Preschoolers' Self-Regulation and Behavior Problems in the Midst of Caregiver Depression and Chaos

OBJECTIVES

Preschoolers' self-regulation is partially developed through home and child care routines. COVID-19-related child care closures increased caregiver depressive symptoms, household chaos, and children's behavior problems. This longitudinal study examined how preschoolers' prepandemic self-regulation was related to behavior problems early in the pandemic, including buffering against the adverse effects of caregiver depressive symptoms and household chaos.

METHODS

A sample of 264 caregivers of preschoolers reported on their children's self-regulation (Behavior Rating Inventory of Executive Function-Preschool Version Inhibitory Self Control Index) before the pandemic and caregiver depressive symptoms (Center for Epidemiological Studies), household chaos (Confusion, Hubbub, and Order Scale), and children's behavior problems (Behavior Rating Index for Children) during the pandemic. We used linear mixed models to examine predictors of children's behavior problems, including prepandemic self-regulation, and further examined moderation by pandemic-related caregiver depressive symptoms and household chaos.

RESULTS

Children were 64% non-Hispanic White and 24% non-Hispanic Black, with mean pandemic age 5.9 years. Prepandemic self-regulation significantly predicted early pandemic behavior problems (β = -0.38 [95% confidence interval, -0.69 to -0.07]). This association was moderated by pandemic-related caregiver depressive symptoms and household chaos; the protective association was maintained at high levels of caregiver depressive symptoms or household chaos, although the association diminished when these co-occurred.

CONCLUSION

The protective association between prepandemic self-regulation and subsequent behavior problems suggests longitudinal benefits of preschoolers' inhibitory and emotional control. Despite reduced protection associated with co-occurring caregiver and household challenges, self-regulation continued to demonstrate protection against subsequent behavior problems, even in the midst of a pandemic.

Commentary: A nurturing care perspective on bundling interventions - a reflection on Jeong et al. (2023)

Bundling multiple interventions have been implemented and evaluated in response to global recognition that young children benefit from the multiple components of nurturing care. Engaging Fathers for Effective Child Nutrition and Development in Tanzania Study evaluated the impact of adding a parenting intervention to a nutrition program and involving fathers on children's development. The study found that the bundled nutrition-parenting intervention improved children's short-term cognitive and receptive language scores over the nutrition only intervention, with no difference between involving mother-father couples versus mothers only. This study adds to recommendations for future multiple component interventions, including to investigate the mechanisms driving interventions, to address the potential for both benefits and harms, to involve household and community caregivers, and to incorporate implementation research to transition evidence-based programs to scale. Expanding nurturing care through multiple component interventions has the potential to promote equity by ensuring that all children have opportunities for healthy growth and development.

Childcare centre attendance and health, growth, and development among children aged 0-3 years in low- and middle-income countries: A systematic review

Background

Lack of childcare for children aged 0-3 years has emerged as a global crisis, accentuated by women's increasing workforce participation and recognition that young children require nurturing care. Through this systematic review, we sought to examine associations between childcare centre attendance in low- and middle-income countries (LMICs) and children's health, growth, and development, and to generate childcare centre programmatic and research recommendations for children aged 0-3 years.

Methods

We systematically searched PsycINFO, MEDLINE, PubMed, and Cochrane for articles on centre-based childcare for children aged 0-3 years in LMICs, published between 2000 and 2021 in English (or which were translated into English). We excluded articles on specialised subgroups or interventions. We imported the retrieved articles into Covidence for review and assessed them for bias using the National Institutes of Health (NIH) quality assessment tool.

Results

Twenty-two articles (24 studies) met the inclusion criteria, encompassing 36 927 children from 10 countries across Mexico and South America (n = 12), Africa (n = 5), and Asia (n = 5). Outcomes included health (n = 12), growth/nutrition (n = 6), and development (n = 6). Study quality assessments were low; 41% exceeded 50% of quality criteria and 45% adjusted for confounders. Associations between childcare attendance and outcome measures were primarily negative for health (n/N = 7/12) and positive for growth/nutrition (n/N = 5/6) and development (n/N = 4/6). Childcare centre programmatic recommendations for children aged 0-3 years included: age-specific policies; program quality, including safety, hygiene, nutrition, and curriculum; access and affordability; parent engagement; financial support; and workforce development. Research recommendations included: study design, including enrolment age, frequency, duration, childcare type, home and childcare sociodemographic and cultural environments, child and caregiver outcomes, and analytical approaches; longitudinal studies; and implementation research.

