Association of Tree Nut Consumption with Cardiovascular Disease and Cardiometabolic Risk Factors and Health Outcomes in US Adults: NHANES 2011-2018

Background

Tree nuts are nutrient dense, and their consumption has been associated with improvements in health outcomes.

Objective

To estimate the usual tree nut intake and examine the association between tree nut consumption and cardiometabolic (CM) health outcomes in a nationally representative sample of US adults.

Methods

Cross-sectional data were analyzed from a sample of 18,150 adults aged ≥ 20y who provided at least one reliable 24-h dietary recall and had complete data for the variables of interest in the NHANES 2011-2018. Tree nut consumers were defined as those consuming ≥ ¼ ounce/d (7.09 g). The National Cancer Institute Method was used to estimate the usual tree nut intake among consumers. Measurement error calibrated regression models were used to assess the association between tree nut consumption and each health outcome of interest.

Results

Approximately 8% of all participants (n = 1238) consumed tree nuts and had a mean ± SE usual intake of 39.5 ± 1.8 g/d. Tree nut consumers were less likely to have obesity (31% vs. 40%, P < 0.001) and low high-density lipoprotein cholesterol (22% vs. 30%, P < 0.001) compared with nonconsumers. Moreover, tree nut consumers had a lower mean waist circumference (WC) (97.1 ± 0.7 vs. 100.5 ± 0.3 cm, P < 0.001) and apolipoprotein B (87.5 ± 1.2 vs. 91.8 ± 0.5 mg/dL, P = 0.004) than nonconsumers. After adjusting models for demographics and lifestyle covariates, the difference in WC between average intake (33.7 g/d) and low threshold intake (7.09/g) of tree nuts was -1.42 ± 0.58 cm (P = 0.005).

Conclusions

Most US adults do not consume tree nuts, yet modest consumption was associated with decreased prevalence of cardiovascular disease and CM risk factors and improvement for some health outcome measures.

COVID-19 Vaccine Uptake Among Students in Public Institutions of Higher Education in Arkansas in 2021

OBJECTIVE

Disparities in COVID-19 vaccine coverage among college students are not well studied. We analyzed the extent of COVID-19 vaccination among all students at public institutions of higher education in Arkansas in spring and fall 2021 and examined factors associated with vaccination rates.

METHODS

We matched student enrollment data for the spring and fall 2021 semesters separately with immunization registry data to determine the COVID-19 vaccination status of students in each semester. We used multivariable logistic regression to determine variables associated with being fully vaccinated.

RESULTS

Overall, by the end of the fall 2021 semester, 49.1% of students were fully vaccinated, compared with 52.3% of students at the end of the spring 2021 semester. However, we observed important differences between student groups. Students who were in rural areas (vs urban areas), freshman (vs all other class years), at a 2-year college (vs 4-year college), non-Hispanic Black (vs Hispanic or non-Hispanic White), or in a nonhealth major (vs health major) were less likely to be fully vaccinated.

CONCLUSION

Given the disparities in COVID-19 vaccine coverage among college students, continued efforts are needed in this young, but important, population segment to address students' confidence in vaccines and to make vaccines more available and accessible on and near campuses. Novel approaches for tailored messaging and interventions to facilitate vaccine uptake may be needed for groups such as non-Hispanic Black students and students in rural areas who are less likely, compared with their counterparts, to accept COVID-19 vaccines.

Variation in Time Between Testing Positive for COVID-19 and Hospital Admission by Race/Ethnicity and Insurance Status

Understanding the extent to which demographic and socioeconomic factors play a role in the disparities associated with duration between testing positive for COVID-19 and hospital admission will help in achieving equitable health outcomes. This project linked the statewide COVID-19 registry to administrative datasets to examine the variation in times between testing positive for COVID-19 and hospital admission by race/ethnicity and insurance. In 2020, there were 11,314 patients admitted for COVID-19 in Arkansas. Approximately 42.2% tested positive for COVID-19 on the same day as hospital admission. Black patients had 38% higher odds of hospitalization on the day of testing compared with White patients (p<.001). Medicaid and uninsured patients had 51% and 50% higher odds of admission on the day of testing compared with privately insured patients (both p<.001), respectively. This study highlights the implications of reduced access to testing with respect to equitable health outcomes.

Racial disparities and prevalence of cardiovascular disease risk factors, cardiometabolic risk factors, and cardiovascular health metrics among US adults: NHANES 2011-2018

This study estimated the prevalence of cardiovascular disease (CVD) risk factors, cardiometabolic (CM) risk factors, and cardiovascular health metrics (CVHMs) among US adults and across race/ethnicity groups. The study comprised 8370 US adults aged ≥ 20 years from the National Health and Nutrition Examination Survey (NHANES) 2011-2018, free of coronary heart disease/heart failure, angina/angina pectoris, heart attack, and stroke, who provided complete data for the outcome variables of interest. Age-adjusted prevalence of CVD and CM risk factors, and CVHMs were computed for all adults and across race/ethnicity groups. All analyses accounted for the complex, multi-stage survey sampling design of the NHANES. Hypertension (45.0%), obesity (40.0%), fasting plasma glucose ≥ 100 mg/dL or hypoglycemic medication (51.0%), ideal physical activity (59.2%) and ideal smoking status (56.9%) were most prevalent for the whole sample. Mexican Americans and non-Hispanic Blacks had elevated risk for some, but not all, CVD and CM risk factors compared to non-Hispanic Whites and non-Hispanic Asians. Reducing further health disparities and persisting differences among racial and ethnic groups is vital to achieving the American Heart Association vision of all people having ideal cardiovascular health, living healthier and longer.

