited, dietary vitamin D intake becomes important for maintaining status. However, Swedish children have been shown to have deficient or marginal status during the winter months even if the recommended dietary intake is met. Since low vitamin D status has been associated with several disease states, this study investigated the metabolic changes associated with improved vitamin D status due to supplementation. During the 3 winter months, 5-7-year-old children (n=170) in northern (Umeå, 63° N) and southern (Malmö, 55° N) Sweden were supplemented daily with 2 (placebo), 10 or 25 μg of vitamin D. BMI-for-age z-scores (BAZ), S-25(OH)D concentrations, insulin concentrations and the serum metabolome were assessed at baseline and follow-up. S-25(OH)D concentrations increased significantly in both supplementation groups (P<.001). Only arginine and isopropanol concentrations exhibited significant associations with improvements in S-25(OH)D. Furthermore, the extent to which S-25(OH)D increased was correlated with a combination of baseline BAZ and the change in serum fructose concentrations from baseline to follow up (P=.012). In particular, the change in S-25(OH)D concentrations was negatively correlated (P=.030) with the change in fructose concentrations for subjects with BAZ ≥0 and consuming at least 20 μg vitamin D daily. These results suggest that although the metabolic changes associated with improved vitamin D status are small, the effectiveness of dietary supplementation may be influenced by serum fructose concentrations.

Fluid restriction negatively affects energy intake and growth in very low birthweight infants with haemodynamically significant patent ductus arteriosus

AIM

We explored if fluid restriction in very low birthweight (VLBW) infants with a haemodynamically significant patent ductus arteriosus (PDA) affected energy and protein intakes and growth.

METHODS

Retrospectively, we identified 90 VLBW infants that were admitted to Umea University Hospital, Sweden, between 2009 and 2012: 42 with and 48 without haemodynamically significant PDA (hsPDA). Anthropometric, fluid, energy and protein intake data during the first 28 days of life were expressed as z-scores.

RESULTS

In the 42 infants diagnosed with hsPDA, fluid intake was restricted after diagnosis, resulting in a decrease in energy and protein intake. No decrease was observed in the other 48 infants in the cohort. Multivariate analysis showed that the z-score of weight change depended on both ductus arteriosus status and energy intake; thus, infants with hsPDA did not grow as expected with the energy provided to them.

CONCLUSION

Energy and protein intake was diminished in prematurely born infants with hsPDA when fluid was restricted after diagnosis. The initial reduction in intakes may have contributed to the lower postnatal growth observed in these infants.

Perinatal risk factors for type 1 diabetes revisited: a population-based register study

AIMS/HYPOTHESIS

Single-centre studies and meta-analyses have found diverging results as to which early life factors affect the risk of type 1 diabetes during childhood. We wanted to use a large, nationwide, prospective database to further clarify and analyse the associations between perinatal factors and the subsequent risk for childhood-onset type 1 diabetes using a case-control design.

METHODS

The Swedish Childhood Diabetes Register was linked to the Swedish Medical Birth Register and National Patient Register, and 14,949 cases with type 1 diabetes onset at ages 0-14 years were compared with 55,712 matched controls born from the start of the Medical Birth Register in 1973 to 2013. After excluding confounders (i.e. children multiple births, those whose mother had maternal diabetes and those with a non-Nordic mother), we used conditional logistic regression analyses to determine risk factors for childhood-onset type 1 diabetes. We used WHO ICD codes for child and maternal diagnoses.

RESULTS

In multivariate analysis, there were small but statistically significant associations between higher birthweight z score (OR 1.08, 95% CI 1.06, 1.10), delivery by Caesarean section (OR 1.08, 95% CI 1.02, 1.15), premature rupture of membranes (OR 1.08, 95% CI 1.01, 1.16) and maternal urinary tract infection during pregnancy (OR 1.39, 95% CI 1.04, 1.86) and the subsequent risk of childhood-onset type 1 diabetes. Birth before 32 weeks of gestation was associated with a lower risk of childhood-onset type 1 diabetes compared with full-term infants (OR 0.54, 95% CI 0.38, 0.76), whereas birth between 32 and 36 weeks' gestation was associated with a higher risk (OR 1.24, 95% CI 1.14, 1.35). In subgroup analyses (birth years 1992-2013), maternal obesity was independently associated with subsequent type 1 diabetes in the children (OR 1.27, 95% CI 1.15, 1.41) and rendered the association with Caesarean section non-significant. In contrast to previous studies, we found no association of childhood-onset type 1 diabetes with maternal-child blood-group incompatibility, maternal pre-eclampsia, perinatal infections or treatment of the newborn with phototherapy for neonatal jaundice. The proportion of children with neonatal jaundice was significantly higher in the 1973-1982 birth cohort compared with later cohorts.