Conclusions

Rigorous primary research in global childcare for young children is urgently needed. Policies, programmes, and investments in high-quality childcare can promote nurturing care for young children, enabling mothers to participate in the workforce.

Registration

PROSPERO: CRD42018105576.

Studying the impact of COVID-19 mitigation policies on childhood obesity, health behaviors, and disparities in an observational cohort: Protocol for the COVID-19 Family Study

BACKGROUND

COVID-19 pandemic control policies, including school closures, suspended extra-curricular activities, and social distancing, were introduced to prevent viral transmission, and disrupted children's daily routines, health behaviors, and wellness. This observational cohort study among 697 families with children or adolescents, based on the Family Stress Model, aims to: 1) evaluate pre- to during-pandemic changes in child health behaviors (diet, physical activity, sleep) and weight gain, 2) identify mechanisms explaining the changes, and 3) determine projected healthcare costs on weight gain and obesity. Each aim includes an examination by racial and ethnic, socioeconomic, and geographic disparities.

METHODS

The study employs a mixed methods design, recruiting children and their caregivers from two obesity prevention trials halted in 2020. Enrolled participants complete annual surveys to assess child health behaviors, family resources, routines, and demographics, and home environment in 2020-2022. Height and weight are measured annually in 2021-2022. Annual semi-structured interviews are conducted within a subsample to understand mechanisms of observed changes. Multilevel mixed models and mediation analyses are used to examine changes in child health behaviors and weight gain and mechanisms underlying the changes. Qualitative data are analyzed within and across time points and integrated with quantitative findings to further explain mechanisms. Markov models are used to determine healthcare costs for unhealthy child behaviors and weight gain.

CONCLUSION

Findings from this study will aid in understanding pandemic-related changes in child health behaviors and weight status and will provide insights for the implementation of future programs and policies to improve child and family wellness.

Perceptions of Parental Support for Physical Activity and Healthy Eating among School-age Children During COVID-19 pandemic

Family routines play a key role in promoting child health behaviors. This study 1) describes changes in children's perceptions of physical activity (PA) and healthy eating family routines across three time points: pre-pandemic (2017-2020), early pandemic (2020), and mid-pandemic (2021); and 2) explores how sex, age, and pandemic-related economic stressors relate to changes. Children's perceptions of family routines were assessed using four subscales adapted from the Comprehensive Home Environment Survey: PA-policies, Diet-policies, Diet-rules, and PA-Diet-role-model. Linear mixed models assessed changes in perceptions and associated factors (child age and sex; caregiver(s) job loss during pandemic). Children (N=277) were aged 9.3-15.5y at pandemic onset (March 2020), dichotomized by median age (12.1y) as younger and older. Children's perceptions of PA-policies (pre-pandemic mean=15.4) and Diet-policies (pre-pandemic mean=26.3) increased significantly from pre- to early (b=1.2 and 2.3, respectively) and mid-pandemic (b=1.0 and 1.2, respectively). Diet-rules (pre-pandemic mean=10.8) decreased significantly from pre- to early (b=-1.1) and mid-pandemic (b=-2.0), with no PA-Diet-role-model changes. Younger children had a greater increase in perceived PA-policies and Diet-policies across the pandemic. Females (59.9%) had a greater decrease in perceived Diet-rules across the pandemic and less increase in Diet-policies and PA-Diet-role-model from pre- to early pandemic. Children whose caregiver(s) lost employment (51.8%) perceived a greater increase in PA-policies. Overall, children reported increased parental policies to support PA and healthy eating and decreased parental rules for diet during the pandemic. Future research is needed to understand how changes in family routines relate to PA and healthy eating behaviors.

Contrasting speed and accuracy approaches to measure executive functions in three low-and middle-income countries

Executive functions (EF) can be measured by tests assessing accuracy, reaction times and by computing scores which combine these two components. Interpretation issues can arise from the use of different scoring methods across studies. Given that EF measures and their scoring methods are predominantly developed and validated in high income countries, little is known about the generalisability of such methods cross- culturally. The current paper compares two different established scoring approaches for measures of inhibition and cognitive flexibility: difference scores (which utilise reaction time only) and computed scores (combining accuracy and reaction time). We utilised data collected in adulthood from three low- and middle-income birth cohorts (Guatemala, Philippines, South Africa). Non-normal distributions were observed for both scoring methods in all three samples; however, this was more pronounced for the difference score method. Differing distribution patterns were observed across the three cohorts, which was especially evident in the Guatemala cohort, highlighting potential issues with using these methods across diverse populations. The data suggest that the computed scores may be a reliable measure of EF. However, the different ways of scoring and interpreting EF instruments need to be considered carefully for each population before use.

