Unmet Dental Needs in Children Following Suspension of School-Based Oral Health Services Due to COVID-19

BACKGROUND

Dental caries (tooth decay) is the world's most prevalent noncommunicable disease and can lead to pain, infection, and edentulism. Many children with caries lack access to traditional dental services. School-based caries prevention can increase access to care and reduce health inequities. Disruptions in school-based care due to pandemic control policies may result in children losing access to their primary dental care option.

METHODS

The CariedAway project was a school-based caries prevention program in operation from 2019 to 2023 in urban schools with a high proportion of low-income, minority students. Program operations were suspended for 2 years due to the COVID-19 pandemic. We estimated the prevalence of untreated decay, swelling, fistula, and pulpal involvement in participants at baseline and again after restrictions were lifted.

RESULTS

A total of 2998 children between the ages of 5 and 13 years were enrolled and received preventive care prior to pandemic shutdowns, and 1398 (47%) completed a follow-up observation after 2 years. At baseline, approximately 30% had untreated caries on any dentition, 11% of children presented with evidence of dental sealants, and no participants had swelling, fistula, or pulpal involvement. After 24 months, 12% of participants had swelling fistula, or pulpal involvement that was not treated during the pandemic period.

CONCLUSION

There are considerable unmet dental needs in high-risk children that may be further exacerbated by a lack of access to care during disease outbreaks.

Targeting mitochondrial dysfunction using methylene blue or mitoquinone to improve skeletal aging

Methylene blue (MB) is a well-established antioxidant that has been shown to improve mitochondrial function in both in vitro and in vivo settings. Mitoquinone (MitoQ) is a selective antioxidant that specifically targets mitochondria and effectively reduces the accumulation of reactive oxygen species. To investigate the effect of long-term administration of MB on skeletal morphology, we administered MB to aged (18 months old) female C57BL/J6 mice, as well as to adult male and female mice with a genetically diverse background (UM-HET3). Additionally, we used MitoQ as an alternative approach to target mitochondrial oxidative stress during aging in adult female and male UM-HET3 mice. Although we observed some beneficial effects of MB and MitoQ in vitro, the administration of these compounds in vivo did not alter the progression of age-induced bone loss. Specifically, treating 18-month-old female mice with MB for 6 or 12 months did not have an effect on age-related bone loss. Similarly, long-term treatment with MB from 7 to 22 months or with MitoQ from 4 to 22 months of age did not affect the morphology of cortical bone at the mid-diaphysis of the femur, trabecular bone at the distal-metaphysis of the femur, or trabecular bone at the lumbar vertebra-5 in UM-HET3 mice. Based on our findings, it appears that long-term treatment with MB or MitoQ alone, as a means to reduce skeletal oxidative stress, is insufficient to inhibit age-associated bone loss. This supports the notion that interventions solely with antioxidants may not provide adequate protection against skeletal aging.

Development of primary osteoarthritis during aging in genetically diverse UM-HET3 mice

Background

Primary osteoarthritis (OA) occurs without identifiable underlying causes such as previous injuries or specific medical conditions. Age is a major contributing factor to OA, and as one ages, various joint tissues undergo gradual change, including degeneration of the articular cartilage, alterations in subchondral bone (SCB) morphology, and inflammation of the synovium.

Methods

We investigated the prevalence of primary OA in aged, genetically diverse UM-HET3 mice. Articular cartilage (AC) integrity and SCB morphology were assessed in 182 knee joints of 22-25 months old mice using the Osteoarthritis Research Society International (OARSI) scoring system and micro-CT, respectively. Additionally, we explored the effects of methylene blue (MB) and mitoquinone (MitoQ), two agents that affect mitochondrial function, on the prevalence and progression of OA during aging.

Results

Aged UM-HET3 mice showed a high prevalence of primary OA in both sexes. Significant positive correlations were found between cumulative AC (cAC) scores and synovitis in both sexes, and osteophyte formation in female mice. Ectopic chondrogenesis did not show significant correlations with cAC scores. Significant direct correlations were found between AC scores and inflammatory markers in chondrocytes, including matrix metalloproteinase-13, inducible nitric oxide synthase, and the NLR family pyrin domain containing-3 inflammasome in both sexes, indicating a link between OA severity and inflammation. Additionally, markers of cell cycle arrest, such as p16 and β-galactosidase, also correlated with AC scores. In male mice, no significant correlations were found between SCB morphology traits and cAC scores, while in female mice, significant correlations were found between cAC scores and tibial SCB plate bone mineral density. Notably, MB and MitoQ treatments influenced the disease's progression in a sex-specific manner. MB treatment significantly reduced cAC scores at the medial knee joint, while MitoQ treatment reduced cAC scores, but these did not reach significance.