CONCLUSIONS/INTERPRETATION

Perinatal factors make small but statistically significant contributions to the overall risk of childhood-onset type 1 diabetes. Some of these risk factors, such as maternal obesity, may be amendable with improved antenatal care. Better perinatal practices may have affected some previously noted risk factors over time.

Protein-Reduced Complementary Foods Based on Nordic Ingredients Combined with Systematic Introduction of Taste Portions Increase Intake of Fruits and Vegetables in 9 Month Old Infants: A Randomised Controlled Trial

Abstract: Fruits and vegetables are healthy foods but under-consumed among infants and children. Approaches to increase their intake are urgently needed. This study investigated the effects of a systematic introduction of taste portions and a novel protein-reduced complementary diet based on Nordic foods on fruit and vegetable intake, growth and iron status to 9 months of age. Healthy, term infants (n = 250) were recruited and randomly allocated to either a Nordic diet group (NG) or a conventional diet group (CG). Infants were solely breast- or formula-fed at study start. From 4 to 6 months of age, the NG followed a systematic taste portions schedule consisting of home-made purées of Nordic produce for 24 days. Subsequently, the NG was supplied with baby food products and recipes of homemade baby foods based on Nordic ingredients but with reduced protein content compared to the CG. The CG was advised to follow current Swedish recommendations on complementary foods. A total of 232 participants (93%) completed the study. The NG had significantly higher intake of fruits and vegetables than the CG at 9 months of age; 225 ± 109 g/day vs. 156 ± 77 g/day (p < 0.001), respectively. Energy intake was similar, but protein intake was significantly lower in the NG (-26%, p < 0.001) compared to the CG. This lower protein intake was compensated for by higher intake of carbohydrate from fruits and vegetables. No significant group differences in growth or iron status were observed. The intervention resulted in significantly higher consumption of fruits and vegetables in infants introduced to complementary foods based on Nordic ingredients.

Study protocol: optimized complementary feeding study (OTIS): a randomized controlled trial of the impact of a protein-reduced complementary diet based on Nordic foods

Background

What we eat as infants and children carries long-term consequences. Apart from breastfeeding, the composition of the complementary diet, i.e. the foods given to the infant during the transition from breast milk/infant formula to regular family foods affects the child’s future health. A high intake of protein, a low intake of fruits, vegetables and fish and an unfavorable distribution between polyunsaturated and saturated fats are considered to be associate with health risks, e.g. obesity, type 2 diabetes and dyslipidemia later in life.

Methods

In a randomized, controlled study from 6 to 18 months of age we will compare the currently recommended, Swedish complementary diet to one based on Nordic foods, i.e. an increased intake of fruits, berries, vegetables, tubers, whole-grain and game, and a lower intake of sweets, dairy, meat and poultry, with lower protein content (30% decrease), a higher intake of vegetable fats and fish and a systematic introduction of fruits and greens. The main outcomes are body composition (fat and fat-free mass measured with deuterium), metabolic and inflammatory biomarkers (associated with the amount of body fat) in blood and urine, gut microbiota (thought to be the link between early diet, metabolism and diseases such as obesity and insulin resistance) and blood pressure.

We will also measure the participants’ energy and nutrient intake, eating behavior and temperament through validated questionnaires, acceptance of new and unfamiliar foods through video-taped test meals and assessment of cognitive development, which we believe can be influenced through an increased intake of fish and milk fats, notably milk fat globule membranes (MFGM).

Discussion

If the results are what we expect, i.e. improved body composition and a less obesogenic, diabetogenic and inflammatory metabolism and gut microbiota composition, a more sustainable nutrient intake for future health and an increased acceptance of healthy foods, they will have a profound impact on the dietary recommendations to infants in Sweden and elsewhere, their eating habits later in life and subsequently their long-term health.

Trial registration

NCT02634749. Registration date 18 December 2015.