The Effects of Multiple Micronutrient Fortified Beverage and Responsive Caregiving Interventions on Early Childhood Development, Hemoglobin, and Ferritin among Infants in Rural Guatemala

Undernutrition and a lack of learning opportunities can jeopardize long-term growth and development among infants in low- and middle-income countries. We conducted a 6-month 2 × 2 cluster-randomized trial to assess the effects of multiple micronutrient-fortified beverages and responsive caregiving interventions among infants 6-18 months in 72 community sectors in southwest Guatemala. We administered baseline and endline assessments of childhood development (Bayley Scales of Infant and Toddler Development) and socioemotional development (Brief Infant Toddler Socio-Emotional Assessment) and measured ferritin and hemoglobin on a subsample. The trial was analyzed using linear mixed models. At the baseline, the mean age (SD) was 13.0 (4.6) months, including 49% males, 32% who were stunted, 55% who were anemic, and 58% who were iron deficient. At the endline (n = 328/386, 85% retention), there was no synergistic effect on the fortified beverage and responsive caregiving intervention. Compared to the non-fortified beverage group, socioemotional development improved in the fortified beverage group. There were no intervention effects on other measures of child development, hemoglobin, or ferritin. In a setting with high rates of anemia and iron deficiency, a multiple micronutrient-fortified beverage improved infants' socioemotional development.

Determinants of food preparation and hygiene practices among caregivers of children under two in Western Kenya: a formative research study

INTRODUCTION

Diarrhea is a leading cause of child morbidity and mortality worldwide and is linked to early childhood stunting. Food contamination from improper preparation and hygiene practices is an important transmission pathway for exposure to enteric pathogens. Understanding the barriers and facilitators to hygienic food preparation can inform interventions to improve food hygiene. We explored food preparation and hygiene determinants including food-related handwashing habits, meal preparation, cooking practices, and food storage among caregivers of children under age two in Western Kenya.

METHODS

We used the Capabilities, Opportunities, and Motivations model for Behavior Change (COM-B) framework in tool development and analysis. We conducted 24 focus group discussions with mothers (N = 12), fathers (N = 6), and grandmothers (N = 6); 29 key informant interviews with community stakeholders including implementing partners and religious and community leaders; and 24 household observations. We mapped the qualitative and observational data onto the COM-B framework to understand caregivers' facilitators and barriers to food preparation and hygiene practices.

RESULTS

Facilitators and barriers to food hygiene and preparation practices were found across the COM-B domains. Caregivers had the capability to wash their hands at critical times; wash, cook, and cover food; and clean and dry utensils. Barriers to food hygiene and preparation practices included lack of psychological capability, for instance, caregivers' lack of knowledge of critical times for handwashing, lack of perceived importance of washing some foods before eating, and not knowing the risks of storing food for more than four hours without refrigerating and reheating. Other barriers were opportunity-related, including lack of resources (soap, water, firewood) and an enabling environment (monetary decision-making power, social support). Competing priorities, socio-cultural norms, religion, and time constraints due to work hindered the practice of optimal food hygiene and preparation behaviors.

CONCLUSION

Food hygiene is an underexplored, but potentially critical, behavior to mitigate fecal pathogen exposure for young children. Our study revealed several knowledge and opportunity barriers that could be integrated into interventions to enhance food hygiene.

Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya

Background

Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections.

Objectives

To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya.

Methods

Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development.

Results

Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices.

Conclusions

Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

On the Move or Barely Moving? Age-Related Changes in Physical Activity, Sedentary, and Sleep Behaviors by Weekday/Weekend Following Pandemic Control Policies

This study examined pre-pandemic (2017-early March 2020) to early-pandemic (Spring 2020) changes in moderate-to-vigorous PA (MVPA), light PA (LPA), and sedentary behavior/sleep (SS), by weekday/weekend, and age (preschool, elementary, middle school). We re-enrolled children from two pre-pandemic obesity prevention trials and examined differences in accelerometer-measured PA from pre-pandemic to early-pandemic across age groups using linear mixed models. Children (n = 75) were 51% multiple race/ethnicities, 29% preschool, 28% elementary, 43% middle school, 65% suburban, 21% rural, and 13% urban. Pre-pandemic to early-pandemic changes in weekday MVPA (p = 0.006), LPA (p = 0.018), and SS (p = 0.003) differed by age. On weekdays, middle schoolers' MVPA decreased 15.36 min/day (p = 0.002) and SS increased 94.36 min/day (p < 0.001) with non-significant changes among preschoolers and elementary schoolers. Compared to elementary schoolers, middle schoolers' changes in weekday MVPA (b = -16.34, p = 0.036) and SS (b = 63.28, p = 0.039) significantly differed. Declines in weekday MVPA and increases in SS among middle schoolers suggest that, compared with younger children, middle schoolers are dependent on school and recreational facilities for PA, and in their absence engage in more sedentary activities and sleep.

