Anthropometric Changes During Pregnancy and Their Association with Adequacy of Gestational Weight Gain

Background

Gestational weight gain (GWG) is an expected component of a healthy pregnancy. Gaining weight within the recommended range helps support the mother's health by providing energy reserves and nutrients to meet the increased metabolic demands during pregnancy. Too much or too little GWG has been associated with adverse health outcomes for the mother and child.

Objective

The objective of the study was to examine how changes in anthropometric indicators during pregnancy, including fat gain, vary, compare changes among body mass index (BMI) (kg/m2) groups, and examine how the changes were associated with adequacy of GWG defined using the 2009 Institute of Medicine guidelines.

Methods

Data came from a cohort of 360 pregnant women with measured anthropometric indicators (weight, midupper arm circumference, and skin folds of the triceps, thigh, and upper iliac) at <12-, 16 to 22-, and 28 to 32-wks of gestation. Fat gain was calculated using a formula. Analysis of variance was used to test for differences in anthropometric changes by BMI and adequacy of GWG in the third trimester. Multiple logistic regression was used to examine associations between changes in anthropometric indicators and GWG recommendations.

Results

Women with normal weight had greater increases in all anthropometric indicators, which differed from women with obesity, who had negative changes and gained less weight. Women who gained inadequately (21%) had negative changes that were all less, compared with women who gained adequately (46%) (except in upper iliac) or excessively (34%). Women with BMI of >25 who gained adequately also had negative changes. Logistic regression results indicated that changes in midupper arm circumference, triceps, and thigh skin folds, and fat gain were all inversely associated with inadequate GWG, whereas all indicators were positively associated with excessive GWG.

Conclusions

Anthropometric changes during pregnancy differ by BMI and are associated with adequacy of GWG. Women who gained adequately had minimal fat gain, lending support for current GWG guidelines.

Aligning Prevention Evidence Gaps With Prevention Research

This Viewpoint describes the development of tools to communicate actionable steps to address research needs and gaps for USPSTF recommendations that have insufficient evidence to make definitive guidance.

Addressing the Gender Gap in Academic Success: A History of the University of North Carolina Association of Professional Women in the Medical Sciences

Despite efforts at many institutions, nationally, women still lag behind their male counterparts in leadership, promotion, and seniority. In this paper, we describe the efforts to improve the environment for women faculty at one large academic medical center through the creation of an Association of Professional Women in Medical Sciences. Over the years, the group has helped influence policies that directly affect women faculty, provided high-yield programming on topics related to women's success, and created interprofessional networking opportunities for women faculty. We describe the challenges and successes of this group to serve as a model and inspiration for other institutions.

FIGO opinion paper: Drivers and solutions to the cesarean delivery epidemic with emphasis on the increasing rates in Africa and Southeastern Europe

Cesarean delivery rates are rapidly increasing in Southeastern Europe (to more than 60%), North Africa (with a rate as high as 72% in Egypt), and in urban areas in Southern Africa (a rate of over 50% in Lagos, Nigeria). Data on the background to these increases are scarce, but likely to include poor birthing facilities in general hospitals, convenience for the doctor, private medicine, fear of litigation, socioeconomic status, shortage of midwives and nurses, and disappearance of vaginal instrumental deliveries. Options to reverse cesarean delivery trends are discussed. In this context there is a need to be better informed about how women are being counseled regarding vaginal or cesarean delivery. The long-term consequences in subsequent pregnancies for mothers and children may well be largely ignored, while these risks are highest in LMICs where higher birth numbers are desired. FIGO has begun discussions with obstetric and gynecologic societies, healthcare bodies, and governments in several countries discussed in this article, to find ways to lower the cesarean delivery rate. The requests came from the countries themselves, which may prove beneficial in helping advance progress.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

Prep-for-Labor: Overview of FIGO's labor and delivery triage bundles of care to optimize maternal and newborn outcomes