COVID-19 Vaccine Uptake Among Arkansas Public K-12 School Teachers and Staff

In December 2020, the first coronavirus disease 2019 (COVID-19) vaccines received emergency use authorization from the Food and Drug Administration (FDA). To strategically allocate the limited availability of COVID-19 vaccines, the Advisory Committee on Immunization Practices (ACIP) developed a phased approach for eligibility that prioritized certain population groups that were more vulnerable to infection and severe outcomes. Public K-12 teachers and staff were included in Phase 1b. The Arkansas Department of Health (ADH) sought to evaluate the uptake of COVID-19 vaccines within this priority group. In partnership with the Arkansas Department of Education (ADE), ADH received a list of 66,076 certified staff, classified staff, and teachers within the public K-12 school system. This list was matched to the state immunization registry via deterministic methods across three identifiers: first name, last name and date of birth. Uptake was assessed and the population was characterized using descriptive analyses. After 13 weeks of availability, 34,783 (51.2 %) of public K-12 teachers and staff had received at least one dose and 29,870 (44.0 %) had completed the series. School districts with the least robust uptake of COVID-19 vaccines tended to be in more rural areas, with some districts having less than 10 % of teachers and staff with at least one dose. The proportion of public K-12 teachers and staff with at least one dose of any COVID-19 vaccine grew quickly between January 18th and February 14th (4 % to 43 %) but has plateaued in the most recent seven weeks (45 % to 51 %). Although not directly measured, it is possible that vaccine hesitancy could be a factor in the attenuated uptake of COVID-19 vaccines within certain factions of the Arkansas public K-12 teacher and staff population. Overcoming vaccine hesitancy during the COVID-19 vaccine rollout will be critical in bringing an end to the pandemic.

Pediatric SARS-CoV-2 Seroprevalence in Arkansas Over the First Year of the COVID-19 Pandemic

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) seroprevalence studies largely focus on adults, but little is known about spread in children. We determined SARS-CoV-2 seroprevalence in children and adolescents from Arkansas over the first year of the coronavirus disease of 2019 (COVID-19) pandemic.

METHODS

We tested remnant serum samples from children ages 1-18 years who visited Arkansas hospitals or clinics for non-COVID-19-related reasons from April 2020 through April 2021 for SARS-CoV-2 antibodies. We used univariable and multivariable regression models to determine the association between seropositivity and participant characteristics.

RESULTS

Among 2357 participants, seroprevalence rose from 7.9% in April/May 2020 (95% CI, 4.9-10.9) to 25.0% in April 2021 (95% CI, 21.5-28.5). Hispanic and black children had a higher association with antibody positivity than non-Hispanic and white children, respectively, in multiple sampling periods.

CONCLUSIONS

By spring 2021, most children in Arkansas were not infected with SARS-CoV-2. With the emergence of SARS-CoV-2 variants, recognition of long-term effects of COVID-19, and the lack of an authorized pediatric SARS-CoV-2 vaccine at the time, these results highlight the importance of including children in SARS-CoV-2 public health, clinical care, and research strategies.

Mission, Organization and Future Direction of the Serological Sciences Network for COVID-19 (SeroNet) Epidemiologic Cohort Studies

Global efforts are needed to elucidate the epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the underlying cause of coronavirus disease 2019 (COVID-19) including seroprevalence, risk factors and long-term sequelae, as well as immune responses following vaccination across populations and the social dimensions of prevention and treatment strategies. In the U.S., the National Cancer Institute in partnership with the National Institute of Allergy and Infectious Diseases, established the SARS-CoV-2 Serological Sciences Network (SeroNet) as the nation’s largest coordinated effort to study COVID-19. The network is comprised of multidisciplinary researchers bridging gaps and fostering collaborations between immunologists, epidemiologists, virologists, clinicians and clinical laboratories, social and behavioral scientists, policy makers, data scientists, and community members. In total, 49 institutions form the SeroNet consortium to study individuals with cancer, autoimmune disease, inflammatory bowel diseases, cardiovascular diseases, HIV, transplant recipients, as well as otherwise healthy pregnant women, children, college students, and high-risk occupational workers (including health care workers and first responders). Several studies focus on underrepresented populations, including ethnic minorities and rural communities. To support integrative data analyses across SeroNet studies, efforts are underway to define common data elements for standardized serology measurements, cellular and molecular assays, self-reported data, treatment, and clinical outcomes. In this paper, we discuss the overarching framework for SeroNet epidemiology studies, critical research questions under investigation, and data accessibility for the worldwide scientific community. Lessons learned will help inform preparedness and responsiveness to future emerging diseases.

