The impact of ordinary illnesses on the dietary intakes of malnourished children

The effect of respiratory infections, diarrhea, illness-induced apathy, and of a summary variable of selected common symptoms on food intake was estimated from data collected on preschool children from rural Guatemala. The presence of selected common symptoms was associated with an average reduction in daily intake of nearly 20%, equivalent to 175 kcal and 4.8 g of protein. Effects were of similar magnitude for diarrhea and for apathy but lower for respiratory infections, namely 61 kcal and 1.0 g of protein. It is concluded that common illnesses are an important cause of low dietary intakes in children from Guatemama.

Influence of maternal nutrition on birth weight

This paper discusses some conditions necessary to detect an effect of maternal nutrition on birth weight and the relative contribution of calories and protein to such an effect. The expected dose- and time-response relationships for nutritional interventions aimed at the improvement of birth weight are also discussed. There appears to be a minimal level of nutrients which must be available in order to obtain adequate birth weight. However, above this minimum level, pregnant women can adapt themselves to a wide variety of food intake, both in quantity and quality, without affecting birth weight. The relative contribution of calories and protein to an increase in birth weight depends on the limiting nutrients of the home diet in the population under study. Other factors like physical activity, prevalence of disease and magnitude of the maternal nutritional stores before pregnancy are also important determinants of the relative contribution of calories and protein to birth weight. The anticipated input of a nutritional intervention on birth weight should range between 25 and 84 g of birth weight/10,000 kcal ingested during pregnancy. This estimate was computed from analyses based on four sources of published data: weight gain during pregnancy, prepregnant weight, fetomaternal body composition, and food intake during pregnancy. The expected reduction in proportion of low birth weight (LBW less than 2.5 kg) babies following a nutritional intervention will depend not only on the estimated range of fetal weight increase but also on the total amount of supplemented calories ingested during pregnancy as well as on the existent proportion of low birth weight babies prior to the intervention. The offspring of women who have low prepregnant weight, poor diet, low level of replacement of the home diet by the supplement, low physical activity during pregnancy and good health status will show larger increase in birth weight per unit of supplemented calories. Finally, nutritional interventions during pregnancy as opposed to earlier in the life of the mother, should have the higher impact on birth weight. In consequence, interventions as of pregnancy are recommended.

Diarrheal diseases and growth retardation in preschool Guatemalan children

The relationship between diarrheal diseases and growth increments in total body length and weight was investigated in 716 rural Ladino Gautemalan children. Data on diarrheal diseases were provided by the mothers through retrospective surveys carried out at 14-day intervals. Increments in length and weight, semestral from near birth at four years and yearly thence to seven, were related to days ill with diarrheal diseases during the same time interval. Because the data here reported were collected over a two year period, a child may have had information for more than one period. In total, 1,343 child periods were investigated. Days ill with diarrheal diseases were found to be significantly associated with reduced growth in length and weight. It was assumed that the average differences in growth by seven years of age between children in the present sample and children from well-to-do societies, are mainly a function of environmental differences and consequently, a measure of the extent of growth retardation. By expressing the growth retardation specifically associated with diarrheal diseases as a fraction of the above differences it was then estimated that around 10% of this growth retardation was associated with diarrheal diseases.

The indentification and evaluation of measurement variability in the anthropometry of preschool children

Measurement variability estimates for 18 different anthropometric dimensions were collected within the context of an ongoing longitudinal in vestigation of preschool Guatemalan children. Estimates of total measurement variance, intra-observer variance, and short-term intra-subject variance are presented for each variable. A simple procedure for the evaluation of measurement variance in cross-sectional and longitudinal investigations is described in which the total measurement variance is expressed as a percentage of the appropriate inter-subject variance. This statistic serves as an index of the relative reproducibility of anthropometric variables.