Childbirth is an intense event in which decisions may need to be made in seconds to guarantee the health of both mother and newborn. Despite health systems and care approaches varying widely according to real-life scenarios, availability of facilities, beliefs, resources, staff, and geography, among others, optimal outcomes should be ensured worldwide. Triaging low-risk pregnancies from high-risk pregnancies is the first step to ensure proper allocation of resources. From this need, we developed FIGO's Prep-For-Labor triage methods, a series of 2-minute labor and delivery bundles of care, with special regard given to low- and middle-income countries and rural settings. Around 80% of women, once properly triaged, can pursue vaginal delivery with minimal intervention, while those at risk can either be managed on site or transferred promptly to an advanced care site. FIGO's bundles of care and good practice recommendations for labor and delivery and immediate newborn triage cover four clinical scenarios: (1) preterm labor; (2) induced or spontaneous labor at term; (3) cesarean delivery; and (4) newborn care. From rapid triage of the mother (low vs high risk) to the list of required equipment, description of skilled staff, and coordination of resources, the recommendations for care are introduced across these four areas in this overview article. Implementing the proposed management steps described in each summary can improve maternal and neonatal outcomes.

Optimizing the childbirth experience: A pragmatic approach

In our efforts to optimize the labor experience and mitigate childbirth‐associated disability and mortality, we offer a call to action to identify drivers of and provide solutions to rising cesarean delivery rates, provide equitable care to mothers requesting elective cesarean, improve the operative safety of indicated cesarean deliveries, and provide guidance on acute care decision‐making in the labor suite and referral to levels of care.

FIGO good practice recommendations for cesarean delivery on maternal request: Challenges for medical staff and families

Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.

Addressing Gaps in Research to Reduce Disparities and Advance Health Equity: The USPSTF Incorporation of the NASEM Taxonomy on Closing Evidence Gaps in Clinical Prevention

This Viewpoint reviews the evidence gaps reported to Congress by the US Preventive Services Task Force (USPSTF) in 2021 on improving health inequities in prevention and uses the 3 taxonomies provided by National Academies of Sciences, Engineering, and Medicine (NASEM) to classify these gaps.

Social Relationships and Risk of Type 2 Diabetes Among Postmenopausal Women

OBJECTIVES

We examined whether social relationship variables (social support, social strain, social network size, and stressful life events) were associated with risk of developing type 2 diabetes among postmenopausal women.

METHOD

139,924 postmenopausal women aged 50-79 years without prevalent diabetes at baseline were followed for a mean of 14 years. 19,240 women developed diabetes. Multivariable Cox proportional hazard models tested associations between social relationship variables and diabetes incidence after consideration of demographics, depressive symptoms, and lifestyle behaviors. We also examined moderating effects of obesity and race/ethnicity, and we tested whether social variable associations were mediated by lifestyle or depressive symptoms.

RESULTS

Compared with the lowest quartile, women in the highest social support quartile had lower risk of diabetes after adjusting for demographic factors, health behaviors, and depressive symptoms (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.89-0.97). Social strain (HR = 1.09, 95% CI = 1.04-1.13) and stressful life events (HR = 1.10, 95% CI = 1.05-1.15) were associated with higher diabetes risks. The association between diabetes and social strain was stronger among African American women. Social relationship variables had direct relationships to diabetes, as well as indirect effects partially mediated by lifestyle and depressive symptoms.

DISCUSSION

Social support, social strain, and stressful life events were associated with diabetes risk among postmenopausal women independently of demographic factors and health behaviors. In addition to healthy behaviors such as diet and physical activity, healthy social relationships among older women may be important in the prevention of diabetes.

Reward-related eating, self-regulation, and weight change in pregnancy and postpartum: the Pregnancy Eating Attributes Study (PEAS)

Background/Objectives.

Reward-related eating is hypothesized to underlie risk for weight gain in obesogenic environments, but its role is unknown during pregnancy and postpartum when weight change is normative, but excess weight gain and weight retention are common. This study examined associations of self-reported reward-related eating, self-regulation, and the home food environment with excessive gestational weight gain (GWG) and postpartum weight change.

Subjects/Methods.

Participants in the Pregnancy Eating Attributes Study observational cohort were enrolled at ≤12 weeks pregnancy and followed through one-year postpartum (458 recruited; 367 retained through delivery). Participants completed four measures of reward-related eating – Modified Yale Food Addiction Scale, Power of Food Scale, Multiple Choice Procedure, and a Reinforcing Value of Food Questionnaire; two measures of self-regulation – Barratt Impulsiveness Scale and Delay of Gratification Inventory; and a Home Food Inventory. Measured weight and skinfolds were obtained. Multinomial logistic and multiple linear regression analyses estimated associations of reward-related eating, self-regulation, and home food environment with excessive GWG, gestational fat gain, postpartum weight change, and percent of GWG retained.

Results.

