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Khan UI, Shah S, Viswanathan S, Qureshi A, Noornabi Y, Niaz M, Wylie-Rosett J. Integrating a Community-Based Health Information System with a Patient-Centered Medical Home to improve care of patients with hypertension: a longitudinal observational study protocol. BMC Health Serv Res 2024; 24:540. [PMID: 38678236 PMCID: PMC11055355 DOI: 10.1186/s12913-024-11012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The primary healthcare system in Pakistan focuses on providing episodic, disease-based care. Health care for low-middle income communities is largely through a fee-for-service model that ignores preventive and health-promotive services. The growing burden of cardiovascular illnesses requires restructuring of the primary health care system allowing a community-to-clinic model of care to improve patient- and community-level health indicators. METHODS We propose a model that integrates a Patient-Centered Medical Home (PCMH) with a Community-Based Health Information System (CBHIS) using hypertension (HTN) as an example. This protocol describes the integration and evaluation of the PCMH-CBHIS infrastructure through a population-based, observational, longitudinal study in a low-middle income, urban community in Pakistan. Participants are being enrolled in CBHIS and will be followed longitudinally over two years for HTN outcomes. A mixed-methods approach is adopted to evaluate the process of integrating PCMH with CBHIS. This involves building partnerships with the community through formal and informal meetings, focus group discussions, and a household health assessment survey (HAS). Community members identified with HTN are linked to PCMH for disease management. A customized electronic medical record system links community-level data with patient-level data to track changes in disease burden. The RE-AIM evaluation framework will be used to monitor community and individual-level metrics to guide implementation assessment, the potential for generalization, and the effectiveness of the PCMH in improving HTN-related health outcomes. Ethical clearance has been obtained from the Ethics Review Committee at Aga Khan University (2022-6723-20985). DISCUSSION This study will evaluate the value of restructuring the primary care health system by ensuring systematic community engagement and measurement of health indicators at the patient- and community-level. While HTN is being used as a prototype to generate evidence for the effectiveness of this model, findings from this initiative will be leveraged towards strengthening the management of other acute and chronic conditions in primary care settings. If effective, the model can be used in Pakistan and other LMICs and resource-limited settings.
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Affiliation(s)
- Unab I Khan
- Department of Family Medicine, Aga Khan University, Karachi, Sindh, Pakistan.
| | - Sabeen Shah
- Department of Family Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Shankar Viswanathan
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Asra Qureshi
- Department of Family Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Yasmeen Noornabi
- Department of Family Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Mahnoor Niaz
- Department of Family Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Judith Wylie-Rosett
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
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Khan UI, Farazdaq H, Naseem A, Suleman W, Saleem S, Qadir MA, Fatima K. Evaluation of FamMed essentials: a blended-learning program for capacity building of general practitioners in Pakistan. BMC Med Educ 2024; 24:218. [PMID: 38429735 PMCID: PMC10908083 DOI: 10.1186/s12909-024-05069-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/18/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND To provide access to primary care and universal health coverage, Pakistan requires 60,000 trained family physicians by 2030. At present, most primary care is provided by general practitioners (GPs) who do not have any post-graduate training. Empowering GPs through competency-based programs, that strengthen their knowledge and skills, may be a cost-effective strategy for improving healthcare quality. We describe the development and evaluation of FamMed Essentials, a modular, blended-learning program to improve clinical knowledge and skills of GPs. METHODS This is a mixed method study. We used the CIPP (content, input, process and product) framework for course development and evaluation. We describe the steps used in content development, strategies for teaching and assessments, and evaluation of strengths and weaknesses of the program. In depth focus group discussions were conducted to gather insight on participants' and faculty's perceptions regarding the program's effectiveness. RESULTS Of the 137 participants who have completed the program, 72% were women and 49% had been practicing for more than five years. We saw a significant improvement in knowledge across all modules (p = < 0.001) and perceived confidence in clinical skills (p = < 0.001). An objective assessment showed participants' competence in patient management. Participants reported a high level of satisfaction (4.4 ± 0.83 on a 5-point Likert Scale). Focus group discussions revealed a positive impact on clinical practice. Flexibility and use of different teaching and learning strategies were additional strengths. In addition, participants reported an interest in further training. Power outages were highlighted as a major challenge. CONCLUSION In resource-constrained health systems, a modular, blended-learning, competency-based program is helpful to upgrade GPs knowledge without impacting their busy schedules. Accreditation of such programs and provision of a career trajectory for the trained GPs are pivotal to expansion of such initiatives.
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Affiliation(s)
- Unab I Khan
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan.
| | - Hamida Farazdaq
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan
| | - Azra Naseem
- Blended & Digital Learning Network, Aga Khan University, Karachi, Pakistan
| | - Waseem Suleman
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan
| | - Sania Saleem
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan
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Gupta K, Baloch F, Kakar TS, Agarwal H, Rawlley B, Khan UI, Iqbal R, Barolia R, Virani SS. The Pandemic of Coronary Heart Disease in South Asia: What Clinicians Need to Know. Curr Atheroscler Rep 2023:10.1007/s11883-023-01110-5. [PMID: 37233946 DOI: 10.1007/s11883-023-01110-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE OF REVIEW South Asia has around 1/6th of the current global population. Epidemiological studies suggest that South Asians living in South Asia and diaspora are at an increased risk of premature atherosclerotic cardiovascular diseases (ASCVDs). This is due to an interplay of genetic, acquired, and environmental risk factors. Due to its increasing share of the global population, clinicians need to know the reasons for this early predisposition, and strategies for early identification and mitigation. RECENT FINDINGS South Asians have earlier onset of cardiometabolic risk factors such as insulin resistance, hypertension, and central adiposity. This increased risk is seen in both native South Asians and the diaspora. South Asians have earlier onset of ASCVD due to an earlier onset of cardiometabolic risk factors. Health promotion and early identification of these risk factors are essential to mitigate this ongoing crisis.
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Affiliation(s)
- Kartik Gupta
- Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Farhala Baloch
- Section of Cardiology, Department of Medicine, Aga Khan University Medical College, Karachi, Pakistan
| | - Tanya S Kakar
- Division of Hospital Medicine, Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Harsh Agarwal
- All India Institute of Medical Sciences, New Delhi, India
| | - Bharat Rawlley
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Unab I Khan
- Department of Family Medicine, Aga Khan University Medical College, Karachi, Pakistan
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University Medical College, Karachi, Pakistan
| | - Rubina Barolia
- School of Nursing & Midwifery, Aga Khan University Medical College, Karachi, Pakistan
| | - Salim S Virani
- Office of the Vice Provost (Research), Aga Khan University Medical College, Karachi, Pakistan.