State-wide random seroprevalence survey of SARS-CoV-2 past infection in a southern US State, 2020

The purpose of this cross-sectional study was to estimate the proportion of Arkansas residents who were infected with the SARS-CoV-2 virus between May and December 2020 and to assess the determinants of infection. To estimate seroprevalence, a state-wide population-based random-digit dial sample of non-institutionalized adults in Arkansas was surveyed. Exposures were age, sex, race/ethnicity, education, occupation, contact with infected persons, comorbidities, height, and weight. The outcome was past COVID-19 infection measured by serum antibody test. We found a prevalence of 15.1% (95% CI: 11.1%, 20.2%) by December 2020. Seropositivity was significantly elevated among participants who were non-Hispanic Black, Hispanic (prevalence ratio [PRs]:1.4 [95% CI: 0.8, 2.4] and 2.3 [95% CI: 1.3, 4.0], respectively), worked in high-demand essential services (PR: 2.5 [95% CI: 1.5, 4.1]), did not have a college degree (PR: 1.6 [95% CI: 1.0, 2.4]), had an infected household or extra-household contact (PRs: 4.7 [95% CI: 2.1, 10.1] and 2.6 [95% CI: 1.2, 5.7], respectively), and were contacted in November or December (PR: 3.6 [95% CI: 1.9, 6.9]). Our results indicate that by December 2020, one out six persons in Arkansas had a past SARS-CoV-2 infection.

Temporal Variations in Seroprevalence of SARS-CoV-2 Infections by Race and Ethnicity in Arkansas

Background

The aim of this study was to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates in the small rural state of Arkansas, using SARS-CoV-2 antibody prevalence as an indicator of infection.

Methods

We collected residual serum samples from adult outpatients seen at hospitals or clinics in Arkansas for non–coronavirus disease 2019 (COVID-19)–related reasons. A total of 5804 samples were identified over 3 time periods: 15 August–5 September 2020 (time period 1), 12 September–24 October 2020 (time period 2), and 7 November–19 December 2020 (time period 3).

Results

The age-, sex-, race-, and ethnicity-standardized SARS-CoV-2 seroprevalence during each period, from 2.6% in time period 1 to 4.1% in time period 2 and 7.4% in time period 3. No statistically significant difference in seroprevalence was found based on age, sex, or residence (urban vs rural). However, we found higher seroprevalence rates in each time period for Hispanics (17.6%, 20.6%, and 23.4%, respectively) and non-Hispanic Blacks (4.8%, 5.4%, and 8.9%, respectively) relative to non-Hispanic Whites (1.1%, 2.6%, and 5.5%, respectively).

Conclusions

Our data imply that the number of Arkansas residents infected with SARS-CoV-2 rose steadily from 2.6% in August to 7.4% in December 2020. There was no statistical difference in seroprevalence between rural and urban locales. Hispanics and Blacks had higher rates of SARS-CoV-2 antibodies than Whites, indicating that SARS-CoV-2 spread disproportionately in racial and ethnic minorities during the first year of the COVID-19 pandemic.

Deployment of Health Equity Strike Teams to Address COVID-19 Vaccine Disparities in Arkansas, 2021

Minority populations have been disproportionately affected by the COVID-19 pandemic, and disparities have been noted in vaccine uptake. In the state of Arkansas, health equity strike teams (HESTs) were deployed to address vaccine disparities. A total of 13 470 vaccinations were administered by HESTs to 10 047 eligible people at 45 events. Among these individuals, 5645 (56.2%) were African American, 2547 (25.3%) were White, and 1068 (10.6%) were Hispanic. Vaccination efforts must specifically target populations that have been disproportionately affected by the pandemic. (Am J Public Health. 2022;112(1):29-33. https://doi.org/10.2105/AJPH.2021.306564).

Association of the COVID-19 pandemic and dying at home due to ischemic heart disease

The coronavirus disease 2019 (COVID-19) pandemic has been associated with a declining volume of patients seen in the emergency department. Despite the need for seeking urgent care for conditions such as myocardial infarction, many people may not seek treatment. This study seeks to measure associations between the COVID-19 pandemic and location of death among individuals who died from ischemic heart disease (IHD). Data obtained from death certificates from the Arkansas Department of Health was used to conduct a difference-in-difference analysis to assess whether decedents of IHD were more likely to die at home during the pandemic (March 2020 through September 2020). The analysis compared location of death for decedents of IHD pre and during the pandemic to location of death for decedents from non-natural causes. Before the pandemic, 50.0% of decedents of IHD died at home compared to 57.9% dying at home during (through September 2020) the pandemic study period (p < .001). There was no difference in the proportion of decedents who died at home from non-natural causes before and during the pandemic study period (55.8% vs. 53.5%; p = .21). After controlling for confounders, there was a 48% increase in the odds of dying at home from IHD during the pandemic study period (p < .001) relative to the change in dying at home due to non-natural causes. During the study period, there was an increase in the proportion of decedents who died at home due to IHD. Despite the ongoing pandemic, practitioners should emphasize the need to seek urgent care during an emergency.