Excessive GWG was associated with food reinforcement intensity, but not with any other measure of reward-related eating, self-regulation, or home food environment. Greater gestational fat gain was associated only with higher Multiple Choice Procedure. Postpartum weight change and percent of GWG retained were associated with greater Delay of Gratification and obesogenic home food environment, but not with any measure of reward-related eating or with impulsivity.

Conclusions.

Findings do not support the hypothesis that self-reported reward-related eating is associated with weight outcomes in pregnancy and postpartum but indicate a relation of Delay of Gratification with postpartum weight retention. Further research using both surveys and objective measures of reward-related eating is needed to advance our understanding of the relation of reward-related eating with weight changes during this critical period of a woman’s life.

Associations of Maternal Sociodemographic Characteristics and Eating Behaviors with Infant Feeding Behaviors

Objectives

This study examines associations of maternal characteristics with infant feeding of discretionary and health-promoting foods.

Methods

Mothers in PEAS, a prospective cohort study, reported maternal and child dietary intake, demographics, and eating competence (EC). Maternal diet quality (Healthy Eating Index-2015, HEI) was calculated combining 24-hour diet recalls at 6 weeks, 6, and 12 months postpartum (n = 209). Infant food frequency questionnaires were completed at 6, 9, and 12 months, assessing age of introduction and intake frequency of food groups. T-tests examined bivariate associations of demographics with feeding of discretionary sweets, discretionary savory foods, fruit, and vegetables. Linear regressions examined associations of maternal EC and HEI with infant feeding controlling for demographics.

Results

Fruit, vegetables, discretionary sweet, and discretionary savory foods were introduced at 5.8 ± 1.7, 5.9 ± 1.7, 8.0 ± 2.0, and 8.8 ± 1.8 months, respectively. Earlier introduction of fruit and vegetables was associated with higher maternal education, white race, and nulliparity; earlier introduction of vegetables was also associated with higher income. Age of introduction of discretionary sweet and savory foods was not associated with maternal demographics, HEI, or EC. At age 12 months, greater infant intake frequency of fruit and vegetables was associated with higher education and income, white race, and breastfeeding, while greater intake frequency of discretionary sweet and savory foods was associated with lower maternal education and minority race. Greater intake frequency of sweets was also associated with multiparity and greater intake frequency of discretionary savory foods was associated with lower income. Maternal HEI was positively associated with infant intake frequency of fruit, vegetables, and discretionary sweet and savory foods. Maternal EC was positively associated with infant intake frequency of fruit and vegetables.

Conclusions

Demographic differences in infant feeding behaviors indicates these behaviors as critical intervention targets to address disparities in child diet quality. Associations of maternal HEI and EC with infant feeding behaviors suggest potential pathways of maternal influence on infant diet.

Funding Sources

This research was supported by the NICHD Intramural Research Program.

DiabetesSistersVoices: Virtual Patient Community to Identify Research Priorities for Women Living With Diabetes

Background

Women with or at high risk of diabetes have unique health concerns across their life course. Effective methods are needed to engage women living with diabetes to develop and carry out a patient-centered research agenda.

Objective

This study aimed to (1) describe the creation of DiabetesSistersVoices, a virtual patient community for women living with and at risk for diabetes and (2) assess the feasibility and acceptability of DiabetesSistersVoices for engaging women in talking about their experiences, health care, and research priorities.

Methods

We partnered with a national advocacy organization to create DiabetesSistersVoices and to develop recruitment strategies, which included use of social media, Web-based newsletters, and weblinks through partnering organizations. Study inclusion criteria were as follows: Being a woman aged ≥18 years, residing in the United States, and self-reporting a diagnosis of diabetes or risk of diabetes. Eligible participants were given access to DiabetesSistersVoices and completed online surveys at enrollment and 6 months. We assessed trends in participants’ activities, including posting questions, sharing experiences about living with diabetes, and searching for posted resources.

Results

We enrolled 332 women (white: 86.5%; type 1 diabetes: 76.2%; median age: 51 years [interquartile range: 31 to 59 years]) over 8 months. Most (41.6%, 138/332) were classified as being active users (ie, posting) of the virtual community, 36.1% (120/332) as observers (ie, logged in but no posts), and 22.3% (74/332) as never users (ie, completed baseline surveys but then never logged in). Online activities were constant during the study, although participants had the highest website usage during the first 10 weeks after their enrollment.