Pre-pandemic to early-pandemic changes in risk of household food insecurity among Maryland families with children

OBJECTIVE

The objective was to examine risk and protective factors associated with pre- to early-pandemic changes in risk of household food insecurity (FI).

DESIGN

We re-enrolled families from two statewide studies (2017-2020) in an observational cohort (May-August 2020). Caregivers reported on risk of household FI, demographics, pandemic-related hardships, and participation in safety net programs (e.g. CARES stimulus payment, school meals).

SETTING

Maryland, United States.

PARTICIPANTS

Economically, geographically, and racially/ethnically diverse families with preschool to adolescent-age children. Eligibility included reported receipt or expected receipt of the CARES stimulus payment or a pandemic-related economic hardship (n=496).

RESULTS

Prevalence of risk of FI was unchanged (pre-pandemic: 22%, early-pandemic: 25%, p=0.27). Risk of early-pandemic FI was elevated for non-Hispanic Black (aRR=2.1 [95% CI 1.1, 4.0]) and Other families (aRR=2.6 [1.3, 5.4]) and families earning ≤300% federal poverty level. Among pre-pandemic food secure families, decreased income, job loss, and reduced hours were associated with increased early-pandemic FI risk (aRR=2.1 [1.2, 3.6] to 2.5 [1.5, 4.1]); CARES stimulus payment (aRR=0.5 [0.3, 0.9]) and continued school meal participation (aRR=0.2 [0.1, 0.9]) were associated with decreased risk. Among families at risk of FI pre-pandemic, safety net program participation was not associated with early-pandemic FI risk.

CONCLUSIONS

The CARES stimulus payment and continued school meal participation protected pre-pandemic food secure families from early-pandemic FI risk but did not protect families who were at risk of FI pre-pandemic. Mitigating pre-pandemic FI risk and providing stimulus payments and school meals may support children's health and reduce disparities in response to pandemics.

Longitudinal Associations of Pubertal Timing and Tempo With Adolescent Mental Health and Risk Behavior Initiation in Urban South Africa

PURPOSE

In high-income countries, early and rapid pubertal development is consistently associated with poor adjustment and increased risk behavior in adolescence. This study contributes to the meager knowledge of these associations in lower income countries.

METHODS

We used longitudinal data from 1,784 urban black South Africans in the Birth to Twenty Plus cohort. We used regression analyses to assess associations between age at menarche and latent classes of pubertal timing and tempo and adolescent internalizing and externalizing emotional and behavioral problems, eating attitudes, and patterns of health risk behavior initiation.

RESULTS

Relatively earlier and faster pubertal timing and tempo were associated with increased health risk behavior initiation (e.g., adjusted odds ratio [95% confidence interval] high- vs. low-risk pattern = 5.7 [1.7, 19.06] for male genital development; adjusted odds ratio = 3.45 [1.13, 10.49] for female breast development). Among males, earlier and faster pubertal timing and tempo were associated with increased externalizing problems in early adolescence and increased oppositional defiant problems in midadolescence, whereas later and slower pubertal timing and tempo were associated with decreases. Among females, earlier and faster pubertal timing and tempo were associated with increased internalizing and externalizing problems in midadolescence and increased dieting behaviors in early and late adolescence (β [95% confidence interval] = 2.51 [.87, 4.15] for pubic hair development), whereas later and slower pubertal timing and tempo were associated with decreases.

CONCLUSIONS

In this urban South African cohort, relatively earlier and faster pubertal development was detrimental to mental health and risk behavior activity, whereas later and slower maturation was somewhat protective.

Initial engagement and persistence of health risk behaviors through adolescence: longitudinal findings from urban South Africa

Background

Little is known about longitudinal patterns of adolescent health risk behavior initial engagement and persistence in low- and middle-income countries.