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Saeed S, Kashif U, Zaki S, Samad K, Yousuf MZ, Raza M, Jabbar S, I Khan U. Teaching Clinical Skills Using Online Modality through Modified Peyton's Framework: An Experience from a Medical University in Pakistan. J Adv Med Educ Prof 2023; 11:15-23. [PMID: 36685146 PMCID: PMC9846095 DOI: 10.30476/jamp.2022.95986.1669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/22/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Medical institutions worldwide faced an unprecedented situation during COVID-19 of identifying alternative strategies to sustain the continuum of learning process. This led to several innovations in the traditional medical curriculum. This study explored the effectiveness and feasibility of using the Peyton's framework modified for a virtual platform (Microsoft Teams) for teaching clinical skills to first and second-year medical students at The Aga Khan University, Karachi, Pakistan. METHODS In 2020-2021, the modified Peyton's framework was integrated in the clinical skills (CS) curriculum for all first- and second-year students (N=200). For evaluation, a mixed-method design was used, with pre-and post-session questionnaires. Students' satisfaction was obtained through the standard session evaluation tool of the university. For the qualitative arm, to explore the instructors' experiences, purposive sampling was used (n=8) and a focused group discussion (FGD) was conducted. Finally, performance of the students at the end of year summative Objective Structured Clinical Examination (OSCE) was compared with the students of previous year. Quantitative data were analysed using STATA® version 15.1, using paired t-test to compare the differences in OSCE scores in selected CS stations. A p-value of <0.05 was considered significant for all tests. The FGD was transcribed and analysed through manual content analysis. RESULTS Nine clinical skills (that included history and examination skills) were taught using the virtual platform. There was a significant improvement in post-session questionnaires in seven of these skills (p value <0.01). Session evaluations showed that most students were satisfied with the learning experience. The instructors showed that the online teaching offered a promising platform for teaching history taking skills. The OSCE scores showed mixed results, with significant improvement in two out of four repeated stations by using paired t-test [abdominal exam (87.33 ± 8.99, <0.001); and precordial examination (88.45 ± 8.36, 0.001)]. CONCLUSIONS Modifying Peyton's framework to a virtual platform allowed us to sustain the continuum of clinical education during the COVID-19 pandemic. The results support the use of a blended learning environment for teaching clinical skills.
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Affiliation(s)
- Sana Saeed
- Department of Pediatrics and Child Health and Department for Educational Development, The Aga Khan University, Karachi, Pakistan
| | - Urooj Kashif
- Department of Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
| | - Samar Zaki
- Department of Family Medicine, The Aga Khan University, Karachi, Pakistan
| | - Khalid Samad
- Department of Anesthesiology, The Aga Khan University, Karachi, Pakistan
| | - Muhammad Zuhair Yousuf
- Department of Biological & Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Mahanoor Raza
- Department of Pediatrics and Child Health and Department for Educational Development, The Aga Khan University, Karachi, Pakistan
| | - Shahjahan Jabbar
- Office of Undergraduate Medical Education, The Aga Khan University, Karachi, Pakistan
| | - Unab I Khan
- Department of Family Medicine, The Aga Khan University, Karachi, Pakistan
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Khan UI, Qureshi A, Lal K, Ali S, Barkatali A, Nayani S. Implementation and evaluation of Employee Health and Wellness Program using RE-AIM framework. IJWHM 2021. [DOI: 10.1108/ijwhm-04-2021-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe study describes the design, implementation and evaluation of an employer-sponsored health screening program – Employee Health and Wellness Program (EHWP) – in an academic healthcare system in Pakistan.Design/methodology/approachOne year after implementation, RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework was used to evaluate and report participant- and organizational-level indicators of success.FindingsOf the 5,286 invited employees, 4,523 (86%) completed blood work and 1809 (34%) completed health risk assessment (reach). Of the 915 (51%) who required referrals, 3% were referred for new diagnoses of diabetes, hepatitis C or severe anemia; 63% for elevated 10-year risk of cardiometabolic diseases (cardiovascular disease and diabetes); and 25% for counseling for depression, obesity or smoking cessation (effectiveness). Employees' barriers to enrollment were explored (adoption). While institutional costs were considered nominal (USD 20/employee), organizational barriers were identified (implementation). Finally, 97% of users reported interest in enrollment if EHWP was offered again (maintenance).Originality/valueIn a country with minimal focus on adult preventive care, the study reports the impact of an employer-offered wellness program that identified new risk factors and offered a referral for ongoing care. Employees reported a positive experience and were willing to re-enroll. Using the RE-AIM framework, the study has defined indicators in the real-world setting that can be used effectively by other institutions to start such a program.
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Al-Makki A, DiPette D, Whelton PK, Murad MH, Mustafa RA, Acharya S, Beheiry HM, Champagne B, Connell K, Cooney MT, Ezeigwe N, Gaziano TA, Gidio A, Lopez-Jaramillo P, Khan UI, Kumarapeli V, Moran AE, Silwimba MM, Rayner B, Sukonthasan A, Yu J, Saraffzadegan N, Reddy KS, Khan T. Hypertension Pharmacological Treatment in Adults: A World Health Organization Guideline Executive Summary. Hypertension 2021; 79:293-301. [PMID: 34775787 PMCID: PMC8654104 DOI: 10.1161/hypertensionaha.121.18192] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hypertension is a major cause of cardiovascular disease and deaths worldwide especially in low- and middle-income countries. Despite the availability of safe, well-tolerated, and cost-effective blood pressure (BP)-lowering therapies, <14% of adults with hypertension have BP controlled to a systolic/diastolic BP <140/90 mm Hg. We report new hypertension treatment guidelines, developed in accordance with the World Health Organization Handbook for Guideline Development. Overviews of reviews of the evidence were conducted and summary tables were developed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. In these guidelines, the World Health Organization provides the most current and relevant evidence-based guidance for the pharmacological treatment of nonpregnant adults with hypertension. The recommendations pertain to adults with an accurate diagnosis of hypertension who have already received lifestyle modification counseling. The guidelines recommend BP threshold to initiate pharmacological therapy, BP treatment targets, intervals for follow-up visits, and best use of health care workers in the management of hypertension. The guidelines provide guidance for choice of monotherapy or dual therapy, treatment with single pill combination medications, and use of treatment algorithms for hypertension management. Strength of the recommendations was guided by the quality of the underlying evidence; the tradeoffs between desirable and undesirable effects; patient's values, resource considerations and cost-effectiveness; health equity; acceptability, and feasibility consideration of different treatment options. The goal of the guideline is to facilitate standard approaches to pharmacological treatment and management of hypertension which, if widely implemented, will increase the hypertension control rate world-wide.
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Affiliation(s)
- Akram Al-Makki
- Indiana University Health Arnett, Lafayette (A.A.-M.).,Indiana University School of Medicine - West Lafayette (A.A.-M.).,College of Pharmacy, Purdue University, West Lafayette, IN (A.A.-M.)
| | - Donald DiPette
- Department of Medicine, University of South Carolina School of Medicine, University of South Carolina, Columbia (D.D.)
| | - Paul K Whelton
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA (P.K.W.)
| | - M Hassan Murad
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN (M.H.M.)
| | - Reem A Mustafa
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City (R.A.M.).,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada (R.A.M.)
| | - Shrish Acharya
- Indiana University Health Arnett, Lafayette (A.A.-M.).,Department of Internal Medicine, Colonial War Memorial Hospital and National Medicine and Therapeutics Committee, Ministry of Health, Fiji (S.A.)
| | - Hind Mamoun Beheiry
- Faculty of Nursing Sciences, International University of Africa (IUA), Khartoum, Sudan (H.M.B.)
| | - Beatriz Champagne
- Coalition for Americas' Health/Coalición América Saludable CLAS, representing civil society organizations in Latin America, Dallas, TX (B.C.)
| | - Kenneth Connell
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, St. Michael, Barbados (K.C.)
| | | | | | - Thomas Andrew Gaziano
- Harvard Medical School, Boston, MA (T.A.G.).,Brigham and Women's Hospital, Boston, MA (T.A.G.)
| | - Agaba Gidio
- Mulago National Referral Hospital, Kampala, Uganda (A.G.)