Conclusions

We demonstrated the feasibility and acceptability of an online patient community for women living with diabetes by showing durability of recruitment and online usage over 6 months of testing. Next steps are to address barriers to joining a virtual patient community for women of color and women with type 2 diabetes to enhance inclusiveness and gain diverse perspectives to inform diabetes research.

Gestational Diabetes and Health Behaviors Among Women: National Health and Nutrition Examination Survey, 2007-2014

INTRODUCTION

Women with gestational diabetes are at 7 times greater risk of developing type 2 diabetes than are women without gestational diabetes. The objectives of this study were to examine recent changes in the prevalence of gestational diabetes mellitus among women of reproductive age in the United States and assess the prevalence of factors associated with participating in healthy lifestyle behaviors.

METHODS

Data were from 4 waves of the National Health and Nutrition Examination Survey (2007-2014). Gestational diabetes was identified by participants' response to whether they were ever told by a health care professional that they had diabetes during pregnancy. The health behaviors were participation in physical activity, healthy dietary patterns (intake of cholesterol, sodium, and fiber within recommended guidelines), and smoking. The analytical sample included 3,034 women aged 20 to 44 years. Multivariate logistic regression was used to assess the association between gestational diabetes and health behaviors.

RESULTS

The overall prevalence of gestational diabetes was 8.9% (95% confidence interval [CI], 7.6%-10.4%) during 2007-2014. The prevalence increased from 8.4% in 2007-2008 to 10.4% in 2013-2014, an increase of 24%, but the change was not significant (P = .28). The proportions of women meeting recommended guidelines for the health behaviors did not change significantly. We found no significant difference in practicing healthy behaviors between women with gestational diabetes and women without gestational diabetes.

CONCLUSION

The prevalence of gestational diabetes increased slightly in recent years, and women with the condition were generally not meeting guidelines for healthy behaviors. Coordinated interventions are needed to promote healthy lifestyle behaviors among women with gestational diabetes because they are at increased risk for diabetes.

The value of using schools as community assets for health

In planning, designing, procuring and ensuring delivery of improved services ('commissioning') for the school age population, the outcomes should be students who are healthy to learn and who learn to be healthy. Intuitively, linking education and health development together within the wider learning environment seems a good start to planning school health. However there has been a shortage of either theoretical models that can span different settings or experimental research that demonstrates improved community health. Is there evidence that the wider learning environment provided in a school is valuable in improving health? An initial scoping exercise identified domains of health where there was a promise of health gain. International literature on school health outcomes using the framework of Asset-Based Community Development (ABCD) has been reviewed. It was found that research on a variety of interventions was relevant to schools as an asset for public health. Effective areas for health gain were identified for local planning and evaluation using this community model. However, none of the studies reviewed was originally designed to test schools as assets and most of the research lacked methodological rigour, especially regarding children in low income countries. The ABCD model could help national governments develop resources for both education and health, but there is a global need to generate better quality evidence. Then people who commission for their local communities can make more effective use of these multifaceted assets to improve health and education outcomes for children.

Association between adiponectin and tumor necrosis factor-alpha levels at eight to fourteen weeks gestation and maternal glucose tolerance: the Parity, Inflammation, and Diabetes Study

OBJECTIVE

Inflammation may influence gestational hyperglycemia, but to date, the data from observational studies is largely limited to results from the third trimester of pregnancy. Our objective was to evaluate first trimester adipocytokine levels. We sought to determine whether first trimester adiponectin and tumor necrosis factor-alpha (TNF)-alpha concentrations were independently associated and predictive of maternal glucose tolerance, as measured by the 1-hour glucose challenge test (GCT), after adjustment for maternal lifestyle behaviors and body mass index (BMI).

MATERIAL AND METHODS

Prospective study of pregnant women (n=211) enrolled in the Parity, Inflammation, and Diabetes Study. Nonfasting serum levels of adiponectin and TNF-r2 were measured at 8-14 weeks of pregnancy. GCT results were abstracted from electronic prenatal records. Multiple linear regression models were developed to determine the association of adiponectin and TNF-r2 levels with response to the GCT, adjusting for demographics, pregravid dietary intake and physical activity, first trimester BMI, and gestational weight gain.