Methods

Birth to Twenty Plus is a longitudinal birth cohort in Soweto-Johannesburg, South Africa. We used reports from Black African participants on cigarette smoking, alcohol, cannabis, illicit drug, and sexual activity initial engagement and adolescent pregnancy collected over 7 study visits between ages 11 and 18 y. We fit Kaplan-Meier curves to estimate behavior engagement or adolescent pregnancy, examined current behavior at age 18 y by age of first engagement, and performed a clustering analysis to identify patterns of initial engagement and their sociodemographic predictors.

Results

By age 13 y, cumulative incidence of smoking and alcohol engagement were each > 21%, while the cumulative incidence of other behaviors and adolescent pregnancy were < 5%. By age 18 y (15 y for cannabis), smoking, alcohol, and sexual activity engagement estimates were each > 65%, cannabis and illicit drug engagement were each > 16%; adolescent pregnancy was 31%. Rates of engagement were higher among males. Current risk behavior activity at age 18 y was generally unrelated to age of initial engagement. We identified three clusters reflecting low, moderate, and high-risk patterns of initial risk behavior engagement. One-third of males and 17% of females were assigned to the high-risk cluster. Sociodemographic factors were not associated with cluster membership.

Conclusions

Among urban dwelling Black South Africans, risk behavior engagement across adolescence was common and clustered into distinct patterns of initial engagement which were unrelated to the sociodemographic factors assessed. Patterns of initial risk behavior engagement may inform the timing of primary and secondary public health interventions and support integrated prevention efforts that consider multiple behaviors simultaneously.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02486-y.

Motor Competence and Attainment of Global Physical Activity Guidelines among a Statewide Sample of Preschoolers

Global physical activity guidelines for preschoolers include 60 min of moderate-to-vigorous physical activity (MVPA) daily. This study, based on the developmental model of motor skill competence, examines how motor competence relates to preschoolers’ likelihood of meeting global guidelines using ankle accelerometry. We measured physical activity using 24-h ankle-placement accelerometry (Actical) for at least two consecutive days (87% with six-seven days), motor competence using the Test of Gross Motor Development-2 (TGMD-2), and BMI-for-age z-scores (BMIz) using anthropometry and age- and sex-specific CDC norms. Caregivers provided demographic characteristics of children’s age, sex, and race. We used multivariable logistic regression to examine how motor competence, BMIz weight status, and demographic characteristics related to meeting global physical activity guidelines. The sample included 588 preschoolers, age 3–5 years; 55% male; 60% white; and 28% overweight/obese; 75% attained the recommended 60 min of MVPA per day. The odds of meeting MVPA guidelines were associated with higher gross motor quotient, higher object control scores, sex (male), age (older), and race (white), but not with BMIz weight status. Findings support the use of 24-h ankle accelerometry among preschoolers and are consistent with the developmental model of motor competence applied to preschoolers, whereby object control competence relates positively to attaining global physical activity guidelines.

Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.

Comparison of Cardiovascular Events Among Users of Different Classes of Antihypertension Medications: A Systematic Review and Network Meta-analysis

Importance

Antihypertension medications have been associated with prevention of cardiovascular events, although less is known about the comparative effectiveness of different medication classes.

Objective

To compare contemporary aggregated first-in-trial cardiovascular events among patients with hypertension and no substantial comorbidities.

Data Sources

The PubMed, Embase, and Cochrane Library databases were systematically searched for articles published between January 1, 1990, and October 24, 2017.

Study Selection

Randomized clinical trials that tested commonly used antihypertension medications (angiotensin-converting enzyme inhibitors, dihydropyridine calcium channel blockers, nondihydropyridine calcium channel blockers, β-blockers, angiotensin receptor blockers, and diuretics) and that reported selected cardiovascular outcomes for at least 6 months of follow-up.

Data Extraction and Synthesis

The analysis was conducted from October 2017 to December 2019. Two reviewers extracted the number of cardiovascular events at the end of treatment for all study groups. For each outcome, a frequentist network meta-analysis was used to compare risk reductions between medication classes (random-effects models weighted by the inverse variance). The dose-response association between a 10-mm Hg reduction of systolic blood pressure and a 5-mm Hg reduction of diastolic blood pressure and the risk of first-in-trial cardiovascular events was estimated.

Main Outcomes and Measures

First-in-trial cardiovascular events, including cardiovascular death, myocardial infarction, stroke, and revascularization.