Conclusions

Our study provides comprehensive insights into the prevalence and progression of primary OA in aged UM-HET3 mice, highlighting the sex-specific effects of MB and MitoQ treatments. The correlations between AC scores and various pathological factors underscore the multifaceted nature of OA and its association with inflammation and subchondral bone changes.

Development of primary osteoarthritis during aging in genetically diverse UM-HET3 mice

This study investigated the prevalence and progression of primary osteoarthritis (OA) in aged UM-HET3 mice. Using the Osteoarthritis Research Society International (OARSI) scoring system, we assessed articular cartilage (AC) integrity in 182 knee joints of 22-25 months old mice. Aged UM-HET3 mice showed a high prevalence of primary OA in both sexes. Significant positive correlations were found between cumulative AC (cAC) scores and synovitis in both sexes, and osteophyte formation in female mice. Ectopic chondrogenesis did not show significant correlations with cAC scores. Significant direct correlations were found between AC scores and inflammatory markers in chondrocytes, including matrix metalloproteinase-13 (MMP-13), inducible nitric oxide synthase (iNOS), and the NLR family pyrin domain containing-3 (NLRP3) inflammasome in both sexes, indicating a link between OA severity and inflammation. Additionally, markers of cell cycle arrest, such as p16 and β-galactosidase, also correlated with AC scores. Using micro-CT, we examined the correlations between subchondral bone (SCB) morphology traits and AC scores. In male mice, no significant correlations were found between SCB morphology traits and cAC scores, while in female mice, significant correlations were found between cAC scores and tibial SCB plate bone mineral density. Finally, we explored the effects of methylene blue (MB) and mitoquinone (MitoQ), two agents that affect mitochondrial function, on the prevalence and progression of OA during aging. Notably, MB and MitoQ treatments influenced the disease's progression in a sex-specific manner. MB treatment significantly reduced cAC scores at the medial knee joint, while MitoQ treatment reduced cAC scores, but these did not reach significance. In conclusion, our study provides comprehensive insights into the prevalence and progression of primary OA in aged UM-HET3 mice, highlighting the sex-specific effects of MB and MitoQ treatments. The correlations between AC scores and various pathological factors underscore the multifaceted nature of OA and its association with inflammation and subchondral bone changes.

Long-term effects of canagliflozin treatment on the skeleton of aged UM-HET3 mice

Sodium glucose cotransporter-2 inhibitors (SGLT2is) promote urinary glucose excretion and decrease plasma glucose levels independent of insulin. Canagliflozin (CANA) is an SGLT2i, which is widely prescribed, to reduce cardiovascular complications, and as a second-line therapy after metformin in the treatment of type 2 diabetes mellitus. Despite the robust metabolic benefits, reductions in bone mineral density (BMD) and cortical fractures were reported for CANA-treated subjects. In collaboration with the National Institute on Aging (NIA)-sponsored Interventions Testing Program (ITP), we tested skeletal integrity of UM-HET3 mice fed control (137 mice) or CANA-containing diet (180 ppm, 156 mice) from 7 to 22 months of age. Micro-computed tomography (micro-CT) revealed that CANA treatment caused significant thinning of the femur mid-diaphyseal cortex in both male and female mice, did not affect trabecular bone architecture in the distal femur or the lumbar vertebra-5 in male mice, but was associated with thinning of the trabeculae at the distal femur in CANA-treated female mice. In male mice, CANA treatment is associated with significant reductions in cortical bone volumetric BMD by micro-CT, and by quantitative backscattered scanning electron microscopy. Raman microspectroscopy, taken at the femur mid-diaphyseal posterior cortex, showed significant reductions in the mineral/matrix ratio and an increased carbonate/phosphate ratio in CANA-treated male mice. These data were supported by thermogravimetric assay (TGA) showing significantly decreased mineral and increased carbonate content in CANA-treated male mice. Finally, the sintered remains of TGA were subjected to X-ray diffraction and showed significantly higher fraction of whitlockite, a calcium orthophosphate mineral, which has higher resorbability than hydroxyapatite. Overall, long-term CANA treatment compromised bone morphology and mineral composition of bones, which likely contribute to increased fracture risk seen with this drug.