Nutritional status and the timing of deciduous tooth eruption

The number of deciduous teeth in a sample of rural Ladino Guatemalan children was counted every 3 months through 24 months of age, and at 6-month intervals from 24 to 36 months. Nutritional status at birth, whether expressed as full-term birth weight or as maternal caloric supplementation during pregnancy, influences the timing of deciduous tooth eruption. Furthermore, the timing of deciduous tooth eruption seems more closely associated with postnatal weight than with birth weight. Although indices of nutritional deficiencies are associated with retarded tooth eruption, the use of mean number of deciduous teeth erupted as an estimate of mean chronological age in populations living under conditions of mild-to-moderate malnutrition is relatively accurate because errors of age estimation based on mean values for the present sample only vary between 1 and 2 months.

Upper arm anthropometric indicators of nutritional status

The growth in arm muscle area and arm fat area of preschool children from rural Guatemala is compared to that of a standard from the U.S.A. It was found that although the Guatemalan children have reduced arm muscle and fat areas, the relative reduction in arm fat area was greater than in arm muscle area. Further, the upper arm cross-sectional area of Guatemalan children had proportionately more muscle than fat when compared to that of U.S.A. children. Lastly, for the same body weight, Guatemalan children had a similar arm muscle area but a clearly smaller arm fat area than North American children. It is concluded that these findings suggest that energy rather than protein is the main nutritional problem in these Guatemalan children.

Relations between nutrition and cognition in rural Guatemala

The nutritional status of three and four year old children, as measured by height and head circumference, is related to cognitive performance in four rural Guatemalan villages. The relationships persist when social factors are taken into account. Families in two of the villages participate in a voluntary, high protein-calorie supplementation program. In the other two villages, the families receive a vitamin and mineral supplement with one-third of the calories. Although the longitudinal study still is ongoing there is some evidence that the children who receive the higher calorie supplement (or whose mothers received it during pregnancy and lactation) are most likely to score high in cognitive performance. The results support other animal and human studies that report an association between nutrition and cognitive development. The findings, while not diminishing social environmental explantions of differences in cognitive function, suggest the worth of nutrition intervention programs in rural areas of lesser-developed countries.

Effect of moderate maternal malnutrition on the placenta

The results of two studies of the influence of moderate maternal malnutrition on the weight and chemical characteristics of the placenta are discussed. In the first study, two groups of pregnant women of high and low socioeconomic status from Guatemala City were studied. Socioeconomic status was defined by family income, educational level of the mother, and environmental sanitary conditions. Both groups were very similar with respect to age, parity, gestational age, and absence of severe disease during pregnancy. The average placental weight in the low socioeconomic group was 15 per cent below that of the high socioeconomic group and there was a consistent association between the postpartum maternal weight and placental weight. There were no differences between the two groups regarding placental concentration of fat, protein, water, ash, hemoglobin, and DNA; hydroxyproline and fat concentration were significantly lower in the low socioeconomic group. The hypothesis that the difference in placental weight observed between the two groups was primarily due to maternal nutritional status was tested in the second study by means of nutritional intervention in four rural villages in Guatemala. Two of the villages received a protein-calorie preparation while the other two received a calorie supplement. Placental weight was higher among women with high levels of supplemented calories during pregnancy, independently of the type of food supplement ingested. On the average, the groups with low caloric supplementation (smaller than 20,000 calories) had placental weight 11 per cent below those with high caloric supplementation (larger than or equal to 20,000 calories), In contrast to placental weight, the concentration of placental chemical components studied was not associated with caloric supplementation. It was concluded that moderate protein-calorie malnutrition during pregnancy leads to lower placental weight without significantly changing the concentration of the biochemical components studied. The reduction of placental weight may be the mechanism by which maternal malnutrition is associated with high prevalence of low-birth-weight babies in these populations.