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.)
| | - Unab I Khan
- Department of Family Medicine, The Aga Khan University, Pakistan (U.I.K.)
| | - Vindya Kumarapeli
- Directorate of Non-Communicable Diseases, Ministry of Health, Colombo, Sri Lanka (V.K.)
| | - Andrew E Moran
- Global Hypertension Control, Resolve to Save Lives, an initiative of Vital Strategies, NY (A.E.M.).,Division of General Medicine, Columbia University Irving Medical Centre, NY (A.E.M.)
| | - Margaret Mswema Silwimba
- University Teaching Hospital (Adult), Lusaka, Zambia and Faculty of Pharmacy, Lusaka Apex Medical University (M.M.S.)
| | - Brian Rayner
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, South Africa (B.R.)
| | - Apichard Sukonthasan
- Department of Medicine, Bangkok Hospital Chiang Mai, Mueang Chiang Mai, Thailand (A.S.)
| | - Jing Yu
- Hypertension Center, Department of Cardiology, Lanzhou University Second Hospital, China (J.Y.)
| | - Nizal Saraffzadegan
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Iran (N.S.).,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada (N.S.)
| | | | - Taskeen Khan
- Department of Non-Communicable Diseases, World Health Organization, Geneva, Switzerland (T.K.).,Department of Public Health Medicine, University of Pretoria, Gauteng, South Africa (T.K.)
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Shah SM, Aziz F, Al Meskari F, Al Kaabi J, Khan UI, Jaacks LM. Metabolic syndrome among children aged 6 to 11 years, Al Ain, United Arab Emirates: Role of obesity. Pediatr Diabetes 2020; 21:735-742. [PMID: 32304158 DOI: 10.1111/pedi.13027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/20/2020] [Accepted: 04/02/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To evaluate the association of metabolic syndrome with the varying degrees of obesity among children aged 6 to 11 years in Al Ain, United Arab Emirates (UAE). METHODS As an ancillary to the primary study examining prevalence of MetS in a random sample of 1186 adolescents from 114 schools in Al Ain, parents and siblings aged 6 to 11 years were invited to participate in this study. After informed consent from parents and assent from children, trained nurses administered questionnaires to assess socio-demographic and lifestyle variables and conducted anthropometric measurements. Fasting blood samples were drawn to measure plasma lipids and glucose. We used Centers for Diseases Control and Prevention (CDC)-defined categories of body mass index (BMI = kg/m2 ) for normal weight (<85th percentile), overweight (≥85th to 94th percentile), and obese (≥95th percentiles). MetS was defined according to National Cholesterol Education Program's (NCEP)/Adult Treatment Panel III (ATP III) criteria. RESULTS Of the total 234 siblings aged 6 to 11 years, 8.9% (95% Confidence Interval [CI]: 5.6-13.4) had MetS. The prevalence of MetS increased with the severity of obesity, 4.5% in normal, 16.7% in overweight, and 30.0% in obese subjects. The age, sex, and ethnicity adjusted odds (1.55, 95% CI: 1.23-1.96) of MetS increased significantly with per unit increase in BMI. CONCLUSIONS The prevalence of MetS in study subjects increased with an increase in BMI. School-based interventions targeting metabolic risks in this population are urgently needed.
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Affiliation(s)
- Syed Mahboob Shah
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE.,Department of Family Medicine, Aga Khan University, Karachi, Pakistan
| | - Faisal Aziz
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Fatima Al Meskari
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Juma Al Kaabi
- Department of Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Unab I Khan
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan
| | - Lindsay M Jaacks
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Breakwell L, Whaley M, Khan UI, Bandy U, Alexander-Scott N, Dupont L, Vanner C, Chang HY, Vuong JT, Martin S, MacNeil JR, Wang X, Meyer SA. Meningococcal carriage among a university student population - United States, 2015. Vaccine 2017; 36:29-35. [PMID: 29183735 DOI: 10.1016/j.vaccine.2017.11.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Several outbreaks of serogroup B meningococcal disease have occurred among university students in recent years. In the setting of high coverage of the quadrivalent meningococcal conjugate vaccine and prior to widespread use of serogroup B meningococcal vaccines among adolescents, we conducted surveys to characterize the prevalence and molecular characteristics of meningococcal carriage among university students. METHODS Two cross-sectional oropharyngeal carriage surveys were conducted among undergraduates at a Rhode Island university. Isolates were characterized using slide agglutination, real-time polymerase chain reaction (rt-PCR), and whole genome sequencing. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression to determine risk factors for carriage. RESULTS A total of 1837 oropharyngeal specimens were obtained from 1478 unique participants. Overall carriage prevalence was 12.7-14.6% during the two survey rounds, with 1.8-2.6% for capsular genotype B, 0.9-1.0% for capsular genotypes C, W, or Y, and 9.9-10.8% for nongroupable strains by rt-PCR. Meningococcal carriage was associated with being male, smoking, party or club attendance, recent antibiotic use (inverse correlation), and recent respiratory infections. CONCLUSIONS In this university setting, the majority of meningococcal carriage was due to nongroupable strains, followed by serogroup B. Further evaluation is needed to understand the dynamics of serogroup B carriage and disease among university students.
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Affiliation(s)
- Lucy Breakwell
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States; Epidemic Intelligence Service, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30329, United States
| | - Melissa Whaley
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Unab I Khan
- University Health Services, Brown University, 13 Brown Street, Providence, RI 02906, United States
| | - Utpala Bandy
- Rhode Island Department of Health, 3 Capitol Hill, Providence, RI 02908, United States
| | | | - Lynn Dupont
- University Health Services, Brown University, 13 Brown Street, Providence, RI 02906, United States
| | - Cindy Vanner
- Rhode Island Department of Health, 3 Capitol Hill, Providence, RI 02908, United States
| | - How-Yi Chang
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Jeni T Vuong
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Stacey Martin
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Jessica R MacNeil
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Xin Wang
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States
| | - Sarah A Meyer
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, United States.