Excess Growth Hormone Triggers Inflammation-Associated Arthropathy, Subchondral Bone Loss, and Arthralgia

Growth hormone (GH) is a key mediator of skeletal growth. In humans, excess GH secretion due to pituitary adenoma, seen in patients with acromegaly, results in severe arthropathies. This study investigated the effects of long-term excess GH on the knee joint tissues. One year-old wild-type (WT) and bovine GH (bGH) transgenic mice were used as a model for excess GH. bGH mice showed increased sensitivity to mechanical and thermal stimuli, compared with WT mice. Micro-computed tomography analyses of the distal femur subchondral bone revealed significant reductions in trabecular thickness and significantly reduced bone mineral density of the tibial subchondral bone-plate that were associated with increased osteoclast activity in both male and female bGH compared with WT mice. bGH mice showed severe loss of matrix from the articular cartilage, osteophytosis, synovitis, and ectopic chondrogenesis. Articular cartilage loss in the bGH mice was associated with elevated markers of inflammation and chondrocyte hypertrophy. Finally, hyperplasia of synovial cells was associated with increased expression of Ki-67 and diminished p53 levels in the synovium of bGH mice. Unlike the low-grade inflammation seen in primary osteoarthritis, arthropathy caused by excess GH affects all joint tissues and triggers severe inflammatory response. Data of this study suggest that treatment of acromegalic arthropathy should involve inhibition of ectopic chondrogenesis and chondrocyte hypertrophy.

Dental erosion as an indicator of gastroesophageal reflux disease

While evidence shows that dental erosion (DE) is often caused by gastroesophageal reflux disease (GERD), the relationship of DE severity to a patient's symptoms and receipt of appropriate medical treatment for GERD is not clearly understood. The purpose of this study was to evaluate the association between DE and GERD. Eighty participants underwent a Basic Erosive Wear Examination for DE and completed the Patient-Reported Outcomes Measurement Information System (PROMIS) survey on symptoms of gastrointestinal reflux (PROMIS Scale v1.0, Gastrointestinal Gastroesophageal Reflux 13a) in English. Patients with observed erosive patterns were referred for gastroenterologic evaluation. The association between DE and GERD was assessed using multiple regression. The results showed that the extent of DE was positively associated with GERD symptoms (B = 0.585; 95% CI, 0.21-0.96), as measured by the PROMIS survey, in participants without a current diagnosis of GERD. Of the 80 patients in the study, 28 with more severe DE were evaluated in the gastroenterology department. A diagnosis of GERD was established for 27 of the 28, 9 of whom denied a past history of the disease. Twenty patients with GERD underwent upper endoscopy, and esophageal lesions were found in 6 patients (erosive esophagitis in 5 and Barrett esophagus in 1). Patients with clinically identified DE may benefit from medical evaluation and, if necessary, management of GERD. For a subset of patients, DE may be the only clinical indication of untreated or undertreated GERD, which could lead to serious esophageal changes. Dentists should consider referring patients with DE to primary care providers or gastrointestinal specialists to ensure that systemic conditions are identified and managed appropriately.

Lifelong Excess in GH Elicits Sexually Dimorphic Effects on Skeletal Morphology and Bone Mechanical Properties