Active Image-Assisted Food Records in Comparison to Regular Food Records: A Validation Study against Doubly Labeled Water in 12-Month-Old Infants

Overreporting of dietary intake in infants is a problem when using food records (FR), distorting possible relationships between diet and health outcomes. Image-assisted dietary assessment may improve the accuracy, but to date, evaluation in the pediatric setting is limited. The aim of the study was to compare macronutrient and energy intake by using an active image-assisted five-day FR against a regular five-day FR, and to validate image-assistance with total energy expenditure (TEE), was measured using doubly labeled water. Participants in this validation study were 22 healthy infants randomly selected from the control group of a larger, randomized intervention trial. The parents reported the infants’ dietary intake, and supplied images of main course meals taken from standardized flat-surfaced plates before and after eating episodes. Energy and nutrient intakes were calculated separately using regular FR and image-assisted FRs. The mean (± standard deviations) energy intake (EI) was 3902 ± 476 kJ/day from the regular FR, and 3905 ± 476 kJ/day from the FR using active image-assistance. The mean EI from main-course meals when image-assistance was used did not differ (1.7 ± 55 kJ, p = 0.89) compared to regular FRs nor did the intake of macronutrients. Compared to TEE, image-assisted FR overestimated EI by 10%. Without validation, commercially available software to aid in the volume estimations, food item identification, and automation of the image processing, image-assisted methods remain a more costly and burdensome alternative to regular FRs in infants. The image-assisted method did, however, identify leftovers better than did regular FR, where such information is usually not readily available.

Urban residential greenness and adiposity: A cohort study in Stockholm County

BACKGROUND

Increasing evidence suggests that exposure to residential greenness is associated with positive health outcomes among urban populations. However, few studies have considered effects on adiposity development in a longitudinal setting.

OBJECTIVES

This study aimed to explore the association between long-term exposure to urban residential greenness and markers of adiposity.

METHODS

A cohort of 5126 adults from five municipalities in Stockholm County was examined clinically at baseline (1992-1998) and follow-up (2002-2006) after on average nine years. Time-weighted average exposure to urban greenness was estimated by Normalized Difference Vegetation Index (NDVI) within 100 m, 250 m, and 500 m buffers around the residential addresses of each participant. Multiple linear and Poisson regression models were used to estimate associations between greenness and change in weight and waist circumference as well as risk of overweight, obesity and central obesity. Co-exposures to air pollution, traffic noise and distance to water were also examined.

RESULTS

In women, higher levels of residential greenness were associated with a reduced increase in waist circumference during follow-up (β = -0.11 cm/year, 95% CI -0.14; -0.08 per one interquartile range increase in NDVI) and decreased risk for central obesity (IRR = 0.88: 95% CI 0.79; 0.99) in the 500 m buffer. No associations were observed for men or with regard to weight development or the risk of developing overweight or obesity. Exposure to low NDVI levels in combination with high NO_x from road traffic and transportation noise as well as long distance to water rendered statistically significant increases in waist circumference in both sexes.

CONCLUSION

Higher long-term exposure to greenness was associated with a reduced increase in waist circumference and lower risk of central adiposity in women but not in men. In both sexes, low NDVI exposure in combination with other environmental risk factors appeared particularly harmful.

IMPACT-III is a valid and reliable questionnaire for assessing health-related quality of life in Swedish children with inflammatory bowel disease

AIM

This study examined the reliability, validity and factor structure of the Swedish version of the IMPACT-III questionnaire for assessing health-related quality of life in children with inflammatory bowel disease.

METHODS

We recruited 202 participants aged eight to 18 years, who were enrolled from 16 of the 23 paediatric gastroenterology clinics across Sweden during 2010-2013. This cross-sectional study compared two versions of the IMPACT-III questionnaire - one with six factors and 35 items and one with four factors and 19 items - plus the Paediatric Quality of Life Inventory 4.0 Generic Core Scale. Disease activity was assessed and defined as active or inactive.

RESULTS

The mean total score for the six-factor IMPACT-III scale was 143.7/175, with a standard deviation (SD) of 17.9. There was a significant difference in mean total scores between the 133 children with inactive disease (147.8, SD: 14.9) and the 52 with active disease (133.0, SD: 20.3). Confirmatory factor analysis showed that the four-factor scale was more robust than the original six-factor scale. Concurrent validity and discriminant validity were high for both versions.

CONCLUSION

The Swedish version of the IMPACT-III questionnaire was valid and reliable, but the shorter, four-factor version is quicker and may be more convenient in clinical settings.