Use of Community-Based Participatory Research Partnerships to Reduce COVID-19 Disparities Among Marshallese Pacific Islander and Latino Communities - Benton and Washington Counties, Arkansas, April-December 2020

Marshallese and Latino communities in Benton and Washington counties, Arkansas, were disproportionately affected by COVID-19. We evaluated the effectiveness of a comprehensive community-based intervention to reduce COVID-19 disparities in these communities. We examined all laboratory-confirmed COVID-19 cases in the 2 counties reported from April 6, 2020, through December 28, 2020. A 2-sample serial t test for rate change was used to evaluate changes in case rates before and after implementation of the intervention. After implementation, the proportions of cases among Marshallese and Latino residents declined substantially and began to align more closely with the proportions of these 2 populations in the 2 counties. Infection rates remained lower throughout the evaluation period, and weekly incidence also approximated Marshallese and Latino population proportions. Leveraging community partnerships and tailoring activities to specific communities can successfully reduce disparities in incidence among populations at high-risk for COVID-19 .

Abstract P164: Risk Factors Of Undiagnosed Diabetes And Hypertension In Arkansas

Introduction: Hypertension and diabetes are issues in the US especially in the south. In Arkansas, an estimated 797,000 adults have prediabetes and are at risk for diabetes. We aimed to assess cardiometabolic risk factors and impact of nutrition-related indicators in self-identified diabetes and hypertension patients and those at risk.

Method: Data were analyzed from the 2008 Arkansas Cardiovascular Health Examination Survey (n=1,383), which used probability sampling to obtain a representative sample of Arkansas residents. A self-report survey was administered on health history, socioeconomic status (SES), lifestyle, and diet. Blood biomarkers were measured and compared for those who self-reported diabetes or hypertension with those who were at risk.

Results: We used t-tests for continuous variables and chi-square test for categorical variables with statistical significance at p<0.05. We hypothesized that participants with undiagnosed diabetes or hypertension had less access to care (SES as a surrogate) and worse health behavior than the diagnosed groups. Significant differences in SES, behaviors, nutrients, and biomarkers were observed between healthy vs. both diagnosed and undiagnosed groups. Surprisingly, we found that undiagnosed groups had higher average food security than the diagnosed groups. Also, some of the health behaviors including alcohol consumption were 5-6 fold higher among the undiagnosed and healthy groups as compared to currently diagnosed diabetes group. Moderate physical activity was about 2 fold higher among the healthy (5.5 hours/week) as compared to undiagnosed hypertension group (3 hours/week). In addition, the currently diagnosed groups seem to have some improved dietary habits based on higher levels of vegetable and fruit consumption and lower blood cholesterol. We have also found that both the healthy and undiagnosed diabetes groups had above normal or high triglyceride levels.

Conclusion: Undiagnosed diabetes and hypertension do not have serious symptoms, but are dangerous health conditions. From our findings, targeted education should be implemented among all people, especially on access to food, vegetable and fruit consumption, alcohol use, physical activity, cholesterol and triglyceride levels.

Abstract A081: Using the Arkansas State-Wide Health and Nutrition Examination Survey to understand metabolic health among healthy African-American and White smokers and non-smokers

Introduction. African-Americans (AAs) have a higher smoking–attributable cancer mortality than any other racial/ethnic groups in the United States and in Arkansas. Cigarette smoking prevalence among adults in Arkansas is the 5th highest (22.3%) and smokeless tobacco (ST) use is 3rd highest in the nation (7.8%). Use of tobacco products, poor nutrition, as well as obesity, have been indicated as major risk factors for various cancers and other chronic diseases. Few studies have examined state-specific metabolic biomarkers representing the status of metabolism among smokers and non-smokers in Arkansas and among racial/ethnic groups. The purpose of this study was to compare the differences in markers of dietary lipids and metabolic health in blood among healthy AA and non-Hispanic white (NHW) adult smokers and non-smokers. Methods. Data were analyzed using the 2008 Arkansas Cardiovascular Health Examination Survey (ARCHES, n=1,385), a survey that used probability sampling methods to obtain a representative sample of Arkansas residents, and the analytical sample was limited to adults with no history of cancer or chronic diseases such as diabetes (n=769). Two-way ANCOVA was used adjusting for age and sex to determine the differences in biomarkers among four groups: non-smokers (n=587, 76.3%), current cigarette smokers (n=130, 16.9%), and current smokeless tobacco users (n=21, 2.7%), and dual users of any two tobacco products (n=21, 2.7%). P-value less than 0.05 was considered significant. Results. Of the 769 adult participants, 25% were AA and 75% were NHW. Nearly 31% were male and the mean age was 52.0 (SD=14.8) years. AA non-smokers had a significant higher BMI (mean 34.1, SD=7.9; NHW mean 29.5, SD=6.3), higher markers of fasting glucose (mean 110.0, SD=64.4; NHW mean 95.6, SD=28.3), fasting insulin (mean 28.3, SD=27.8; NHW mean 20.9, SD=32.8), and levels of dietary fats than NHWs. NHW non-smokers had a higher LDL (mean 124.9, SD=33.4; AA mean 115.5, SD=35.6) and triglycerides (mean 177.3, SD=116.7; AA mean 143.7, SD=107.8) than AA non-smokers. NHW cigarette smokers had significant higher levels of triglycerides than AA smokers. AA smokers had higher blood pressure, trans-fat than NHWs. NHW ST users had higher pulse rate than AA ST users. AA dual users had higher BMI and dietary fats than NHWs. Conclusions. Our results indicate poorer metabolic health among AAs compared to white adult non-smokers, smokers, and ST users. However, differences varied by tobacco use type and for some indicators, there were no differences between racial/ethnic groups potentially due to small sample sizes. Larger and more recent studies including dual use of different products are needed in Arkansas to understand the health burden among tobacco user.