RESULTS

At baseline, higher adiponectin concentrations were inversely and statistically significantly associated with maternal response to the GCT [regression coefficient (β) -0.68; 95% confidence interval (CI): -1.29, -0.06). Adjustment for lifestyle factors did not alter the association of adiponectin with the GCT (β -0.74; 95% CI: -1.43, -0.05). After adjustment for first trimester BMI, the association of adiponectin was attenuated and no longer significant (β -0.46; 95% CI: -1.15, 0.24). TNF-r2 levels were not associated with the GCT (β -0.003; 95% CI: -0.011, 0.005).

CONCLUSIONS

First trimester adiponectin levels are not predictive of the 1-hour GCT response, but may be a marker for the effect of maternal BMI on glucose response to the GCT.

USPSTF perspective on evidence-based preventive recommendations for children

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

NIH consensus development conference draft statement on vaginal birth after cesarean: new insights

OBJECTIVE

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).

PARTICIPANTS

A non-DHHS, nonadvocate 15-member panel representing the fields of obstetrics and gynecology, urogynecology, maternal and fetal medicine, pediatrics, midwifery, clinical pharmacology, medical ethics, internal medicine, family medicine, perinatal and reproductive psychiatry, anesthesiology, nursing, biostatistics, epidemiology, health care regulation, risk management, and a public representative, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.

EVIDENCE

Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.

CONFERENCE PROCESS

The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision. The data reviewed in this report show that both trial of labor and elective repeat cesarean delivery for a pregnant woman with one prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman, as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about trial of labor compared with elective repeat cesarean delivery. The panel was mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations. One of the panel’s major goals is to support pregnant women with one prior transverse uterine incision to make informed decisions about trial of labor compared with elective repeat cesarean delivery. The panel recommends that clinicians and other maternity care providers use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored. The panel is concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor. Given the low level of evidence for the requirement for "immediately available" surgical and anesthesia personnel in current guidelines, the panel recommends that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their trial of labor policies and VBAC rates, as well as their plans for responding to obstetric emergencies. The panel recommends that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor. The panel is concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor. Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care. High-quality research is needed in many areas. The panel has identified areas that need attention in response to question 6. Research in these areas should be given appropriate priority and should be adequately funded--especially studies that would help to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of trial of labor and elective repeat cesarean delivery.

Weight loss programs for urban-based, postpartum African-American women: perceived barriers and preferred components

OBJECTIVES

There are currently 1.85 million reproductive-aged women in the United States with diabetes or glucose intolerance. While it is known that postpartum weight retention can lead to obesity and diabetes, particularly among African-American women, little is known about African-American women's preferences for postpartum weight loss programs. Our objective was to explore urban-based African-American women's attitudes toward weight gain, perceived barriers to postpartum weight loss, and preferences for weight intervention strategies.

METHODS

Focus groups of pregnant African-American women (n = 22) were conducted by a race-concordant moderator. Open-ended questions were posed to stimulate discussions which were audio taped and transcribed verbatim. Transcriptions were independently reviewed by two investigators who extracted quotations and coded each statement to identify major themes.

RESULTS

The median age of participants was 26 years. Median pre-pregnancy or first trimester body-mass index was 31 kg/m(2). Fifty-seven percent of the women were multiparous and 68% were Medicaid recipients. We identified 16 themes with the majority of participant comments focused on: (1) effect of postpartum depression on motivation to lose weight; (2) strong desire to lose weight; (3) knowledge of adverse effects of obesity; (4) costs of weight loss programs; (5) negative impact of media coverage of successful celebrity postpartum weight loss; (6) limitations of childcare on ability to exercise; and (7) family-centered lifestyle behaviors that promote unhealthy eating.

CONCLUSIONS

Weight loss interventions for African-American women with postpartum obesity should address psychological effects of childbearing, affordability, and perceptions of body image. Interventions should incorporate family-centered approaches and weight loss maintenance strategies.

The association between women’s health information use and health care visits

OBJECTIVE

To determine the effect of the type of information sources used on health services use.

METHODS

Population-based random-digit dialing survey of 498 women, between December 1999 and January 2000, on use of health information sources and health visits.

RESULTS

After adjustment for sociodemographic and medical factors, use of print health media and computer-based resources was associated with 1.9 and 1.6 more visits, respectively compared to non-use (Regression coefficients 1.9; [95% confidence interval {CI} 0.1, 3.7] and 1.6; [95% CI 0.3, 3.0]).

CONCLUSIONS

Print health media and computer-based sources are associated with a higher number of health care visits.