Estimating marginal causal effects in a secondary analysis of case-control data

When an initial case-control study is performed, data can be used in a secondary analysis to evaluate the effect of the case-defining event on later outcomes. In this paper, we study the example in which the role of the event is changed from a response variable to a treatment of interest. If the aim is to estimate marginal effects, such as average effects in the population, the sampling scheme needs to be adjusted for. We study estimators of the average effect of the treatment in a secondary analysis of matched and unmatched case-control data where the probability of being a case is known. For a general class of estimators, we show the components of the bias resulting from ignoring the sampling scheme and demonstrate a design-weighted matching estimator of the average causal effect. In simulations, the finite sample properties of the design-weighted matching estimator are studied. Using a Swedish diabetes incidence register with a matched case-control design, we study the effect of childhood onset diabetes on the use of antidepressant medication as an adult. Copyright © 2017 John Wiley & Sons, Ltd.

Increased vitamin D intake differentiated according to skin color is needed to meet requirements in young Swedish children during winter: a double-blind randomized clinical trial

Background: Dark skin and low exposure to sunlight increase the risk of vitamin D insufficiency in children.Objective: The aim of the study was to evaluate the amount of vitamin D needed to ascertain that most children >4 y of age attain sufficient serum 25-hydroxyvitamin D [S-25(OH)D; i.e., ≥50 nmol/L] during winter regardless of latitude and skin color.Design: In a longitudinal, double-blind, randomized, food-based intervention study, 5- to 7-y-old children from northern (63°N) and southern (55°N) Sweden with fair (n = 108) and dark (n = 98) skin were included. Children, stratified by skin color by using Fitzpatrick's definition, were randomly assigned to receive milk-based vitamin D₃ supplements that provided 2 (placebo), 10, or 25 μg/d during 3 winter months.Results: Mean daily vitamin D intake increased from 6 to 17 μg and 26 μg in the intervention groups supplemented with 10 and 25 μg, respectively. In the intention-to-treat analysis, 90.2% (95% CI: 81.1%, 99.3%) of fair-skinned children randomly assigned to supplementation of 10 μg/d attained sufficient concentrations, whereas 25 μg/d was needed in dark-skinned children to reach sufficiency in 95.1% (95% CI: 88.5%, 100%). In children adherent to the study product, 97% (95% CI: 91.3%, 100%) and 87.9% (95% CI: 76.8%, 99%) of fair- and dark-skinned children, respectively, achieved sufficient concentrations if supplemented with 10 μg/d. By using 95% prediction intervals for 30 and 50 nmol S-25(OH)D/L, intakes of 6 and 20 μg/d are required in fair-skinned children, whereas 14 and 28 μg/d are required in children with dark skin.Conclusion: Children with fair and dark skin require vitamin D intakes of 20 and 28 μg/d, respectively, to maintain S-25(OH)D ≥50 nmol/L, whereas intakes of 6 and 14 μg/d, respectively, are required to maintain concentrations ≥30 nmol/L during winter. This trial was registered at clinicaltrials.gov as NCT01741324.

The dynamics of the oesophageal squamous epithelium 'normalisation' process in patients with gastro-oesophageal reflux disease treated with long-term acid suppression or anti-reflux surgery

BACKGROUND

Proton pump inhibitors and laparoscopic anti-reflux surgery (LARS) offer long-term symptom control to patients with gastro-oesophageal reflux disease (GERD).

AIM

To evaluate the process of 'normalisation' of the squamous epithelium morphology of the distal oesophagus on these therapies.

METHODS

In the LOTUS trial, 554 patients with chronic GERD were randomised to receive either esomeprazole (20-40 mg daily) or LARS. After 5 years, 372 patients remained in the study (esomeprazole, 192; LARS, 180). Biopsies were taken at the Z-line and 2 cm above, at baseline, 1, 3 and 5 years. A severity score was calculated based on: papillae elongation, basal cell hyperplasia, intercellular space dilatations and eosinophilic infiltration. The epithelial proliferative activity was assessed by Ki-67 immunohistochemistry.

RESULTS

A gradual improvement in all variables over 5 years was noted in both groups, at both the Z-line and 2 cm above. The severity score decreased from baseline at each subsequent time point in both groups (P < 0.001, all comparisons), attaining a normal level by 5 years. Corresponding decreases in Ki-67 expression were observed (P < 0.001, all comparisons). No significant differences were found between esomeprazole treatment and LARS. Neither baseline severity score nor Ki-67 expression predicted the risk of treatment failure.