Citation Format: Ping-Ching Hsu, Abigail Nowell, Brandy Sutphin, Pebbles Fagan, Lihchyun Joseph Su, Namvar Zohoori. Using the Arkansas State-Wide Health and Nutrition Examination Survey to understand metabolic health among healthy African-American and White smokers and non-smokers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A081.

Community Team-Based Care for Hypertension Management: A Public-Private Partnership in Rural Arkansas

Hypertension is a major public health problem in Arkansas. Team-based care (TBC), delivered by health care professionals such as a nurse, dietician, social worker, or community health worker rather than a physician alone, has been shown to improve blood pressure control.

Hepatitis C in Arkansas: updates on epidemiology, testing and treatment

Hepatitis C infection is the most common blood-borne infection in the United States with an estimated 2.7 million individuals suffering from chronic infection. Of those who are infected with Hepatitis C virus, 75-85% develop chronic infection. Without treatment for chronic infection, individuals can develop liver diseases, such as cirrhosis and hepatocellular carcinoma, during many years of asymptomatic infection. To examine the burden of Hepatitis C virus infection in the state, the Arkansas Department of Health created an epidemiologic profile based on data collected in 2013 from several data sources, including the department's Hepatitis C surveillance program. In order to make more Arkansans aware of their infection, the local health units in all 75 counties of the state recently began screening individuals at risk for the disease, including persons born during the years 1945-1965. Despite recent advances in treatment efficacy, identifying infected individuals and connecting patients to affordable HCV treatment and care remain priorities.

Nutrition of elderly people in China

Cross-sectional data from the 1991 (n = 1657) and 1993 (n = 1773) China Health and Nutrition Surveys were used to describe patterns in the diets, activity levels and body mass index (BMI) of elderly Chinese (aged 60 or older). In 1991 and 1993, the prevalence of low BMI (BMI < 18.5 or BMI < 22.0) exceeded 15%, while the prevalence of high BMI (BMI > 25.0 or BMI > 27.0) ranged between 4% and 24%. The BMI was consistently, positively and significantly associated with urban residence. Urban residence and income were consistently and positively associated with energy from fat and protein intakes, and decreasing physical activity levels. The results suggest that under- and overnutrition coexist among Chinese elders and are differentially distributed across income and urban/rural strata.

Conducting a statewide health examination survey: the Arkansas Cardiovascular Health Examination Survey (ARCHES)

INTRODUCTION

The Arkansas Cardiovascular Health Examination Survey is a health and nutrition examination survey designed to serve as a demonstration project for collection of data on the prevalence of chronic diseases and their risk factors at the state level. The survey was conducted from mid-2006 through early 2008.

METHODS

We chose a cross-sectional representative sample of adult residents in Arkansas by using a 3-stage, cluster sample design. Trained interviewers conducted interviews and examinations in respondents' homes, collecting data on risk factors and diseases, blood pressure and anthropometric measurements, and blood and urine samples for analysis and storage. Food frequency questionnaires provided dietary and nutrient intake data. We accomplished the project using a collaborative model among several programs and partners within the state.

RESULTS

A total of 4,894 eligible households were contacted by telephone. Of these, refusals accounted for 2,748, and 2,146 gave initial consent to participate, for an initial response rate of 44%. The final number of completed household visits was 1,385, resulting in a final response rate of 28.3%.

CONCLUSION

The Arkansas Cardiovascular Health Examination Survey is among the first state-level health and nutrition examination surveys to be conducted in the United States. By using a collaborative model and leveraging federal funds, we engaged several partners who provided additional resources to complete the project. The survey provides the state with valuable state-level data and information for program design and delivery.