Results

In this systematic review and network meta-analysis, data were pooled from 46 eligible clinical trials (248 887 total participants with a mean [SD] age of 65.6 [5.8] years; 52.8% men). In the network meta-analysis, compared with placebo, angiotensin-converting enzyme inhibitors, dihydropyridine calcium channel blockers, and thiazide diuretics were reported to be similarly effective in reducing overall cardiovascular events (25%), cardiovascular death (20%), and stroke (35%); angiotensin-converting enzyme inhibitors were reported to be the most effective in reducing the risk of myocardial infarction (28%); and diuretics were reported to be the most effective in reducing revascularization (33%). In the metaregression analyses, each 10-mm Hg reduction in systolic blood pressure and 5-mm Hg reduction in diastolic blood pressure was significantly associated with a lower risk of cardiovascular death, stroke, and overall cardiovascular events.

Conclusions and Relevance

In this network meta-analysis of clinical trials of patients with hypertension and no substantial comorbidities, different classes of antihypertension medications were associated with similar benefits in reducing cardiovascular events. Future studies should compare the effectiveness of combinations of antihypertension medications in reducing cardiovascular events.

Linear Growth through 12 Years is Weakly but Consistently Associated with Language and Math Achievement Scores at Age 12 Years in 4 Low- or Middle-Income Countries

Background

Whether linear growth through age 12 y is associated with language and math achievement at age 12 y remains unclear.

Objective

Our objective was to investigate associations of linear growth through age 12 y with reading skill, receptive vocabulary, and mathematics performance at age 12 y in 4 low- or middle-income countries (LMICs).

Methods

We analyzed data from the Young Lives Younger Cohort study in Ethiopia (n = 1275), India (n = 1350), Peru (n = 1402), and Vietnam (n = 1594). Age 1, 5, 8, and 12 y height-for-age z scores (HAZ) were calculated. Language and math achievement at age 12 y was assessed with the use of country-specific adaptations of the Peabody Picture Vocabulary Test, the Early Grades Reading Assessment, and a mathematics test; all test scores were standardized by age within country. We used path analysis to examine associations of HAZ with achievement scores. Twelve models were examined at each age (3 tests across 4 countries).

Results

Mean HAZ in each country was <-1.00 at all ages. Overall, linear growth through age 12 y was associated with 0.4-3.4% of the variance in achievement scores. HAZ at 1 y was positively and significantly associated with the test score in 11 of the 12 models. This association was significantly mediated through HAZ at 5, 8, and 12 y in 9 of the models. HAZ at 5, 8, and 12 y was positively and significantly associated with test scores in 8, 8, and 6 models, respectively. These associations were mediated through HAZ at older ages in 6 of the HAZ at 5-y models and in 6 of the HAZ at 8-y models.

Conclusion

Child relative linear growth between ages 1 and 12 y was weakly but consistently associated with language and math achievement at age 12 y in 4 LMICs.

Long-term Sustainability of Diabetes Prevention Approaches: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance

Diabetes prevention is imperative to slow worldwide growth of diabetes-related morbidity and mortality. Yet the long-term efficacy of prevention strategies remains unknown.

Objective

To estimate aggregate long-term effects of different diabetes prevention strategies on diabetes incidence.

Data Sources

Systematic searches of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases. The initial search was conducted on January 14, 2014, and was updated on February 20, 2015. Search terms included prediabetes, primary prevention, and risk reduction.

Study Selection

Eligible randomized clinical trials evaluated lifestyle modification (LSM) and medication interventions (>6 months) for diabetes prevention in adults (age ≥18 years) at risk for diabetes, reporting between-group differences in diabetes incidence, published between January 1, 1990, and January 1, 2015. Studies testing alternative therapies and bariatric surgery, as well as those involving participants with gestational diabetes, type 1 or 2 diabetes, and metabolic syndrome, were excluded.

Data Extraction and Synthesis

Reviewers extracted the number of diabetes cases at the end of active intervention in treatment and control groups. Random-effects meta-analyses were used to obtain pooled relative risks (RRs), and reported incidence rates were used to compute pooled risk differences (RDs).

Main Outcomes and Measures

The main outcome was aggregate RRs of diabetes in treatment vs control participants. Treatment subtypes (ie, LSM components, medication classes) were stratified. To estimate sustainability, post-washout and follow-up RRs for medications and LSM interventions, respectively, were examined.