Extreme spore UV resistance of Bacillus pumilus isolates obtained from an ultraclean Spacecraft Assembly Facility

Recent environmental microbial sampling of the ultraclean Spacecraft Assembly Facility at NASA Jet Propulsion Laboratory (JPL-SAF) identified spores of Bacillus pumilus as major culturable bacterial contaminants found on and around spacecraft. As part of an effort to assess the efficacy of various spacecraft sterilants, purified spores of 10 JPL-SAF B. pumilus isolates were subjected to 254-nm UV and their UV resistance was compared to spores of standard B. subtilis biodosimetry strains. Spores of six of the 10 JPL-SAF isolates were significantly more resistant to UV than the B. subtilis biodosimetry strain, and one of the JPL-SAF isolates, B. pumilus SAFR-032, exhibited the highest degree of spore UV resistance observed by any Bacillus spp. encountered to date.

Engineering physiologically regulated insulin secretion in non-beta cells by expressing glucagon-like peptide 1 receptor

Glucagon-like peptide 1 (GLP-1) is released from neuroendocrine cells in the intestine in the postprandial state and augments glucose-stimulated insulin secretion from pancreatic beta cells. To develop non-beta cells that exhibit physiologically regulated insulin secretion, we coexpressed the GLP-1 receptor and human insulin in primary rat pituitary cells using adenovirus-mediated gene transfer. The transduced cells were analyzed in a perifusion system and after transplantation into mice. Normal pituitary cells do not express the GLP-1 receptor as shown by the absence of GLP-1 receptor mRNA and the inability of GLP-1 to stimulate pituitary hormone secretion. Following transduction with an adenovirus carrying the GLP-1 receptor cDNA, the pituitary cells expressed functional GLP-1 receptors as reflected by the ability of GLP-1 to stimulate secretion of pituitary hormones. When both the GLP-1 receptor and human insulin were introduced, GLP-1 stimulated cosecretion of human insulin and endogenous pituitary hormones. GLP-1 was similar in potency to the hypothalamic-releasing hormones and stimulated hormone secretion in a dose-dependent fashion. In contrast to pancreatic beta cells, the hormone-releasing effect of GLP-1 on transduced pituitary cells was not dependent on the concentration of extracellular glucose. After transplantation of pituitary cells coexpressing human insulin and GLP-1 receptor into mice, enteral glucose stimulated insulin secretion. These results demonstrate a new approach to engineer physiologically regulated insulin secretion by non-beta cells.

The effect of feeding on cerebrospinal fluid corticotropin-releasing hormone levels in humans

Corticotropin-releasing hormone (CRH) is a neuropeptide thought to play a role in appetite regulation. In this report, we used a serial cerebrospinal fluid (CSF) sampling technique to examine the relationship between CSF CRH, plasma ACTH and cortisol and perceptions of hunger and satiety in fasting and sated volunteers. CSF was withdrawn continuously from 11:00 AM to 5:00 PM via an indwelling subarachnoid catheter. Blood was withdrawn every 10 min via an antecubital vein catheter. Fed subjects received a meal at 1:00 PM. Subjects who were fed had lower post-prandial ratings on hunger scales and higher ratings on satiety scales. Fed subjects also had slightly lower levels of CSF CRH after feeding. Furthermore, fed subjects had higher ACTH and cortisol concentrations in the first 3 h; by the fourth h the opposite was true. Our findings do not support the hypothesis that CNS CRH is a central satiety factor in the human. Instead our findings of slightly diminished CSF CRH levels after feeding may be accounted for by the rises in glucocorticoids and their associated negative feedback effects on CNS CRH. Alternatively, our findings could also reflect changes in CRH levels associated with feeding in multiple brain areas and in the spinal cord with the net effect being in the negative direction.

Preterm delivery in patients admitted with preterm labor: a prediction study

OBJECTIVE

To develop a model for prediction of preterm delivery in patients treated with parenteral tocolysis using combinations of maternal demographic and clinical factors.

METHODS

We performed a retrospective cohort study using a perinatal database to identify women admitted with preterm labor and treated with parenteral tocolysis from 1980 to 1994. We developed an explanatory model using multiple logistic regression to determine the effect of four variables (prior preterm delivery, substance abuse, maternal complications and third-trimester care) on the likelihood of preterm delivery. For the prediction model, we initially included these four variables and then removed them in a stepwise fashion to determine the combination of the variables that offered the greatest model sensitivity and specificity.