Length and weight in rural Guatemalan Ladino children: birth to seven years of age

The present study reports 5,029 length and weight measurements as well as percentile distributions for a mixed longitudinal series of 1,119 rural Guatemalan Ladino children. The study sample, birth through seven years, is representative of children in clinically good health, but of suboptimal nutrition. Boys are longer and heavier than girls over the age range. Guatemalan children of both sexes are smaller than American white children from Denver. Differences are least at birth, and increase through two years of age. Between two and five years, differences between the rural Guatemalan Ladino and Denver samples are rather stable, but then increase through seven years. Despite these differences there is a linear weight for length relationship which is the same across all preschool ages, both sexes, and for both the Guatemalan and Denver populations. This implies that age, sex, ethnic differences between the two groups compared, and mild-to-moderate protein-calorie malnutrition do not affect the relationship between weight and length in preschool children.

Trends in Treatment and Spending for Patients Receiving Outpatient Treatment of Depression in the United States, 1998-2015

CONTEXT

After marked increases from 1987 to 1997, trends in depression treatment in the United States increased modestly from 1998 to 2007. However, multiple policy changes that expanded insurance coverage for mental health conditions may have shifted these trends again since 2007.

OBJECTIVE

To examine national trends in outpatient treatment of depression from 1998 to 2015, with particular focus on 2007 to 2015.

DESIGN, SETTING, AND PARTICIPANTS

This analysis of the use of health services and spending for treatment of depression in the United States assessed data from the 1998 (n = 22 953), 2007 (n = 29 370), and 2015 (n = 33 893) Medical Expenditure Panel Surveys (MEPSs). Participants included respondent households to the nationally representative survey. Data were analyzed from June 15 through December 18, 2018.

MAIN OUTCOMES AND MEASURES

Rates of outpatient and pharmaceutical treatment of depression; counts of outpatient visits, psychotherapy visits, and prescriptions; and expenditures.

RESULTS

The analysis included 86 216 individuals from the 1998, 2007, and 2015 MEPSs. Respondents' mean (SD) age was 37.2 (22.7) years; 45 086 (52.3%) were female, 24 312 (28.2%) were Hispanic, 15 463 (17.9%) were black, and 62 926 (72.9%) were white. Rates of outpatient treatment of depression increased from 2.36 (95% CI, 2.12-2.61) per 100 population in 1998 to 3.47 (95% CI, 3.16-3.79) per 100 population in 2015. The proportion of respondents who were treated for depression using psychotherapy decreased from 53.7% (95% CI, 48.3%-59.1%) in 1998 to 43.2% (95% CI, 39.0%-47.4%) in 2007 and then increased to 50.4% (95% CI, 46.0%-54.9%) in 2015, whereas the proportion receiving pharmacotherapy remained steady at 81.9% (95% CI, 77.9%-85.9%) in 1998, 82.4% (95% CI, 79.3%-85.4%) in 2007, and 80.8% (95% CI, 77.9%-83.7%) in 2015. After adjusting for inflation using 2015 US dollars, prescription expenditures for these individuals decreased from $848 (95% CI, $713-$984) per year in 1998 to $603 (95% CI, $484-$722) per year in 2015, whereas the mean number of prescriptions decreased from 7.64 (95% CI, 6.61-8.67) in 1998 to 7.03 (95% CI, 6.51-7.56) in 2015. National expenditures for outpatient treatment of depression increased from $12 430 000 000 in 1997 to $15 554 000 000 in 2007 and then to $17 404 000 000 in 2015, consistent with a slowing growth in national outpatient expenditures for depression. The percentage of this spending that came from self-pay (uninsured) individuals decreased from 32% in 1998 to 29% in 2007 and then to 20% in 2015. This decrease was largely associated with increasing Medicaid coverage, because the percentage of this spending covered was 19% in 1998, 15% in 2007, and 36% in 2015.

CONCLUSIONS AND RELEVANCE

Recent policy changes that increased insurance coverage for depression may be associated with reduced uninsured burden and with modest increases in the prevalence of and overall spending for outpatient treatment of depression. The lower-than-expected rate of treatment suggests that substantial barriers remain to individuals receiving treatment for their depression.

Prescription Drug Monitoring Programs Produce a Limited Impact on Painkiller Prescribing in Medicare Part D

OBJECTIVE

To measure the impact of prescription drug monitoring programs (PDMPs) on prescribing of opioid and nonopioid painkillers.