Factors affecting study efficiency and item non-response in health surveys in developing countries: the Jamaica national healthy lifestyle survey

BACKGROUND

Health surveys provide important information on the burden and secular trends of risk factors and disease. Several factors including survey and item non-response can affect data quality. There are few reports on efficiency, validity and the impact of item non-response, from developing countries. This report examines factors associated with item non-response and study efficiency in a national health survey in a developing Caribbean island.

METHODS

A national sample of participants aged 15-74 years was selected in a multi-stage sampling design accounting for 4 health regions and 14 parishes using enumeration districts as primary sampling units. Means and proportions of the variables of interest were compared between various categories. Non-response was defined as failure to provide an analyzable response. Linear and logistic regression models accounting for sample design and post-stratification weighting were used to identify independent correlates of recruitment efficiency and item non-response.

RESULTS

We recruited 2012 15-74 year-olds (66.2% females) at a response rate of 87.6% with significant variation between regions (80.9% to 97.6%; p < 0.0001). Females outnumbered males in all parishes. The majority of subjects were recruited in a single visit, 39.1% required multiple visits varying significantly by region (27.0% to 49.8% [p < 0.0001]). Average interview time was 44.3 minutes with no variation between health regions, urban-rural residence, educational level, gender and SES; but increased significantly with older age category from 42.9 minutes in the youngest to 46.0 minutes in the oldest age category. Between 15.8% and 26.8% of persons did not provide responses for the number of sexual partners in the last year. Women and urban residents provided less data than their counterparts. Highest item non-response related to income at 30% with no gender difference but independently related to educational level, employment status, age group and health region. Characteristics of non-responders vary with types of questions.

CONCLUSION

Informative health surveys are possible in developing countries. While survey response rates may be satisfactory, item non-response was high in respect of income and sexual practice. In contrast to developed countries, non-response to questions on income is higher and has different correlates. These findings can inform future surveys.

Nutritional status of older adults in urban Jamaica

The aim of the study was to determine the energy intake and nutritional status of a sample of Jamaican adults, and to compare them among different age groups. Measured height and weight data from a survey in Spanish Town, Jamaica, consisting of 2100 adults aged 25-74 years, with 22 per cent over age 60 years, were used to calculate body mass index (BMI). Using BMI cut-off points of 20 and 27, the prevalence of underweight and overweight, respectively, were determined for different age groups. Energy intake was calculated from a food frequency questionnaire from 967 of the respondents. Among males, mean daily energy intake declined from a high of 3681 kcal (15,401 kJ) for 25-29 year-olds, to a low of 2227 kcal (9318 kJ) for those aged 70-74 years. Corresponding numbers among females were 2935 kcal (12,280 kJ) and 1844 kcal (7715 kJ), respectively. Among those aged 65-74 years, 26.9 per cent of males and 50 per cent of females report daily energy intakes of less than 1600 kcal (6694 kJ) (below the lowest recommended dietary allowance (RDA)), compared to 4.5 and 13.7 per cent of males and females aged 25-34 years. While there are moderate declines in the prevalence of overweight, the prevalence of male underweight increased from 4 per cent among 50-54 year-olds to over 35 per cent among those 65 years and older; and among females the corresponding numbers are from 2 per cent to 10 per cent. All trends with age were significant (p < 0.005). There are significant declines in energy intake, and alarming increases in the prevalence of underweight with increasing age among males. These results are cause for concern and further research in this area is warranted.

Summary measure of dietary musculoskeletal nutrient (calcium, vitamin D, magnesium, and phosphorus) intakes is associated with lower-extremity physical performance in homebound elderly men and women

BACKGROUND

Nutritional intake has been overlooked as a possible contributing factor to lower-extremity physical performance, especially in homebound elderly persons.

OBJECTIVES

Our objectives were to examine the association of a summary measure of calcium, vitamin D, magnesium, and phosphorus intakes with 1) the inability to perform lower-extremity physical performance tests and 2) declining levels of summary lower-extremity physical performance.

DESIGN

Baseline data from the Nutrition and Function Study were used to calculate a summary musculoskeletal nutrient (SMN) score as a measure of nutrient intake (factor analysis) and to examine the association of SMN intake with physical performance (multivariable regression models) among recipients of home-delivered meals who completed an in-home assessment (anthropometric measures and performance-based physical tests) and three 24-h dietary recalls.

RESULTS

Among the 321 participants, elderly age, black race, body mass index (in kg/m2) > or = 35, arthritis, frequent fear of falling, and lowest SMN intake were independently associated with being unable to perform functional tests. The lowest SMN intake and the highest BMI were both significantly associated with increasingly worse levels of lower-extremity physical performance, after adjustment for health and demographic characteristics.

CONCLUSIONS

Considering the importance of identifying short- and long-term outcomes that help elderly persons maintain adequate nutritional status and remain functionally independent at home, the results of this study suggest the need to identify intervention strategies that target the improvement of dietary intake and physical performance. Further investigation is indicated to identify the manner in which nutritional status contributes to the preservation or deterioration of physical performance in homebound elderly persons.