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Maslyanskaya S, Coupey SM, Chhabra R, Khan UI. Predictors of Early Discontinuation of Effective Contraception by Teens at High Risk of Pregnancy. J Pediatr Adolesc Gynecol 2016; 29:269-75. [PMID: 26526036 DOI: 10.1016/j.jpag.2015.10.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 07/20/2015] [Accepted: 10/16/2015] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE In the United States, teen pregnancy rates are declining. However, the United States still has the highest teen pregnancy rate among high-income countries. Understanding factors that predict discontinuation of effective contraception might help to further decrease teen pregnancy. We aimed to assess predictors of early discontinuation of effective contraception during typical use by high-risk teens. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We recruited 145 women aged 13-20 years (mean, 17.7 ± 1.8 years); 68% (99/145) Hispanic; 26% (38/145) black; 14% (20/145) ever pregnant; and 4% (6/145) high school dropouts who chose an effective contraceptive method during a health care visit and we prospectively assessed use of the method after 6 months. Contraceptive choices of the 130 participants who were reassessed at 6 months (90% retention) were: intrauterine device (IUD), 26% (34/130); depot medroxyprogesterone acetate (DMPA), 8% (10/130); combined oral contraceptives (COCs), 48% (62/130); transdermal patch (Patch), 13% (17/130); and intravaginal ring (Ring), 5% (7/130). RESULTS After 6 months, only 49 of 130 (38%) continued their chosen method; 28 of 130 (22%) never initiated the method; and 53 of 130 (40%) discontinued. Users and nonusers at 6 months did not differ according to cultural and/or social characteristics (age, ethnicity, acculturation, education, health literacy) but differed according to contraceptive method type. For the 102 of 130 who initiated a method, 88% continued use of the IUD, 20% DMPA, 43% COC, 17% Patch and Ring (P < .001). Using Cox proportional hazards multivariable analysis, compared with IUDs, all other methods predicted discontinuation: DMPA (hazard ratio [HR], 5.6; 95% confidence interval [CI], 1.2-26.7; P < .05); COCs (HR, 6.6; 95% CI, 1.8-25; P < .01); Patch and Ring (HR, 12; 95% CI, 3.0-48; P < .001). Discontinuation was also predicted by past use of hormonal contraceptives (HR, 1.9; 95% CI, 1.0-3.6; P < .05) and high school dropout (HR, 8.2; 95% CI, 1.6-41; P < .01). CONCLUSION Contraceptive method type is the strongest predictor of early discontinuation; compared with IUDs, all other methods are 6-12 times more likely to be discontinued. Cultural and/or social characteristics, with the exception of school dropout, are of little predictive value. Increasing the use of IUDs by high-risk teens could decrease discontinuation rates and possibly teen pregnancy rates.
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Affiliation(s)
- Sofya Maslyanskaya
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York.
| | - Susan M Coupey
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Rosy Chhabra
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Unab I Khan
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Student Health Services, Brown University, Providence, Rhode Island
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Khan UI, McGinn AP, Isasi CR, Groisman-Perelstein A, Diamantis PM, Ginsberg M, Wylie-Rosett J. Differences in Cardiometabolic Risk between Insulin-Sensitive and Insulin-Resistant Overweight and Obese Children. Child Obes 2015; 11:289-96. [PMID: 25774664 PMCID: PMC4485365 DOI: 10.1089/chi.2014.0112] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND It is known that 15-30% overweight/obese adults do not suffer cardiometabolic consequences. There is limited literature examining factors that can be used to assess cardiometabolic health in overweight/obese children. If such factors can be identified, they would aid in differentiating those most in need for aggressive management. METHODS Baseline data from 7- to 12-year-old, overweight, and obese children enrolled in a weight management program at an urban hospital were analyzed. Homeostatic model assessment for insulin resistance (HOMA-IR) <2.6 was used to define insulin-sensitive and HOMA-IR ≥2.6 was used to defined insulin-resistant participants. Demographics, physical activity measures, and cardiometabolic risk factors were compared between the two phenotypes. Odds ratios (ORs) examining the association between intermediate endpoints (metabolic syndrome [MetS], nonalcoholic fatty liver disease [NAFLD], systemic inflammation, and microalbuminuria) and the two metabolic phenotypes were evaluated. RESULTS Of the 362 overweight/obese participants, 157 (43.5%) were insulin sensitive and 204 (56.5%) were insulin resistant. Compared to the insulin-sensitive group, the insulin-resistant group was older (8.6±1.6 vs. 9.9±1.7; p<0.001) and had a higher BMI z-score (1.89±0.42 vs. 2.04±0.42; p=0.001). After multivariable adjustment, compared to the insulin-sensitive group, the insulin-resistant group had higher odds of having MetS (OR, 5.47; 95% confidence interval [CI]: 1.72, 17.35; p=0.004) and NAFLD (OR, 8.66; 95% CI, 2.48, 30.31; p=0.001), but not systemic inflammation (OR, 1.06; 95% CI: 0.56, 2.03; p=0.86) or microalbuminuria (OR, 1.71; 95% CI, 0.49, 6.04; p=0.403). CONCLUSIONS Using a HOMA-IR value of ≥2.6, clinical providers can identify prepubertal and early pubertal children most at risk. Focusing limited resources on aggressive weight interventions may lead to improvement in cardiometabolic health.
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Affiliation(s)
- Unab I. Khan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Aileen P. McGinn
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Carmen R. Isasi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Mindy Ginsberg
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Judith Wylie-Rosett
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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11
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Khan UI, Wang D, Karvonen-Gutierrez CA, Khalil N, Ylitalo KR, Santoro N. Progression from metabolically benign to at-risk obesity in perimenopausal women: a longitudinal analysis of study of women across the nation (SWAN). J Clin Endocrinol Metab 2014; 99:2516-25. [PMID: 24846534 PMCID: PMC4079312 DOI: 10.1210/jc.2013-3259] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known about the natural history of progression from a metabolically benign overweight/obese (MBO) to at-risk overweight/obese (ARO) phenotype. Improved understanding would help clinicians focus on controlling risk factors that predispose an obese individual to progression. METHODS Using discrete-time proportional hazard modeling on data from the Study of Women's Health Across the Nation (SWAN), we examined the incident progression from MBO (less than two metabolic syndrome abnormalities) to ARO (two or more metabolic syndrome abnormalities) and factors associated with progression over a 7-year period. RESULTS Of 866 MBO women at baseline, 43% progressed to the ARO phenotype. Compared with those who remained MBO, those who progressed had higher baseline BMI and a higher prevalence of cardiometabolic abnormalities (elevated glucose, triglycerides, blood pressure and low high-density lipoprotein cholesterol). In multivariable analyses, an increase in body mass index was associated with a modest increase in the risk of progression. Although all cardiometabolic abnormalities were associated with an increased risk, the baseline impaired fasting glucose showed the strongest association with the risk of progression [hazard ratio 3.24; 95% confidence interval 2.10, 4.92; P < .001]. Physical activity played a protective role in decreasing the risk of progression [hazard ratio 0.86; 95% confidence interval 0.80, 0.92; P < .001]. CONCLUSIONS Increasing obesity and the presence of cardiometabolic abnormalities increase the risk of progression, whereas physical activity is the only lifestyle factor protective against progression from metabolically benign to the at-risk overweight/obese phenotype, a state that is unanimously associated with an elevated risk of cardiovascular morbidity and mortality.