DATA SOURCE

2010-2013 physician-level Medicare Part D prescribing data released by the Centers for Medicare and Medicaid Services and Propublica.

STUDY DESIGN

Using difference-in-differences models with physician-level fixed effects, the study compares prescribing in states with and without PDMPs for opioid and nonopioid analgesics, oxycodone, hydrocodone, and opioids by controlled substances Schedules II-IV.

PRINCIPAL FINDINGS

Prescription drug monitoring programs were associated with a 5.2 percent decrease in days supply prescribed per physician for oxycodone in addition to smaller reductions for hydrocodone and opioids overall (2.8 percent and 2 percent, respectively) and a small increase in prescribing for Schedule IV opioids. PDMPs were not associated with changes for nonopioid analgesics or other opioids in Schedules II and III. The effects of PDMPs were negated in states where statutes explicitly did not require use of the PDMP.

CONCLUSIONS

Prescription drug monitoring programs have a modest effect targeted at the high-profile drug oxycodone among the Medicare Part D population and an even smaller effect for hydrocodone and opioids in general. The findings suggest some substitution toward lower schedule opioids. Substantially addressing the widespread opioid abuse problem will require enhancing existing PDMPs or implementing new policies.

A case of cicatricial pemphigoid or cicatricial linear IgA bullous dermatosis

A case has been described with clinical features of cicatricial pemphigoid, but immunofluorescent (IF) biopsy findings are suggestive of linear IgA bullous dermatosis (LABD), i.e., the presence of IgA deposits with a linear pattern at the basement membrane zone. The patient failed to respond to sulfones and gave a limited response to corticosteroid. These findings suggest that therapy of the type found to be effective in cutaneous forms of LABD, i.e., combinations of low doses of sulfones and corticosteroids, may be indicated in such cases.

Acute morbidity and physical growth in rural Guatemalan children

The relationship between morbidity and physical growth increments was investigated in 716 Guatemalan children ranging in age from 15 days to 7 years. The growth variables investigated were semestral and yearly increments in total body length and weight. The number of days ill with diarrhea, fever, and respiratory illnesses per semester or year was used as an indicator of morbidity. The morbidity data were collected through bi-weekly retrospective interviews of mothers. Children less ill with diarrhea had substantially larger increments in length and weight than children who were ill with diarrhea a greater percentage of the time. In contrast, fever and respiratory illnesses did not affect growth rates. These findings highlight the fact that diarrhea is a major public health problem in developing nations.

Head and chest circumferences in rural Guatemalan Ladino children, birth to seven years of age

Growth patterns in head and chest circumferences are reported for a mixed-longitudinal sample of rural Guatemalan Ladino children from birth to 7 years of age. The sample is representative of a population with suboptimal nutrition. Both circumferences show similar rapid growth from birth through 9 months, after which chest circumference continues to increase more rapidly, while head circumference increases at a slower rate. Chest circumference provides nutritional information apparently not contained in length and weight. Compared to a sample of well-nourished children from Denver, the head circumferences of Guatemalan children are consistently smaller. Differences are relatively small at birth, are well established by 6 months, and become progressively greater through 24 months. After 2 years the mean smaller head circumference of the Guatemalan children also reflects stunted growth during the first 2 years of life. Similarly, among 5-year-old Guatemalan children of similar stature, head circumference at 5 years of age indicates which of these children were more stunted in stature at 2 years of age.

Genetic-environmental interactions in physical growth

Variability in stature among young children is often ascribed to health and nutrition differences in malnourished populations and to genetic differences in well-nourished populations. Hence, it was hypothesized that parent-child correlations in malnourished Guatemalan populations would be markedly lower than those reported for European samples. Instead, it was found that parent-child and sibling correlations were similar in both kinds of populations. The simplest interpretation of these results is that variability in stature among malnourished children is as much as reflection of genetic differences as in developed nations. However, explanations can also be advanced which would attribute the higher than expected correlations to the environment. For instance, it could be that socioeconomic and nutritional status is correlated across generations. In other words, parents who had relatively better conditions as children are more likely to provide a better environment for their children. Consequently, the relative contribution of genetics and environment to variability in height is still unsettled. Nonetheless, it appears that variability in body size in malnourished populations, regardless of the relative importance of its causes, is a useful indicator of health and nutrition.