CONCLUSIONS

Five years of treatment is generally required before squamous epithelial cell morphology and proliferation are 'normalised' in patients with chronic GERD, despite endoscopic and symptomatic disease control. Control of the acid component of the refluxate seems to play the predominant role in restoring tissue morphology.

Radiation exposure in patients with inflammatory bowel disease and irritable bowel syndrome in the years 2001-2011

OBJECTIVES

To compare cumulative ionizing radiation in patients with inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) for the years 2001-2011. To study how radiation exposure change over time in patients with newly diagnosed IBD and factors associated with radiation exposure.

MATERIAL AND METHODS

All radiological investigations performed between 1 January 2001 and 31 December 2011 were retrospectively recorded in patients with Crohn's disease (CD) (n = 103), ulcerative colitis (UC) (n = 304) and IBS (n = 149). Analyses were done with Mann-Whitney and Chi-Square test.

RESULTS

The median total cumulative radiation exposure in mSv for CD (20.0, inter quartile range (IQR) 34.8), UC (7.01, IQR 23.8), IBS (2.71, IQR 9.15) and the proportion of patients who had been exposed for more than 50 mSv during the study period (CD 19%, UC 11%, IBS 3%) were significantly higher in the patients with CD compared to patients with UC (p < .001) and IBS (p < .001), respectively. In turn, patients with UC had significantly higher doses than patients with IBS (p = .005). Risk factors for radiation exposure were female gender (CD), early onset (UC), ileocolonic location (CD), previous surgery (CD and UC), depression (IBS) and widespread pain (IBS). In newly diagnosed CD, there was a significant decline in median cumulative radiation dose in mSv (17.2 vs. 12.0; p = .048) during the study period.

CONCLUSIONS

Patients with CD are at greatest risk for high cumulative radiation exposure, but there is a decline in exposure during the late 2000s. Non-colectomized patients with UC and patients with IBS have a relatively low risk of cumulative radiation exposure.

Maternal body mass index in early pregnancy and offspring asthma, rhinitis and eczema up to 16 years of age

Background

Maternal obesity has been linked to offspring asthma; however, other allergy-related diseases, as well as the association beyond early school age, are largely unstudied.

Objective

To examine the associations between maternal body mass index (BMI) in pregnancy and offspring asthma, rhinitis, eczema and sensitization up to 16 years of age.

Methods

A total of 3294 children from the Swedish birth cohort BAMSE were included in the analyses. Maternal BMI was assessed around week 10 in pregnancy. Information on asthma, rhinitis, eczema, lifestyle factors and environmental exposures was obtained by parental questionnaires at 1, 2, 4, 8, 12 and 16 years. Sensitization was defined from IgE levels of inhalant allergens at 4, 8 and 16 years in a subsample of 2850 children. Generalized estimated equation models were used to analyse the associations between maternal BMI and the outcomes at 1–16 years.

Results

Maternal BMI was positively associated with overall risk of asthma up to age of 16 years (adj OR per 5 kg/m² increase: 1.23; 95% CI 1.07–1.40 for prevalent asthma) excluding underweight mothers. In contrast, no significant associations were found for rhinitis, eczema or sensitization. The association with asthma was restricted to obese, rather than overweight mothers, but was attenuated when adjusting for overweight in the offspring. A causal inference test at 16 years further indicated that the child’s own overweight is a mediator in the suggested association between maternal BMI and offspring asthma at 16 years.

Conclusions and Clinical Relevance

Maternal BMI is associated with an increased risk of asthma, but not rhinitis, eczema or sensitization; however, overweight in the offspring seems to have a mediating role. Prevention strategies of maternal pre-pregnancy and childhood obesity might be important to reduce the prevalence of childhood asthma.

Long-term safety of proton pump inhibitor therapy assessed under controlled, randomised clinical trial conditions: data from the SOPRAN and LOTUS studies

BACKGROUND

Control of chronic gastro-oesophageal reflux disease may be achieved either by anti-reflux surgery (ARS) or by long-term medical therapy with proton pump inhibitors (PPIs). The primary efficacy results of the SOPRAN study, comparing long-term omeprazole use with open ARS, and the LOTUS study, comparing long-term esomeprazole use with laparoscopic ARS, have been reported. A secondary objective of these studies was to address the long-term safety of these respective therapeutic strategies and thereby provide a valid scientific platform for assessing long-term PPI safety.

AIM

To assess the safety of long-term PPI therapy with omeprazole and esomeprazole through analyses of data from the randomised SOPRAN and LOTUS studies.