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Affiliation(s)
- Unab I Khan
- Departments of Pediatrics (U.I.K.) and Epidemiology and Population Health (D.W.), Albert Einstein College of Medicine, Bronx, New York 10467; Center for Global Health (N.K.), Boonshoft School of Medicine, Wright State University, Dayton, Ohio 45435; Department of Epidemiology (C.A.K.-G. and K.R.Y.), University of Michigan School of Public Health, Ann Arbor, Michigan 48109; and Department of Obstetrics and Gynecology and Women's Health (N.S.), University of Colorado-Denver School of Medicine, Aurora, Colorado 80045
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12
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Khan UI, Ogorodnikova AD, Xu L, Wang D, Wassertheil-Smoller S, Ho GYF, Sowers MFR, Rajpathak SN, Allison MA, Mackey RH, Vitolins MZ, Manson JE, Wildman RP. The adipokine profile of metabolically benign obese and at-risk normal weight postmenopausal women: the Women's Health Initiative Observational Study. Obesity (Silver Spring) 2014; 22:786-94. [PMID: 24357553 PMCID: PMC3883802 DOI: 10.1002/oby.20139] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 10/12/2012] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Nearly, a third of obese individuals, termed metabolically benign obese, have a low burden of adiposity-related cardiometabolic abnormalities, whereas a substantial proportion of normal-weight individuals possess risk factors. METHODS In cross-sectional analyses of 699 normal weight and 1,294 overweight/obese postmenopausal women enrolled in a nested case-control stroke study ancillary to the Women's Health Initiative Observational Study, we compared levels of adiponectin, leptin, and resistin among metabolically benign normal weight, at-risk normal weight, metabolically benign obese, and at-risk obese women using components of the ATP III definition of the metabolic syndrome (metabolically benign: ≤1 of the four components; at-risk phenotype: ≥2 components or diabetes). RESULTS Overall, 382/699 normal-weight women (54.6%) and 328/1,194 overweight/obese women (27.5%) were metabolically benign. Among normal-weight women, at-risk women had higher leptin and lower adiponectin levels compared to metabolically benign women; multivariate-adjusted odds ratios were significant for having leptin (OR: 2.51; 95% CI: 1.28-5.01) and resistin (1.46; 1.03-2.07) in the top tertile and adiponectin in the bottom tertile (2.64; 1.81-3.84). Compared to metabolically benign overweight/obese women, at-risk obese women had higher odds of having leptin in the top tertile (1.62; 1.24-2.12) and adiponectin in the bottom tertile (2.78; 2.04-3.77). CONCLUSIONS Overall, metabolically benign overweight/obese women had an intermediate adipokine profile (between at-risk obese and metabolically benign normal-weight women), whereas at-risk normal-weight women had a less favorable profile compared to metabolically benign normal-weight women. As adiponectin was the only adipokine independent of BMI, it may be most likely to have a role in the etiological pathway of these phenotypes.
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Affiliation(s)
- Unab I Khan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
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13
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Khan UI, Rieder J, Cohen HW, Coupey SM, Wildman RP. Effect of modest changes in BMI on cardiovascular disease risk markers in severely obese, minority adolescents. Obes Res Clin Pract 2013; 4:e163-246. [PMID: 24345667 DOI: 10.1016/j.orcp.2010.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 03/02/2010] [Accepted: 03/04/2010] [Indexed: 12/20/2022]
Abstract
SUMMARY BACKGROUND African American and Hispanic adolescents have disproportionately higher rates of obesity compared to white adolescents. In adults, modest weight loss of five percent improves CVD risk marker levels. Less is known about the effects of modest changes in BMI on CVD risk markers in adolescents, particularly newer markers such as C reactive protein (CRP), lipoprotein (a) and homocysteine. OBJECTIVE To examine the effect of modest BMI change on CVD risk marker levels in a group of severely obese, African American and Hispanic adolescents. STUDY DESIGN A six-month longitudinal analysis. SUBJECTS Eighty-three African American and Hispanic adolescents were recruited (mean age ± sd: 15.1 ± 2.0 years); 50 (60%) were reevaluated at 6 ± 2 months. RESULTS At baseline, mean BMI was 42.3 ± 7.8 kg/m(2). BMI directly correlated with CRP (p = < 0.001); homocysteine (p = 0.02); insulin (p = 0.05); and systolic and diastolic blood pressures (both p = <0.001). BMI remained significantly associated with CRP and insulin after adjusting for age, sex and ethnicity (p = 0.001). At six-month follow up, there was a significant p for trend between the three groups of BMI change (those with a ≥5% BMI decrease, those who maintained BMI within 5% and those with ≥5% BMI increase) and CRP (p = 0.05) and insulin (p = 0.04). CONCLUSIONS A modest decrease in BMI is associated with improvement in CRP and insulin levels. Obese adolescents should be encouraged to continue with modest weight loss goals as they result in improvement in cardiovascular disease risk markers.
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Affiliation(s)
- Unab I Khan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Jessica Rieder
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Hillel W Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Susan M Coupey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Rachel P Wildman
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
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14
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Rieder J, Khan UI, Heo M, Mossavar-Rahmani Y, Blank AE, Strauss T, Viswanathan N, Wylie-Rosett J. Evaluation of a community-based weight management program for predominantly severely obese, difficult-to-reach, inner-city minority adolescents. Child Obes 2013; 9:292-304. [PMID: 23865528 PMCID: PMC3728727 DOI: 10.1089/chi.2012.0147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Few interventions targeting severely obese minority youth have been implemented in community-based settings. We evaluate a 9-month multicomponent, community-based program for obese, inner-city adolescents. METHODS Of 5250 estimated eligible adolescents, 349 were recruited; they had a mean age of 15 ± 2 years, mean BMI %ile 98.9 ± 1.5, and comprised 52% African American and 44% Hispanic. Longitudinal trends of anthropometric measures were compared 1 year before enrollment (T-12), at baseline (T0) and after program completion (T9). Dietary and physical activity behaviors were compared at T0 and T9. Anthropometric changes were compared at T9 and 18 months (T18) in completers and noncompleters. RESULTS A majority of participants were severely obese (67%) and expressed low readiness to change behaviors (82%). For intervals T-12 to T0 versus T0 to T9, there were significant decreases in rates of gain in BMI (0.13 vs. 0.04, p < 0.01), BMI percentile (0.0002 vs. -0.0001, p < 0.01), percent overweight (0.001 vs. -0.001, p < 0.01), and BMI z-score (0.003 vs. -0.003, p < 0.01). Significant increases in vegetable and fruit consumption and in vigorous physical activity participation were observed. From T9 to T18, except for a significant increase in BMI (38.3 ± 7.4 vs. 39.0 ± 7.5, p < 0.01) in completers, all other anthropometric measures remained unchanged in completers and noncompleters. CONCLUSIONS We demonstrate modest clinical improvements and increased healthy lifestyle behaviors in predominantly severely obese, difficult-to-reach, ethnic minority adolescents attending a community-based weight management program. The loss of clinical improvements 9 months after program completion implies that extending the duration of such a program may prevent long-term weight regain in severely obese adolescents.