RESULTS

A total of 900 women were identified for the study and 247 (27%) had a preterm delivery. In the explanatory model, prior preterm delivery (OR 2.4; 95% CI 1.5-3.6), substance abuse (OR 2.2; 95% CI 1.2-5.1), initiation of care in the third trimester (OR 2.0; 95% CI 1.3-2.8) and medical complications of pregnancy (OR 1.8; 95% CI 1.2-2.6) increased the likelihood of preterm delivery. For the prediction tool, a three-variable model (prior preterm delivery, substance abuse and initiation of care in the third trimester) had high specificity (98%) and modest negative predictive value (73%).

CONCLUSIONS

A simple three-variable model can correctly identify 98% of women with preterm labor treated with parenteral tocolysis who will not deliver preterm. Patients with no prior history of preterm delivery, no substance abuse and initiation of prenatal care before the third trimester have a 73% probability of not delivering preterm.

Inhibition of the replication of the DNA polymerase M550V mutation variant of human hepatitis B virus by adefovir, tenofovir, L-FMAU, DAPD, penciclovir and lobucavir

Several nucleoside analogues (penciclovir, lobucavir, dioxalane guanine [DXG], 1-beta-2,6-diaminopurine dioxalane [DAPD], L-FMAU, lamivudine) and acyclic nucleoside phosphonate analogues (adefovir, tenofovir) that are in clinical use, in clinical trials or under preclinical development for the treatment of hepatitis B virus (HBV) infections, were evaluated for their inhibitory effect on the replication of a la- mivudine-resistant HBV variant containing the methionine --> valine substitution (M550V) in the polymerase nucleoside-binding domain. The antiviral activity was determined in the tetracycline-responsive HepAD38 and HepAD79 cells, which are stably transfected with either a cDNA copy of the wild-type pregenomic RNA or with cDNA containing the M550V mutation. As expected, lamivudine was much less ( approximately 200-fold) effective at inhibiting replication of the M550V mutant virus than the wild-type virus. In contrast, adefovir, tenofovir, lobucavir, L-FMAU, DXG and DAPD proved almost equally effective against both viruses. A second objective of this study was to directly compare the antiviral potency of the anti-HBV agents in HepG2 2.2.15 cells (which are routinely used for anti-HBV drug-screening purposes) with that in HepAD38 cells. HepAD38 cells produce much larger quantities of HBV than HepG2 2.2.15 cells, and thus allow drug screening in a multiwell plate format. All compounds were found to be almost equally effective at inhibiting HBV replication in HepAD38 cells (as in HepG2 2.2.15 cells), except for penciclovir, which was clearly less effective in HepAD38 cells.

Factors affecting prophylactic oophorectomy in postmenopausal women

OBJECTIVE

Prophylactic oophorectomy performed concomitantly with hysterectomy may prevent ovarian cancer. Our goal was to better understand the basis for performing concomitant oophorectomy and to determine whether this procedure is associated with increased morbidity.

METHODS

Our cross-sectional study used a hospital discharge database to identify women 50 years and older who, between 1994-1996, had hysterectomies in Maryland for a benign condition. We used multiple logistic regression to examine the independent effect of physician and patient factors on the likelihood of receiving a concomitant oophorectomy.

RESULTS

Concomitant oophorectomy was performed in 61% of the 6227 women in our sample. Patients undergoing total abdominal hysterectomy (odds ratio [OR] 11.42; 95% confidence interval [CI] 9.65, 13.51) and laparoscopically assisted vaginal hysterectomy (OR 11.34; 95% CI 8.13, 15.81) were substantially more likely to have an oophorectomy than patients treated with vaginal hysterectomy, after adjusting for diagnosis and other covariates. We also found significant variation in the likelihood of receiving oophorectomy for women undergoing vaginal hysterectomy in different geographic regions. Additionally, physicians who performed many vaginal hysterectomies were significantly more likely to perform a concomitant oophorectomy. After adjusting for type of procedure, diagnosis, comorbidities, and age, oophorectomy was not associated with increased surgical morbidity.

CONCLUSION

These results suggest that there are marked variations in physician practice style for concomitant oophorectomy. The variation across geographic regions and with case volume suggests the influence of nonclinical factors on oophorectomy rates.