METHODS

Safety data were collected from patients during the 12-year period of the SOPRAN study (n = 298) and the 5-year period of the LOTUS study (n = 514). Reported serious adverse events (SAEs) and changes in laboratory variables were analysed.

RESULTS

Across both studies, SAEs were reported at a similar frequency in the PPI and ARS treatment groups. Taking the time frames into consideration, the number of fatal SAEs in the two studies was low in both treatment groups. Laboratory results, including routine haematology and tests for liver enzymes, electrolytes, vitamin D, vitamin B12 , folate and homocysteine, showed no clinically relevant changes over time. As expected, gastrin and chromogranin A were elevated in the PPI groups, with the greatest increases observed in the first year.

CONCLUSION

No major safety concerns arose during 5-12 years of continuous PPI therapy. (ClinicalTrials.gov: NCT00251927 and NCT00256737).

The impact of prenatal vitamin A and zinc supplementation on birth size and neonatal survival - a double-blind, randomized controlled trial in a rural area of Indonesia

BACKGROUND

Prenatal supplementation with micronutrients may increase birth weight and thus improve infant health and survival in settings where infants and children are at risk of micronutrient deficiencies.

OBJECTIVE

To assess whether vitamin A and/or zinc supplementation given during pregnancy can improve birth weight, birth length, neonatal morbidity, or infant mortality.

METHODS

A double-blind, randomized controlled trial supplementing women (n = 2173) in Central Java, Indonesia throughout pregnancy with vitamin A, zinc, combined vitamin A+zinc, or placebo.

RESULTS

Out of 2173 supplemented pregnant women, 1956 neonates could be evaluated. Overall, zinc supplementation improved birth length compared to placebo or combined vitamin A+zinc (48.8 vs. 48.5 cm, p = 0.04); vitamin A supplementation improved birth length compared to placebo or combined vitamin A+zinc (48.7 vs. 48.2 cm, p = 0.04). These effects remained after adjusting for maternal height, pre-pregnancy weight, and parity. There was no effect of supplementation on birth weight, the proportion of low birth weight, neonatal morbidity, or mortality.

CONCLUSIONS

Prenatal zinc or vitamin A supplementation demonstrates a small but significant effect on birth length, but supplementation with zinc, vitamin A or a combination of zinc and vitamin A, have no effect on birth weight, neonatal morbidity, or mortality.

The link between parental allergy and offspring allergic and nonallergic rhinitis

BACKGROUND

Parental allergy-related disease increases the risk for rhinitis, but it remains unknown how different phenotypes of parental allergy affect this risk. The aim of this study was to investigate how parental hay fever, asthma, and eczema affect the risk of allergic rhinitis (AR) and nonallergic rhinitis (NAR) at 8 years of age.

METHODS

Information on 2413 children from a population-based birth cohort was used combining questionnaire data and IgE to inhalant allergens. Logistic regression was used to estimate the association between parental allergy-related disease and AR and NAR. In addition, cluster analysis was used to search for latent phenotypes of heredity likely to be associated with AR and NAR.

RESULTS

At age 8 years, 13.8% of the children had AR, while 6.4% had NAR. Parental isolated hay fever increased the odds of AR (OR 2.2, 95% CI 1.6-3.2), whereas isolated asthma or eczema did not. The odds of NAR increased when one parent had two or more allergy-related diseases. In the cluster analysis, the highest proportion of AR, 37.5%, was seen in a cluster where both parents had hay fever and pollen allergy and that of NAR, 11.0%, in a cluster where one parent had hay fever, pollen allergy, and eczema.

CONCLUSIONS

Parental allergy-related disease may be an important risk factor for NAR as well as AR, and the risk is comparable for maternal and paternal allergy. Parental hay fever seems to be the dominating hereditary risk factor for AR.

Serum 25-hydroxyvitamin D levels in preschool-age children in northern Sweden are inadequate after summer and diminish further during winter

BACKGROUND AND OBJECTIVE

Despite studies indicating that vitamin D intake among Swedish children does not meet the recommendation, little is known of their vitamin D status. The aim of the present study was to examine vitamin D status in preschool-age children in relation to vitamin D intake, season, body mass index, and skin color.

METHODS

Preschool-age children (n = 90; mean age 54 ± 7.1 months), all living in northern Sweden (latitude 63° north), half of them with fair skin, half with darker complexion, were recruited from well-baby clinics. The study group was examined first in August-September (late summer) and then the following January-February (winter). Skin type, vitamin D intake, anthropometrics, serum 25-hydroxyvitamin D (S-25[OH] D), and serum parathyroid hormone were assessed.