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Affiliation(s)
- Jessica Rieder
- Children's Hospital at Montefiore, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Unab I. Khan
- Children's Hospital at Montefiore, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Moonseong Heo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Yasmin Mossavar-Rahmani
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Arthur E. Blank
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Temima Strauss
- Children's Hospital at Montefiore, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Nisha Viswanathan
- Children's Hospital at Montefiore, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Judith Wylie-Rosett
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
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15
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Ogorodnikova AD, Khan UI, McGinn AP, Zeb I, Budoff MJ, Harman SM, Miller VM, Brinton EA, Manson JE, Hodis HN, Merriam GR, Cedars MI, Taylor HS, Naftolin F, Lobo RA, Santoro N, Wildman RP. Ectopic fat and adipokines in metabolically benign overweight/obese women: the Kronos Early Estrogen Prevention Study. Obesity (Silver Spring) 2013; 21:1726-33. [PMID: 23670850 PMCID: PMC3748250 DOI: 10.1002/oby.20200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 11/15/2012] [Indexed: 12/22/2022]
Abstract
OBJECTIVE It is unclear why despite a comparable cardiometabolic risk profile, "metabolically benign" overweight/obese individuals show an elevated risk of cardiovascular disease compared to normal weight individuals. DESIGN AND METHODS In cross-sectional analyses, we compared levels of ectopic fat (epicardial, pericardial, and hepatic fat) and adipokines (leptin, soluble leptin receptor, and high molecular weight [HMW] adiponectin) among metabolically benign (MBO) and at-risk overweight/obese (ARO), and metabolically benign normal weight (MBNW) women, screened for the Kronos Early Estrogen Prevention Study. We defined "metabolically benign" with ≤ 1, and "at-risk" with ≥2 components of the metabolic syndrome. RESULTS Compared to MBO women, ARO women had significantly elevated odds of being in the top tertile of epicardial fat (OR: 1.76, 95% CI: 1.04-2.99), hepatic fat (OR: 1.90, 95% CI:1.12-3.24) and leptin (OR: 2.15, 95% CI: 1.23-3.76), and the bottom tertile of HMW-adiponectin (OR: 2.90, 95% CI: 1.62-5.19). Compared to MBNW women, MBO women had significantly higher odds of being in the top tertile of epicardial fat (OR: 5.17, 95% CI: 3.22-8.29), pericardial fat (OR: 9.27, 95% CI: 5.52-15.56) and hepatic fat (OR: 2.72, 95% CI: 1.77-4.19) and the bottom tertile of HMW adiponectin levels (OR: 2.51, 95% CI: 1.60-3.94). CONCLUSIONS Levels of ectopic fat and the adverse adipokine profile increase on a continuum of BMI, suggesting that the metabolically benign phenotype may be a transient state.
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Affiliation(s)
- Alexandra D Ogorodnikova
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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16
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Khan UI, Rastogi D, Isasi CR, Coupey SM. Independent and synergistic associations of asthma and obesity with systemic inflammation in adolescents. J Asthma 2012; 49:1044-50. [PMID: 23050876 DOI: 10.3109/02770903.2012.728271] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Both asthma and obesity often occur in the same individual. Each increases the risk of cardiovascular disease (CVD) with systemic inflammation likely playing a vital role. We examined the independent and synergistic associations of asthma and obesity with systemic inflammation using high-sensitivity C-reactive protein (hs-CRP) levels in adolescents. METHODS This study involves the cross-sectional design carried out in the adolescent and respiratory medicine practices in a children's hospital. Out of 124 adolescents (mean age 16.1 ± 2.3 years), who were either of obese (N = 75) or of normal weight (N = 49). 51 had asthma (18 normal weight and 33 obese). RESULTS hs-CRP levels were higher in obese versus normal weight groups (geometric mean ± SD: 2.38 ± 2.91 vs. 0.72 ± 3.54; p < .001), and in the asthmatic versus non-asthmatic groups (geometric mean ± SD: 1.21 ± 3.71 vs.1.96 ± 3.28; p = .039). We found a trend of increasing hs-CRP levels across the four groups (p < .001), with the obese asthmatic group having the highest level. In multivariate regression, we found a strong association between obesity and log-CRP (β ± SE: 1.43 ± 0.23; p < .001) and a moderate association between asthma and log-CRP (β ± SE: 0.48 ± 0.21; p < .028), with additive synergy between obesity and asthma. CONCLUSIONS Both asthma and obesity are independently and synergistically associated with systemic inflammation. These findings underline the need of a multifaceted approach to address CVD risk in adolescence.
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Affiliation(s)
- Unab I Khan
- Division of Adolescent Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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17
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Rastogi D, Khan UI, Isasi CR, Coupey SM. Associations of obesity and asthma with functional exercise capacity in urban minority adolescents. Pediatr Pulmonol 2012; 47:1061-9. [PMID: 22467360 PMCID: PMC3389560 DOI: 10.1002/ppul.22547] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 02/23/2012] [Indexed: 01/01/2023]
Abstract
PURPOSE To examine the independent association of asthma and obesity and of their co-existence with functional exercise capacity among urban adolescents. METHODS One hundred eighteen Hispanic- and African-American adolescents including 33 obese asthmatics, 18 normal-weight asthmatics, 38 obese non-asthmatics, and 29 normal-weight non-asthmatics underwent anthropometric measures, 6-minute walk test (6MWT) as measure of functional exercise capacity and spirometry as measure of pulmonary function. The 6-minute walk distance (6MWD) was compared between the four study groups. The association of 6MWD with measures of lower airway obstruction, and measures of adiposity was assessed. RESULTS The 6MWD was lower among the obese groups with the least distance covered by the obese asthmatic group (P = 0.02). In the obese asthmatic group, there was a negative correlation between 6MWD and body mass index (BMI) (r = -0.35, P = 0.03), but no association was noted with percent-predicted forced expiratory volume in the 1st second (FEV(1) ; r = 0.07, P = 0.70). Conversely, the 6MWD correlated with FEV(1) among normal-weight asthmatics (r = 0.45, P = 0.04) and normal-weight non-asthmatics (r = 0.4, P = 0.03), but was not associated with BMI in either of the two groups. After adjusting for age, height, gender, and ethnicity, BMI was noted to be a significant predictor (β -2.76, 95% CI -4.77 to -0.76, P < 0.01) of the 6MWD among the obese while percent predicted FEV(1) (β 1.87, 95% CI 0.28-3.45, P = 0.02) was a significant predictor among the normal-weight participants. CONCLUSIONS Our findings suggest that among urban minority obese asthmatic adolescents, functional exercise capacity was associated with obesity, rather than pulmonary function.