Results

Forty-three studies were included and pooled in meta-analysis (49 029 participants; mean [SD] age, 57.3 [8.7] years; 48.0% [n = 23 549] men): 19 tested medications; 19 evaluated LSM, and 5 tested combined medications and LSM. At the end of the active intervention (range, 0.5-6.3 years), LSM was associated with an RR reduction of 39% (RR, 0.61; 95% CI, 0.54-0.68), and medications were associated with an RR reduction of 36% (RR, 0.64; 95% CI, 0.54-0.76). The observed RD for LSM and medication studies was 4.0 (95% CI, 1.8-6.3) cases per 100 person-years or a number-needed-to-treat of 25. At the end of the washout or follow-up periods, LSM studies (mean follow-up, 7.2 years; range, 5.7-9.4 years) achieved an RR reduction of 28% (RR, 0.72; 95% CI, 0.60-0.86); medication studies (mean follow-up, 17 weeks; range, 2-52 weeks) showed no sustained RR reduction (RR, 0.95; 95% CI, 0.79-1.14).

Conclusions and Relevance

In adults at risk for diabetes, LSM and medications (weight loss and insulin-sensitizing agents) successfully reduced diabetes incidence. Medication effects were short lived. The LSM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed.

The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: Design and methods to address mental healthcare gaps in India

INTRODUCTION

Depression and diabetes are highly prevalent worldwide and often co-exist, worsening outcomes for each condition. Barriers to diagnosis and treatment are exacerbated in low and middle-income countries with limited health infrastructure and access to mental health treatment. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study tests the sustained effectiveness and cost-effectiveness of a multi-component care model for individuals with poorly-controlled diabetes and depression in diabetes clinics in India.

MATERIALS AND METHODS

Adults with diabetes, depressive symptoms (Patient Health Questionnaire-9 score≥10), and ≥1 poorly-controlled cardiometabolic indicator (either HbA1c≥8.0%, SBP≥140mmHg, and/or LDL≥130mg/dl) were enrolled and randomized to the intervention or usual care. The intervention combined collaborative care, decision-support, and population health management. The primary outcome is the between-arm difference in the proportion of participants achieving combined depression response (≥50% reduction in Symptom Checklist score from baseline) AND one or more of: ≥0.5% reduction in HbA1c, ≥5mmHg reduction in SBP, or ≥10mg/dl reduction in LDL-c at 24months (12-month intervention; 12-month observational follow-up). Other outcomes include control of individual parameters, patient-centered measures (i.e. treatment satisfaction), and cost-effectiveness.

RESULTS

The study trained seven care coordinators. Participant recruitment is complete - 940 adults were screened, with 483 eligible, and 404 randomized (196 to intervention; 208 to usual care). Randomization was balanced across clinic sites.

CONCLUSIONS

The INDEPENDENT model aims to increase access to mental health care and improve depression and cardiometabolic disease outcomes among complex patients with diabetes by leveraging the care provided in diabetes clinics in India (clinicaltrials.gov number: NCT02022111).

Noncommunicable Diseases: Three Decades Of Global Data Show A Mixture Of Increases And Decreases In Mortality Rates

Noncommunicable diseases are the leading health concerns of the modern era, accounting for two-thirds of global deaths, half of all disability, and rapidly growing costs. To provide a contemporary overview of the burdens caused by noncommunicable diseases, we compiled mortality data reported by authorities in forty-nine countries for atherosclerotic cardiovascular diseases; diabetes; chronic respiratory diseases; and lung, colon, breast, cervical, liver, and stomach cancers. From 1980 to 2012, on average across all countries, mortality for cardiovascular disease, stomach cancer, and cervical cancer declined, while mortality for diabetes, liver cancer, and female chronic respiratory disease and lung cancer increased. In contrast to the relatively steep cardiovascular and cancer mortality declines observed in high-income countries, mortality for cardiovascular disease and chronic respiratory disease was flat in most low- and middle-income countries, which also experienced increasing breast and colon cancer mortality. These divergent mortality patterns likely reflect differences in timing and magnitude of risk exposures, health care, and policies to counteract the diseases. Improving both the coverage and the accuracy of mortality documentation in populous low- and middle-income countries is a priority, as is the need to rigorously evaluate societal-level interventions. Furthermore, given the complex, chronic, and progressive nature of noncommunicable diseases, policies and programs to prevent and control them need to be multifaceted and long-term, as returns on investment accrue with time.

Osteopontin: an intrinsic inhibitor of inflammation in cartilage

OBJECTIVE

To identify extracellular and intraarticular matrix components that are differentially expressed in normal and osteoarthritis (OA)-affected cartilage and to investigate their functions with respect to regulation of mediators of inflammation.

METHODS

Differential-display reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of a pool of messenger RNA (mRNA) from 10 human OA cartilage samples and 5 normal cartilage samples was performed using arbitrary primers. Confirmatory analysis of the up-regulated transcripts of fibronectin (FN) and osteopontin (OPN) was performed by RT-PCR of individual RNA samples from a separate set of donors. The effect of recombinant OPN (or anti-OPN antiserum) on chondrocyte function was examined by analyzing the spontaneous or interleukin-1 (IL-1)-induced release of nitric oxide (NO) and prostaglandin E2 (PGE2) from human OA-affected cartilage under ex vivo conditions.