RESULTS

Mean ± SD S-25(OH) D in summer and winter were 60 ± 15 nmol/L and 55 ± 16 nmol/L, respectively (P < 0.001). Fifteen percent and 10% had S-25(OH) D ≥ 75 nmol/L, and 25% and 40% had S-25(OH) D <50 nmol/L, respectively. The mean vitamin D intake was higher in dark-skinned compared with fair-skinned children. In spite of this, S-25(OH) D in dark-skinned children was lower compared with fair-skinned children during both seasons. The dietary intake of vitamin D was positively associated with S-25(OH) D levels.

CONCLUSIONS

Vitamin D status is inadequate in preschool-age children living in northern Sweden, especially in dark-skinned children and during the winter despite vitamin D intakes meeting the recommendations, prompting strategies to improve intake of vitamin D in this population.

Gastric exocrine and endocrine cell morphology under prolonged acid inhibition therapy: results of a 5-year follow-up in the LOTUS trial

BACKGROUND

Sustained acid inhibition with PPI stimulates gastrin secretion, exerting a proliferative drive on enterochromaffin-like cells (ECL cells) of the oxyntic mucosa. It may also accelerate development of gastric gland atrophy in Helicobacter pylori-infected individuals.

AIMS

To evaluate gastric exocrine and endocrine cell changes in GERD patients randomised to laparoscopic antireflux surgery (LARS, n = 288) or long-term (5 years) esomeprazole (ESO) treatment (n = 266).

METHODS

Antral and corpus biopsies were taken at endoscopy and serum gastrin and chromogranin A levels were assayed, at baseline and after 1, 3 and 5 years' therapy.

RESULTS

Biopsies were available at each time point for 158 LARS patients and 180 ESO patients. In H. pylori-infected subjects, antral mucosal inflammation and activity improved significantly (P < 0.001) and stabilised after 3 years on esomeprazole while no change in inflammation was observed after LARS. Oxyntic mucosal inflammation and activity remained stable on esomeprazole but decreased slightly over time after LARS. Neither intestinal metaplasia nor atrophy developed in the oxyntic mucosa. ECL cell density increased significantly after ESO (P < 0.001), corresponding with an increase in circulating gastrin and chromogranin A. After LARS, there was a significant decrease in ECL cell density (P < 0.05), accompanied by a marginal decrease in gastrin and chromogranin.

CONCLUSIONS

Antral gastritis improved in H. pylori-infected GERD patients after 5 years on esomeprazole, with little change in laparoscopic antireflux surgery patients, who acted as a control. Despite a continued proliferative drive on enterochromaffin-like cells during esomeprazole treatment, no dysplastic or neoplastic lesions were found and no safety concerns were raised. NCT 00251927.

Development and comorbidity of eczema, asthma and rhinitis to age 12: data from the BAMSE birth cohort

BACKGROUND

Allergy-related diseases are a public health issue, but knowledge on development and comorbidity among children is scarce. The aim was to study the development of eczema, asthma and rhinitis in relation to sex and parental allergy, in a population-based cohort, during childhood.

METHODS

At 1, 2, 4, 8 and 12 years, parental questionnaires were used to obtain data on allergy-related diseases. Complete data for all five follow-up occasions were available from 2916 children. Odds ratios for the risk of any allergy-related disease in relation to heredity and sex were calculated using generalized estimating equations.

RESULTS

At 12 years, 58% of the children had had eczema, asthma and/or rhinitis at some time. Disease turnover was high for all three diseases throughout the study. Comorbidity increased with age, and at 12 years, 7.5% of all the children were affected by at least two allergy-related diseases. Parental allergy was associated with increased comorbidity and more persistent disease and increased the risk of having any allergy-related disease (adjusted OR 1.76; 95% CI 1.57-1.97) up to 12 years. Male sex was associated with an increased risk throughout childhood. Boys and girls did not differ in disease persistence, and for comorbidity, the differences were minor.

CONCLUSIONS

Allergy-related diseases may affect a majority of children. Eczema, asthma and rhinitis develop dynamically throughout childhood, and allergic comorbidity is common. These findings indicate that allergy-related diseases should be neither seen nor studied as isolated entities.