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Affiliation(s)
- Deepa Rastogi
- Division of Respiratory and Sleep Medicine, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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18
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Khan UI, Wang D, Sowers MR, Mancuso P, Everson-Rose SA, Scherer PE, Wildman RP. Race-ethnic differences in adipokine levels: the Study of Women's Health Across the Nation (SWAN). Metabolism 2012; 61:1261-9. [PMID: 22444780 PMCID: PMC3404256 DOI: 10.1016/j.metabol.2012.02.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 02/07/2012] [Accepted: 02/08/2012] [Indexed: 12/15/2022]
Abstract
Differences in adipose tissue secretory profile, as measured by adipokine levels, may play a role in race-ethnic disparities in cardiovascular disease (CVD). We examined race-ethnic differences in adipokine levels in a group of mid-life Caucasian, African American (AA), Chinese and Japanese women, after accounting for adiposity. Data on 1876 women from the Study of Women's Health Across the Nation were analyzed. In multivariable adjustment, including total fat mass, differences in total and high molecular weight (HMW) adiponectin, leptin and soluble leptin receptor (sOB-R) levels were examined. Despite intermediate levels of adiposity, Caucasian women had higher levels of both total and HMW adiponectin, when compared to both AA and Chinese and Japanese women. After multivariable adjustment, compared to Caucasian women, AA women had significantly lower total (β: -3.40; 95% CI: -4.29, -2.52; P<.001) and HMW adiponectin (β: -0.53; 95% CI: -0.64, -0.43; P<.001) levels, higher leptin levels (β: 3.26; 95% CI: 1.36, 5.16; P<.001) and lower sOB-R levels (β: -0.07; 95% CI: -0.11, -0.03; P<.001). Compared to Caucasian women, both Chinese and Japanese women had lower total (Chinese: β: -5.50; 95% CI: -7.07, -3.93; P<.001; Japanese: β: -5.48; 95% CI: -6.95, -4.02; P<.001) and HMW adiponectin (Chinese: β: -0.57; 95% CI: -0.75, -0.38; P<.001; Japanese: β: -0.61; 95% CI: -0.78, -0.44; P<.001) levels and lower sOB-R levels (Chinese: β: -0.13; 95% CI: -0.20, -0.06; P<.001; Japanese: β: -0.09; 95% CI: -0.15, -0.02; P=.008). Significant race-ethnic differences exist in circulating adipokines, even after accounting for adiposity. Further research is needed to explicitly determine if such differences contribute to known racial differences in CVD risk.
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Affiliation(s)
- Unab I Khan
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA.
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Huang G, Wang D, Khan UI, Zeb I, Manson JE, Miller V, Hodis HN, Budoff MJ, Merriam GR, Harman MS, Brinton EA, Cedars MI, Su Y, Lobo RA, Naftolin F, Santoro N, Taylor HS, Wildman RP. Associations between retinol-binding protein 4 and cardiometabolic risk factors and subclinical atherosclerosis in recently postmenopausal women: cross-sectional analyses from the KEEPS study. Cardiovasc Diabetol 2012; 11:52. [PMID: 22587616 PMCID: PMC3461442 DOI: 10.1186/1475-2840-11-52] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 05/15/2012] [Indexed: 12/31/2022] Open
Abstract
Background The published literature regarding the relationships between retinol-binding protein 4 (RBP4) and cardiometabolic risk factors and subclinical atherosclerosis is conflicting, likely due, in part, to limitations of frequently used RBP4 assays. Prior large studies have not utilized the gold-standard western blot analysis of RBP4 levels. Methods Full-length serum RBP4 levels were measured by western blot in 709 postmenopausal women screened for the Kronos Early Estrogen Prevention Study. Cross-sectional analyses related RBP4 levels to cardiometabolic risk factors, carotid artery intima-media thickness (CIMT), and coronary artery calcification (CAC). Results The mean age of women was 52.9 (± 2.6) years, and the median RBP4 level was 49.0 (interquartile range 36.9-61.5) μg/mL. Higher RBP4 levels were weakly associated with higher triglycerides (age, race, and smoking-adjusted partial Spearman correlation coefficient = 0.10; P = 0.01), but were unrelated to blood pressure, cholesterol, C-reactive protein, glucose, insulin, and CIMT levels (all partial Spearman correlation coefficients ≤0.06, P > 0.05). Results suggested a curvilinear association between RBP4 levels and CAC, with women in the bottom and upper quartiles of RBP4 having higher odds of CAC (odds ratio [95% confidence interval] 2.10 [1.07-4.09], 2.00 [1.02-3.92], 1.64 [0.82-3.27] for the 1st, 3rd, and 4th RBP4 quartiles vs. the 2nd quartile). However, a squared RBP4 term in regression modeling was non-significant (P = 0.10). Conclusions In these healthy, recently postmenopausal women, higher RBP4 levels were weakly associated with elevations in triglycerides and with CAC, but not with other risk factors or CIMT. These data using the gold standard of RBP4 methodology only weakly support the possibility that perturbations in RBP4 homeostasis may be an additional risk factor for subclinical coronary atherosclerosis. Trial registration ClinicalTrials.gov number NCT00154180
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Abstract
Nearly one-third of obese individuals are classified as metabolically benign; however whether this subgroup is at a lower risk of cardiovascular disease (CVD) is unclear. Using pooled data from the Atherosclerosis Risk in Communities and Cardiovascular Health Studies, we assessed incident CVD (coronary heart disease and stroke) using three definitions of the metabolically benign phenotype: (i) the ATP-III metabolic syndrome definition (≤2 of the ATP-III components, excluding abdominal obesity (ii) the expanded ATP-III definition (≤1 of: any ATP-III components, insulin resistance (IR), or systemic inflammation), and (iii) the IR-based definition (sex-specific lowest quartile of the HOMA(IR) distribution). The sample included 6,106 normal weight, 7,115 overweight, and 4,323 obese participants. Among obese, 27.0%, 18.1%, and 20.4% were metabolically benign by the three definitions, respectively. The CVD incidence rates (mean follow-up 11.8 years) were 7.1, 5.8, and 8.4 per 1,000 person-years in metabolically benign obese via the three definitions, respectively, compared to 14.3, 13.8, and 13.3 in at-risk obese, and 7.5, 6.7, and 8.2 in metabolically benign normal weight participants. Multivariable-adjusted hazard ratios of incident CVD in metabolically benign obese compared to their at-risk obese counterparts were 0.59 (95% CI 0.47-0.73), 0.52 (0.39-0.68), and 0.71 (0.57-0.90), respectively; and 1.24 (0.99-1.57), 1.16 (0.86-1.56), and 1.28 (1.01-1.62) compared to metabolically benign normal weight individuals. Only 28.7% of obese participants classified as metabolically benign by at least one definition were "metabolically benign" by all three definitions. Despite similar CVD risk estimates, the three definitions identified different subgroups of the obese population, perhaps suggesting distinct etiologies.