A simple assessment of the risk of low birth weight to select women for nutritional intervention

There is growing evidence that the high prevalence of low-birth-weight (LBW) babies, a characteristic of many poor societies, can be significantly reduced through nutritional intervention programs. In order to increase the efficiency of these programs, pregnant women at risk of delivering LBW babies must be identified. Several risk scales have been extensively used in urban populations of developed countries. However, these indicators are of little use in poor communities, since most of them require expensive laboratory techniques, a long interview, at least two visits to a health center, and a precise estimation of gestational age. The present paper proposes several risk indicators of LBW, appropriate for use in areas with inadequate health resources. In a four-year longitudinal study of pregnant women from poor rural villages in Guatemala, mothers of LBW babies were found to be typically small in stature and head circumference. In addition, their houses tended to be of relatively poor quality. The proportion of LBW babies found among women at risk, as defined by these indicators, was significantly lower among women with similar characteristics receiving adequate food supplementation during pregnancy. Categories of high risk were based on maternal height, head circumference, and house quality. It is concluded that use of these categories will increase the efficiency of these programs without decreasing significantly their effectiveness.

Gaps In Access To Opioid Use Disorder Treatment For Medicare Beneficiaries

In 2016 only 13.8 percent of substance use disorder treatment programs offered medication treatment for opioid use disorder for older adults who used Medicare to pay for treatment. With increasing demand for treatment among older adults and a rapidly aging population, improved access to medication treatment for this population is needed.

Sexual dimorphism in bone growth as a function of body size in moderately malnourished Guatemalan preschool age children

The sexual dimorphism in second metacarpal bone growth was investigated in 710 malnourished Guatemalan children one to seven years old to determine if the sex differences seen are only the result of differences in stature and weight. The study sample was mixed-longitudinal and consisted of 1,586 annual examinations. Boys have greater mean stature, weight, periosteal diameter, medullary diameter and cortical area than girls the same age, while girls have greater age specific mean cortical thickness and percent cortical area than boys. When the effects of stature, weight and age are removed boys still have significantly larger periosteal and medullary diameters and less cortical thickness and percent cortical area than girls. These differences between boys and girls therefore cannot be explained by sex differences in body size. However, no sex differences in cortical area remain after accounting for differences in stature, weight and age.

Relationship of County Opioid Epidemic Severity to Changes in Access to Substance Use Disorder Treatment, 2009-2017

OBJECTIVE

The study measured the association between local opioid problem severity and changes in the availability of substance use disorder treatment programs, including the distance required for travel to treatment.

METHODS

A two-part, multivariable regression estimated the number of treatment facilities in the county (per 100,000 residents) and the number of miles to the nearest program (for all treatment programs, programs offering opioid use disorder medication, and programs accepting Medicaid) using data from the 2009-2017 National Directory of Drug and Alcohol Abuse Treatment Facilities. The unit of analysis was the county-year (N=28,270).

RESULTS

The probability of having at least one treatment program meeting the established criteria was greater in counties with a high-severity opioid problem than in counties with a low-severity problem, and the probability improved over time. In counties with a high-severity problem, the probability of having a treatment program offering buprenorphine, methadone, or both was 60.3% higher than in counties with low-severity problems. Between 2009 and 2017, the likelihood of having a treatment program that accepts Medicaid grew by 25.3%. For counties without treatment programs, the distance to the nearest program improved markedly over time, but there were no differences between distance to treatment in high-, moderate-, and low-severity status counties.

CONCLUSIONS

The treatment system has reduced structural barriers to treatment where it is most needed. However, these findings do not imply that the treatment system has sufficient capacity to address the present scope of the opioid crisis. Policy makers should leverage this responsiveness to incentivize additional improvements in access.