A study of breast feeding rates at a large Australian obstetric hospital

A prospective breast feeding survey in a large obstetric hospital was carried out from 1988 to 1991. For each year, a sample of women were interviewed following delivery and data was collected which included the method of feeding, patient status (public or private patients), age, parity, (including previous breast feeding experience), marital status, country of birth and the number of babies. The mother's feeding method after delivery and on discharge from hospital were recorded. Women who were breast feeding on discharge were interviewed at 3 months. When putting the figures for the 4 years together, the breast feeding commencement rate was 88%, the breast feeding rate on discharge was 80% and the breast feeding rate at 3 months was between 51% and 57%. Factors found to be affecting the breast feeding rate at 3 months included patient status, age and parity. Problems experienced by the mothers after discharge from hospital included nipple pain, nipple trauma and mastitis. Private patients reported a significantly higher rate of mastitis than public patients.

Breastfeeding after reduction mammaplasty

A retrospective study was performed of 30 women who had undergone breast reduction and subsequently wished to breastfeed. Breastfeeding capabilities were assessed by a trained lactation consultant. Findings indicate that in women who have a physiological type of operation then breastfeeding is usually possible (18 patients out of 19), although complementary feeds may be required. We strongly suggest that all functioning breast tissue that remains after reduction mammaplasty be left attached to the nipple in a physiological manner to allow subsequent breastfeeding.

Polypoid cystitis, pyelonephritis, and obstructive uropathy in a cow

Polypoid cystitis, pyelonephritis, and obstructive uropathy was found in a cow with hematuria, dysuria, and colic. The cow was treated with penicillin, multiple B vitamin supplementation, and isotonic sodium chloride. Polypoid cystitis, diagnosed in this cow by use of endoscopic examination, is a common response to chronic inflammation of the bladder and can lead to obstructive uropathy. Although endoscopic confirmation of this diagnosis may not always be feasible, recognition of corresponding clinical signs can allow timely, appropriate treatment.

The regulation of transcription of the gerA spore germination operon of Bacillus subtilis

The gerA operon of Bacillus subtilis 168 comprises three genes concerned with the triggering of spore germination by L-alanine and its analogues. The expression of this operon has been characterized using chromosomal lacZ fusions to the gerA promoter. The gerA promoter is switched on 2.5-3 hours after the initiation of sporulation, in parallel with glucose dehydrogenase. A high proportion of the gerA-driven beta-galactosidase detected in sporulating cells is found in the mature spore; the gerA promoter is therefore active in the forespore compartment of the sporulating cell. The gerA promoter is not expressed in spoO, spoII or spoIIIA, B, E and G mutant backgrounds, but is expressed in spoIIIC and D and in spoIV and V mutants. The in vivo transcriptional startpoint of the operon has been mapped by primer extension experiments; sequences upstream from this startpoint show significant homology with recognition sequences for RNA polymerase containing sigma G (E sigma G). The gerA operon was transcribed in vitro by E sigma G with a startpoint identical to that used in vivo, and expression of the gerA operon was rapidly induced in vegetative cells by induction of sigma G synthesis. These data indicate that the gerA operon is an additional member of the sigma G regulon, which includes a number of genes expressed in parallel only in the forespore compartment of sporulating B. subtilis cells.

Contribution of environmental fibers to respiratory cancer

This article reviews studies of the carcinogenicity of mineral fibers, notably asbestos, and presents seven major recommendations for further research. Mineral fibers represent the greatest cause--after cigarette smoke--of respiratory cancer due to air pollutants. Past asbestos exposure may currently account for 2000 mesothelioma deaths per year and 4000 to 6000 lung cancer deaths per year. All major commercial types of asbestos (crocidolite, amosite, and chrysotile) can cause each of the major asbestos-related respiratory diseases. Lung cancers in asbestos-exposed individuals probably do not have a different distribution of histological types from that of non-asbestos-related lung cancers. Nonoccupational exposures are likely to be associated with malignant disease outcomes qualitatively similar to those associated with occupational exposures. Further investigations of fibers are needed to characterize the relationships among physicochemical properties, patterns of migration and clearance, dose, and adverse health effects. Transmission electron microscopy has been found to be the preferred method of analysis of environmental fibers. Relations among time factors (e.g., age at first exposure), dose, and risk for adverse health effects require analyses of existing and new epidemiologic studies of exposed cohorts. Concomitant exposure, behavioral factors, and host factors affecting susceptibility to asbestos should be identified.