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Affiliation(s)
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Aileen McGinn
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Unab I. Khan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Rachel P. Wildman
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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Khan UI, Dan WD, Thurston RC, Sowers M, Sutton-Tyrrell K, Matthews KA, Barinas-Mitchell E, Wildman RP. Burden of subclinical cardiovascular disease in "metabolically benign" and "at-risk" overweight and obese women: the Study of Women's Health Across the Nation (SWAN). Atherosclerosis 2011; 217:179-86. [PMID: 21310415 PMCID: PMC3117052 DOI: 10.1016/j.atherosclerosis.2011.01.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 12/22/2010] [Accepted: 01/12/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Metabolically benign obese individuals have a 10-year cardiovascular disease (CVD) risk comparable to healthy normal weight individuals. However, the burden of subclinical CVD among metabolically benign obese is not well known. METHODS In cross-sectional analyses of 475 mid-life women, we compared common carotid artery intima media thickness (CCA-IMT), aortic pulse wave velocity (aPWV) and coronary (CAC) and aortic calcification (AC) among three groups: healthy normal weight, metabolically benign overweight/obese (<3 metabolic syndrome components/elevated CRP), and at-risk overweight/obese (≥3 metabolic syndrome components/elevated CRP). RESULTS The mean (SD) CCA-IMT and aPWV were lowest in the normal weight group (n=145), followed by the benign overweight/obese (n=260) and at-risk overweight/obese (n=70) groups [CCA-IMT: 0.64 (0.08) vs. 0.68 (0.09) vs. 0.73 (0.13) mm, p<0.001; aPWV: 731.0 (176.4) vs. 809.9 (182.3) vs. 875.7 (228.8) cm/s, p<0.001]. Similar results were found for the frequency (%) of women with increased CAC and AC [CAC: 13 (9%) vs. 53(20%) vs. 28(40%), p<0.001; AC: 47(32%) vs. 130 (50%) vs. 55(79%), p<0.001]. These differences remained significant after multivariable adjustment. Further adjustment for BMI attenuated the statistical significance of differences in aPWV and calcification between benign and at-risk overweight/obese women, but had little effect on the magnitude of these differences. CONCLUSIONS Metabolically benign overweight/obese women have a significantly greater subclinical CVD burden than normal weight women, despite published data finding similar CVD event rates between the two groups. Prospective studies tracking the progression of subclinical atherosclerosis to clinical CVD in these women are needed.
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Affiliation(s)
- Unab I. Khan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Wang D Dan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Rebecca C. Thurston
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - MaryFran Sowers
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor MI
| | | | - Karen A. Matthews
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Rachel P. Wildman
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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22
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Wildman RP, Janssen I, Khan UI, Thurston R, Barinas-Mitchell E, El Khoudary SR, Everson-Rose SA, Kazlauskaite R, Matthews KA, Sutton-Tyrrell K. Subcutaneous adipose tissue in relation to subclinical atherosclerosis and cardiometabolic risk factors in midlife women. Am J Clin Nutr 2011; 93:719-26. [PMID: 21346089 PMCID: PMC3057544 DOI: 10.3945/ajcn.110.007153] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Limited data suggest that the effects of abdominal subcutaneous adipose tissue (SAT) on cardiovascular disease risk may depend on accompanying amounts of abdominal visceral adipose tissue (VAT). OBJECTIVE The objective was to examine whether abdominal VAT area modifies the effects of abdominal SAT area on subclinical atherosclerosis and cardiometabolic risk factors in both whites and African Americans. DESIGN Computed tomographic measures of abdominal SAT and VAT were examined in relation to carotid intima-media thickness (cIMT) and cardiometabolic risk factor levels in 500 African American and white women in midlife. A VAT × SAT interaction term was evaluated. RESULTS The mean (±SD) age of the sample was 51.0 ± 2.9 y, and 37% were African American. Higher amounts of SAT and VAT were associated with higher cIMT, blood pressure, homeostasis model assessment insulin resistance index (HOMA-IR), and concentrations of glucose, triglycerides, and insulin and with lower concentrations of HDL cholesterol. However, in African Americans, but not in whites, higher amounts of VAT significantly attenuated associations between higher amounts of SAT and higher insulin concentrations (P for interaction = 0.032) and HOMA-IR (P for interaction = 0.011) and reversed associations with cIMT (P for interaction = 0.005) and glucose (P for interaction = 0.044). CONCLUSIONS These results suggest that in midlife African American but not white women, adverse associations between abdominal SAT and cardiometabolic risk factors are attenuated and, in the case of subclinical atherosclerosis, are reversed as VAT amounts increase. Given that African American women suffer disproportionately from obesity and cardiovascular disease, further research into the role of this effect modification on obesity-associated vascular disease in African American women is warranted.
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Affiliation(s)
- Rachel P Wildman
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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Arens R, Sin S, Nandalike K, Rieder J, Khan UI, Freeman K, Wylie-Rosett J, Lipton ML, Wootton DM, McDonough JM, Shifteh K. Upper airway structure and body fat composition in obese children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2010; 183:782-7. [PMID: 20935105 DOI: 10.1164/rccm.201008-1249oc] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Mechanisms leading to obstructive sleep apnea syndrome (OSAS) in obese children are not well understood. OBJECTIVES The aim of the study was to determine anatomical risk factors associated with OSAS in obese children as compared with obese control subjects without OSAS. METHODS Magnetic resonance imaging was used to determine the size of upper airway structure, and body fat composition. Paired analysis was used to compare between groups. Mixed effects regression models and conditional multiple logistic regression models were used to determine whether body mass index (BMI) Z-score was an effect modifier of each anatomic characteristic as it relates to OSAS. MEASUREMENTS AND MAIN RESULTS We studied 22 obese subjects with OSAS (12.5 ± 2.8 yr; BMI Z-score, 2.4 ± 0.4) and 22 obese control subjects (12.3 ± 2.9 yr; BMI Z-score, 2.3 ± 0.3). As compared with control subjects, subjects with OSAS had a smaller oropharynx (P < 0.05) and larger adenoid (P < 0.01), tonsils (P < 0.05), and retropharyngeal nodes (P < 0.05). The size of lymphoid tissues correlated with severity of OSAS whereas BMI Z-score did not have a modifier effect on these tissues. Subjects with OSAS demonstrated increased size of parapharyngeal fat pads (P < 0.05) and abdominal visceral fat (P < 0.05). The size of these tissues did not correlate with severity of OSAS and BMI Z-score did not have a modifier effect on these tissues. CONCLUSIONS Upper airway lymphoid hypertrophy is significant in obese children with OSAS. The lack of correlation of lymphoid tissue size with obesity suggests that this hypertrophy is caused by other mechanisms. Although the parapharyngeal fat pads and abdominal visceral fat are larger in obese children with OSAS we could not find a direct association with severity of OSAS or with obesity.
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Affiliation(s)
- Raanan Arens
- Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
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Khan UI, Collier M. Medical interventions in adolescent obesity. Adolesc Med State Art Rev 2008; 19:406-viii. [PMID: 19227383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The prevalence of adolescent obesity has tripled since the 1960s. Adolescent obesity is a strong predictor of adult obesity and its related comorbidities; hence, its management has become a major focus in adolescent care. Decreasing caloric intake seems to best predict maintenance of long-term weight loss. Although isolated physical activity has not shown to be effective for weight loss, appropriate levels of physical activity can alter body composition and contribute to weight maintenance. Behavior-modification techniques serve as useful adjuncts by facilitating patient adherence. Multidisciplinary weight-loss programs that provide individualized nutritional counseling and physical activity and use behavioral techniques have shown limited success in helping adolescents achieve and sustain weight loss. Pharmacologic agents should be used carefully as adjuncts, but long-term studies regarding their efficacy in sustaining weight loss are not available in adolescents.
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Affiliation(s)
- Unab I Khan
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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