RESULTS

Up-regulation (300-700%) of FN and OPN mRNA was observed in human OA-affected cartilage as compared with normal cartilage. Functional analysis of the role of OPN in OA cartilage showed that 1) Addition of 1 microg/ml (20 nM) of recombinant OPN to human OA-affected cartilage under ex vivo conditions inhibited spontaneous and IL-1beta-induced NO and PGE2 production, and 2) neutralization of intraarticular OPN with anti-OPN antiserum augmented NO production.

CONCLUSION

The data indicate that one of the functions of intraarticular OPN, which is overexpressed in OA cartilage, is to act as an innate inhibitor of IL-1, NO, and PGE2 production. These findings suggest that the production of pleiotropic mediators of inflammation that influence cartilage homeostasis, such as NO and PGE2, is regulated by the interaction of chondrocytes with differentially expressed proteins within the extracellular matrix.

Mice lacking osteopontin show normal development and bone structure but display altered osteoclast formation in vitro

We have used homologous recombination in embryonic stem cells to generate mice with a targeted disruption of the osteopontin (Opn, or Spp1, for secreted phosphoprotein 1) gene. Mice homozygous for this disruption fail to express osteopontin (OPN) as assessed at both the mRNA and protein level, although an N-terminal fragment of OPN is detectable at extremely low levels in the bones of -/- animals. The Opn -/- mice are fertile, their litter size is normal, and they develop normally. The bones and teeth of animals not expressing OPN are morphologically normal at the level of light and electron microscopy, and the skeletal structure of young animals is normal as assessed by radiography. Ultrastructurally, proteinaceous structures normally rich in OPN, such as cement lines, persist in the bones of the Opn-/- animals. Osteoclastogenesis was assessed in vitro in cocultures with a feeder layer of calvarial osteoblast cells from wild-type mice. Spleen cells from Opn-/- mice cells formed osteoclasts 3- to 13-fold more frequently than did control Opn+/+ cells, while the extent of osteoclast development from Opn -/- bone marrow cells was about 2- to 4-fold more than from the corresponding wild-type cells. Osteoclast development occurred when Opn-/- spleen cells were differentiated in the presence of Opn-/-osteoblasts, indicating that endogenous OPN is not required for this process. These results suggest that OPN is not essential for normal mouse development and osteogenesis, but can modulate osteoclast differentiation.

[Cooperation of the physician--gynecology and psychology in treating infertility]

The paper gives an overview of basic principles of cooperation between gynaecologists in infertility treatment. The authors experience in dealing with patients requesting donor insemination is presented. The outline of psychological consultation in such cases is given.

[Does treatment with antiestrogens in men with oligozoospermia influence the course of pregnancy in infertile married women]

Study aimed at obtaining answer to the question if antiestrogenic treatment (tamoxifen or clomiphene) of men having oligozoospermia has an impact on the pregnancy course. The pregnancy courses were live analysed of 34 healthy women, who had been treated with the artificial insemination by husband, having received tamoxifen or clomiphene. No important distinction in the pregnancy courses were found. Delivery at term took place more frequently in the first group than in the second one. There were insignificantly more frequently births of males in both groups.

cAMP radioimmunoassay without interference from calcium or EDTA

Calcium and EDTA interfere with radioimmunoassay of cAMP or acetylated cAMP. Both interferences with the assay of acetylated cAMP can be obviated by including in the buffer 15 mmol of CaCl2 per liter, which at the same time increases the affinity of the antibody by 89%. As a result, antibody can be decreased by 65%. This method requires no prepurification (extraction or chromatography), and no correction for analytical recovery is necessary. This assay can detect 12 fmol of cAMP per tube, so only microliter quantities of plasma are needed.

cAMP radioimmunoassay without interference from calcium or EDTA

Calcium and EDTA interfere with radioimmunoassay of cAMP or acetylated cAMP. Both interferences with the assay of acetylated cAMP can be obviated by including in the buffer 15 mmol of CaCl2 per liter, which at the same time increases the affinity of the antibody by 89%. As a result, antibody can be decreased by 65%. This method requires no prepurification (extraction or chromatography), and no correction for analytical recovery is necessary. This assay can detect 12 fmol of cAMP per tube, so only microliter quantities of plasma are needed.