Socioeconomic factors, rather than diabetes mellitus per se, contribute to an excessive use of antidepressants among young adults with childhood onset type 1 diabetes mellitus: a register-based study

AIMS/HYPOTHESIS

Mood disorders, including depression, are suggested to be prevalent in persons with type 1 diabetes and may negatively affect self-management and glycaemic control and increase the risk of diabetic complications. The aim of this study was to analyse the prevalence of antidepressant (AD) use in adults with childhood onset type 1 diabetes and to compare risk determinants for AD prescription among diabetic patients and a group of matched controls.

METHODS

Young adults ≥ 18 years on 1 January 2006 with type 1 diabetes (n = 7,411) were retrieved from the population-based Swedish Childhood Diabetes Registry (SCDR) and compared with 30,043 age- and community-matched controls. Individual level data were collected from the Swedish National Drug Register (NDR), the Hospital Discharge Register (HDR) and the Labor Market Research database (LMR).

RESULTS

ADs were prescribed to 9.5% and 6.8% of the type 1 diabetes and control subjects, respectively. Female sex, having received economic or other social support, or having a disability pension were the factors with the strongest association with AD prescription in both groups. Type 1 diabetes was associated with a 44% (OR 1.44, 95% CI 1.32, 1.58) higher risk of being prescribed ADs in crude analysis. When adjusting for potential confounders including sex, age and various socioeconomic risk factors, this risk increase was statistically non-significant (OR 1.11, 95% CI 0.99, 1.21).

CONCLUSIONS/INTERPRETATION

The risk factor patterns for AD use are similar among type 1 diabetic patients and controls, and socioeconomic risk factors, rather than the diabetes per se, contribute to the increased risk of AD use in young adults with type 1 diabetes.

Evolution of gastro-oesophageal reflux disease over 5 years under routine medical care--the ProGERD study

BACKGROUND

The evolution of gastro-oesophageal reflux disease (GERD) under current management options remains uncertain.

AIM

To examine whether, depending on the initial presentation, non-erosive (NERD) and erosive reflux disease (ERD) without Barrett's oesophagus will progress to more severe disease under current routine care following the resolution of the initial condition.

METHODS

Patients with the primary symptom of heartburn were included at baseline, and stratified into non-erosive (NERD) and erosive reflux disease (ERD), LA grades A-D (Los Angeles classification). After a 2- to 8-week course with esomeprazole therapy to achieve endoscopic healing in ERD and symptom relief in NERD, patients were treated routinely at the discretion of their physician. We report oesophagitis status and the presence of endoscopic and confirmed Barrett's oesophagus after 5 years.

RESULTS

A total of 6215 patients were enrolled in the study of whom 2721 patients completed the 5-year follow-up. Progression, regression and stability of GERD severity were followed from baseline to 5 years. Only a few patients with NERD and mild/moderate ERD progressed to severe forms of ERD and even Barrett's oesophagus. Most patients remained stable or showed improvement in their oesophagitis; 5.9% of the NERD patients, 12.1% of LA grade A/B patients and 19.7% of LA grade C/D patients in whom no Barrett's oesophagus was recorded at baseline progressed to endoscopic or confirmed Barrett's oesophagus at 5 years.

CONCLUSION

Most GERD patients remain stable or improve over a 5-year observation period under current routine clinical care.

Thirty years of prospective nationwide incidence of childhood type 1 diabetes: the accelerating increase by time tends to level off in Sweden

OBJECTIVE

During the past few decades, a rapidly increasing incidence of childhood type 1 diabetes (T1D) has been reported from many parts of the world. The change over time has been partly explained by changes in lifestyle causing rapid early growth and weight development. The current study models and analyzes the time trend by age, sex, and birth cohort in an exceptionally large study group.

RESEARCH DESIGN AND METHODS

The present analysis involved 14,721 incident cases of T1D with an onset of 0-14.9 years that were recorded in the nationwide Swedish Childhood Diabetes Registry from 1978 to 2007. Data were analyzed using generalized additive models.

RESULTS

Age- and sex-specific incidence rates varied from 21.6 (95% CI 19.4-23.9) during 1978-1980 to 43.9 (95% CI 40.7-47.3) during 2005-2007. Cumulative incidence by birth cohort shifted to a younger age at onset during the first 22 years, but from the birth year 2000 a statistically significant reversed trend (P < 0.01) was seen.

CONCLUSIONS

Childhood T1D increased dramatically and shifted to a younger age at onset the first 22 years of the study period. We report a reversed trend, starting in 2000, indicating a change in nongenetic risk factors affecting specifically young children.