Non-fatal violence-related injuries in Kingston, Jamaica: a preventable drain on resources

Using data for a one-year period from the Kingston Public Hospital (KPH) in Jamaica, we describe patterns of non-fatal violence-related injuries, and carry out simulation analysis to estimate rates of hospital admission under various injury reduction scenarios, and the potential savings that can be realized by reducing violent crimes. In this period there were 6107 registered violence-related visits to the KPH representing 11.5% of all recorded visits. Of these 16.6% (1001) were admitted. The most common methods of inflicting injury was by stabbing (52.1%), blunt injuries (37.9%) and gunshot wounds (7.3%). Multivariate analyses indicated that gunshot injuries, stab injuries, being male between the ages of 15 and 44 years, receiving the injury in November or December, and being injured by a stranger or unknown assailant, were significant correlates of a higher probability of admission. Simulation analysis with various injury reduction scenarios indicated decreases in the probability of admission ranging from 12% to 44%, with estimated savings of up to 31% of the annual supplies budget of KPH.

Inadequate nutrient intakes among homebound elderly and their correlation with individual characteristics and health-related factors

BACKGROUND

The prevalence of inadequate nutrient intakes among the homebound elderly and their correlation with individual characteristics and health-related factors remain poorly understood.

OBJECTIVE

We assessed the extent of inadequate dietary intakes of key nutrients among the homebound elderly by using the newly released dietary reference intakes and examined the associations of individual characteristics and health-related factors with low nutrient intakes.

DESIGN

This was a cross-sectional examination of data collected during the baseline assessment of a prospective study of nutrition and function among a randomly recruited sample of cognitively eligible recipients of home-delivered meals who completed a home visit and three 24-h dietary recalls (n = 345). Nutrient analysis was performed with the NUTRITION DATA SYSTEM software, and associations were identified through multiple regression models.

RESULTS

In multiple regression models, lower intakes of specific nutrients were associated with subjects who were women, who were black, who reported a low income and limited education, and who did not usually eat breakfast. On the basis of the estimated average requirement standard for nutrient inadequacy, the intake of >/= 6 nutrients was inadequate in 27% of subjects, of 3-5 nutrients in 40% of subjects, and of 1-2 nutrients in 29% of subjects. On the basis of the adequate intake standard, a less than adequate intake of calcium was reported by 96% of subjects and of vitamin D by 99% of subjects.

CONCLUSIONS

The findings suggest that home-delivered meals programs should target specific subgroups of participants with interventions, such as a breakfast meal or more-nutrient-dense meals, tailored to increase nutrient intakes and reduce the prevalence of nutrient inadequacy.

Nutrition and healthy functioning in the developing world

There is a general lack of data for studying the relationship between nutrition and healthy functioning among the elderly in developing countries. Nevertheless, knowledge of biological relationships from studies in other countries can be applied to gain an understanding of what can be expected in the developing world. In this respect, the concept of the nutrition transition is important. However, nutrition transition as related to elderly populations in developing countries has not yet been adequately studied. The developing world is not homogeneous with respect to patterns of nutritional status among the elderly, and problems of both under- and overnutrition exist among different populations of the elderly and both will be important factors for future functional status levels. In addition, there are many extrinsic factors (such as socioeconomic, political and cultural factors) in these countries that are even more important in determining nutritional status and its relation to function. Unless research and policy development in developing countries escalate and keep pace with the nutrition and demographic transitions in these countries, high levels of disability and dependency are likely in the near future.

Recent patterns of alcohol consumption in the Russian elderly, 1992-1996

We present data on patterns of alcohol consumption in the Russian elderly aged > or = 60 y (< or = 100 y) between 1992 and 1996. These results come from nationally representative data collected as part of the Russian Longitudinal Monitoring Survey (RLMS), based on three-stage stratified cluster probability samples of the Russian population. The data showed a decreasing prevalence of drinking during this period, but an increase in the amount of alcohol consumed by some members of this population. There were significant differences within the group, with 60-69-y-old men having both the highest prevalence and the highest amounts of alcohol consumption compared with older men and women. Although the decrease in drinking prevalence is reassuring, the increase in the absolute amount of alcohol consumption by drinkers is of concern.

Dies endogeneity matter? A comparison of empirical analyses with and without control for endogeneity

PURPOSE

Using data from the Cebu Longitudinal Health and Nutrition Survey, we perform an empirical investigation of the effects of endogeneity and unobserved heterogeneity in the analysis of health outcomes.

METHODS

First, we lay a theoretical background for this analysis and develop a set of expectations regarding the effects of ignoring endogeneity. Then, by modeling the effect of infant-feeding patterns on time to resumption of menses, we perform parallel analyses with and without control for endogeneity.

RESULTS

We show that in this analysis, as far as the effects of endogeneity are concerned, empirical results do accord with theoretical expectations. There are differences in parameter estimates between models, that lead to somewhat different interpretations.

CONCLUSIONS

We discuss the importance and implications of these findings for epidemiological studies of health outcomes. We outline the steps involved in such an analysis and discuss the practical limitations of the methods, as well as the possible gains.

Econometric approaches to epidemiologic data: relating endogeneity and unobserved heterogeneity to confounding

The concepts of endogeneity and unobserved heterogeneity are well-known among econometricians. However, these issues are rarely addressed in epidemiologic studies. This paper explores these two concepts, their relationship to each other, and the implications for analysis in epidemiologic studies. An endogenous variable is defined as a predictor variable which is partly determined by factors within the model itself, while unobserved heterogeneity is conceptualized as a vector of missing variables acting through the error term. Under certain assumptions, the simultaneous existence of an endogenous variable and unobserved heterogeneity is shown to act in a manner analogous to confounding. Specifically, this occurs due to an association between the error term in the equation and the endogenous predictor variable. The accepted econometric solution to this problem is to replace the endogenous variable with an 'instrumental variable' which is not correlated with the error term and thus not susceptible to confounding. The validity of these concepts and of the proposed solution are discussed.

Longitudinal analysis of the effects of infant-feeding practices on postpartum amenorrhea

The Cebu Longitudinal Health and Nutrition Survey is used to examine the effect of various components of infant-feeding patterns on return of menses postpartum. The results show that factors such as active suckling, the use of two breasts versus one, breast-feeding on demand versus on a fixed schedule. and the feeding of other milks and of nonnutritive or low-caloric other liquids can be important under selected circumstances. Discrete-time logistic hazards modeling is used to estimate the weekly probability of return to menses.

Longitudinal analysis of the effects of infant-feeding practices on postpartum amenorrhea

The Cebu Longitudinal Health and Nutrition Survey is used to examine the effect of various components of infant-feeding patterns on return of menses postpartum. The results show that factors such as active suckling, the use of two breasts versus one, breast-feeding on demand versus on a fixed schedule, and the feeding of other milks and of nonnutritive or low-caloric other liquids can be important under selected circumstances. Discrete-time logistic hazards modeling is used to estimate the weekly probability of return to menses.

The nutritional status of the elderly in Russia, 1992 through 1994

OBJECTIVES

The purpose of this study was to ascertain how economic reform has affected nutritional well-being of the elderly in the Russian Federation.

METHODS

A sample of more than 2932 Russians 60 years of age and older was selected from a nationally representative survey of Russian households. A 24-hour dietary recall and data on weight, height, and socioeconomic status were collected during 1992 and 1993 and from a separate nationally representative sample of 1955 persons in the same age group in 1994.

RESULTS

Russia's elderly did not experience major declines in economic or nutritional well-being during the first 2 years of the reform period. Dietary composition shifted slightly toward reduced fat consumption. A small proportion of individuals showed signs of underweight. Of those who were underweight in 1992, none had lost more than 3 kg of weight by 1993. Among those 70 years of age and older, none who were underweight had lost any appreciable weight, although half lost small amounts.

CONCLUSIONS

Many more underweight elderly people increased than reduced their weight. Mean weight increased among all body mass index groups over the year reported here. However, economic conditions in December 1994 raise concerns.

Does WIC participation improve breast-feeding practices?

The effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on breast-feeding behavior have been sometimes found inadequate. The determinants of breast-feeding initiation and duration among WIC participants and nonparticipants were modeled by using retrospective cross-sectional data from the 1988 National Maternal and Infant Health Survey. This study corrects for self-selection bias as far as the data allow, in addition to controlling for parents' ages, education, race, and family income. Findings suggest that prenatal WIC participation, combined with breast-feeding advice, significantly increases the initiation of breast-feeding but does not affect duration. The exact nature of effective breast-feeding advice given prenatally at WIC clinics is unclear and warrants further research.

The nutrition transition in China: a cross-sectional analysis

Diets and activity patterns are changing rapidly in low-income countries, and problems of undernutrition and overnutrition commonly exist side by side. China has conquered problems of food scarcity at the national level and has undergone a remarkable transition in the structure of its diet in the last decade. In this paper, we use data from the 1989 China Health and Nutrition Survey and national data from the State Statistical Bureau to explore China's recent history with respect to nutrition and to identify patterns of under- and overnutrition. In particular, we see that higher income levels, particularly in urban areas, are associated with consumption of a diet higher in fat and with problems of obesity. At the same time, undernutrition is a problem in important segments of Chinese society. There is a need for the Chinese government to consider ways to address these problems of deficit and excess jointly.

Breast-feeding patterns in the Philippines: a prospective analysis

Data from the Cebu Longitudinal Health and Nutrition Survey have been used to examine breast-feeding patterns in the Metropolitan Cebu region of the Philippines. The results show that there is extensive and early use of non-nutritive liquids, resulting in low levels of exclusive breast-feeding. The use of cross-sectional versus longitudinal data, the definition of exclusive breast-feeding, and movements in and out of the exclusively breast-fed category, are considered.