Excess in growth hormone (GH) levels, seen in patients with acromegaly, is associated with increases in fractures. This happens despite wider bones and independent of bone mineral density. We used the bovine GH (bGH) transgenic mice, which show constitutive excess in GH and insulin-like growth factor 1 (IGF-1) in serum and tissues, to study how lifelong increases in GH and IGF-1 affect skeletal integrity. Additionally, we crossed the acid labile subunit (ALS) null (ALSKO) to the bGH mice to reduce serum IGF-1 levels. Our findings indicate sexually dimorphic effects of GH on cortical and trabecular bone. Male bGH mice showed enlarged cortical diameters, but with marrow cavity expansion and thin cortices as well as increased vascular porosity that were associated with reductions in diaphyseal strength and stiffness. In contrast, female bGH mice presented with significantly smaller-diameter diaphysis, with greater cortical bone thickness and with a slightly reduced tissue elastic modulus (by microindentation), ultimately resulting in overall stronger, stiffer bones. We found increases in C-terminal telopeptide of type 1 collagen and procollagen type 1 N propeptide in serum, independent of circulating IGF-1 levels, indicating increased bone remodeling with excess GH. Sexual dimorphism in response to excess GH was also observed in the trabecular bone compartment, particularly at the femur distal metaphysis. Female bGH mice preserved their trabecular architecture during aging, whereas trabecular bone volume in male bGH mice significantly reduced and was associated with thinning of the trabeculae. We conclude that pathological excess in GH results in sexually dimorphic changes in bone architecture and gains in bone mass that affect whole-bone mechanical properties, as well as sex-specific differences in bone material properties. © 2022 American Society for Bone and Mineral Research (ASBMR).

Longitudinal caries prevalence in a comprehensive, multicomponent, school-based prevention program

BACKGROUND

Globally, children's caries prevalence exceeds 30% and has not markedly changed in 30 years. School-based caries prevention programs can be an effective method to reduce caries prevalence, obviate traditional barriers to care, and use aerosol-free interventions. The objective of this study was to explore the clinical effectiveness of a comprehensive school-based, aerosol-free, caries prevention program.

METHODS

The authors conducted a 6-year prospective open cohort study in 33 US public elementary schools, providing care to 6,927 children in communities with and without water fluoridation. After dental examinations, dental hygienists provided twice-yearly prophylaxis, glass ionomer sealants, glass ionomer interim therapeutic restorations, fluoride varnish, toothbrushes, fluoride toothpaste, oral hygiene instruction, and referral to community dentists as needed. The authors used generalized estimating equations to estimate the change in the prevalence of untreated caries over time.

RESULTS

The prevalence of untreated caries decreased by more than 50%: from 39% through 18% in phase 1, and from 28% through 10% in phase 2. The per-visit adjusted odds ratio of untreated caries was 0.79 (95% confidence interval, 0.73 to 0.85).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

This school-based comprehensive caries prevention program was associated with substantial reductions in children's untreated caries, supporting the concept of expanding traditional practices to include office- and community-based aerosol-free care.

Quality Appraisal of Child Oral Health-Related Quality of Life Measures: A Scoping Review

BACKGROUND

Children's oral health-related quality of life (COHQoL) measures are well known and widely used. However, rigorous systematic reviews of these measures and analyses of their quality are in absence.

OBJECTIVES

To systematically review and quantitatively assess the quality of COHQoL measures through a scoping review.

DATA SOURCES

Systematic literature search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (Excerpta Medica database), HaPI (Health and Psychosocial Instruments), and DOSS (Dentistry and Oral Sciences Source).

STUDY ELIGIBILITY

The measure's focus was COHQoL; the child age ranged from 5 to 14 years; the publication was either a research article or a systematic review and related to caries; and it was written in English or had an English abstract. Two authors independently selected the studies. Disagreements were reconciled by group discussions with a third author.

APPRAISAL

The International Society for Quality of Life Research minimum standards for patient-reported outcome measures were used for quality appraisal.

SYNTHESIS

Descriptive analysis.

RESULTS

We identified 18 measures. Their quality scores ranged from 9.5 to 15.0 on a scale of 16. The quality appeared to bear no relationship to the citation and use of these measures. However, elements of these measures might be more useful than others, depending on the age-specific use and primary quality concerns.

LIMITATIONS

Some of the information on the minimum standards of the 18 measures cannot be found in the existing literature. Measures published without English abstract were not searched.

CONCLUSIONS

The quality of these measures is suboptimal. Researchers and practitioners in this field should exercise caution when choosing and using these measures. Efforts at improving the quality of the COHQoL measures, such as refining existing ones or developing new measures, are warranted.

KNOWLEDGE TRANSFER STATEMENT

Researchers, clinician scientists, and clinicians can use the results of this study when deciding which oral health-related quality of life measure they wish to use in children.

An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program

INTRODUCTION

Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars.

OBJECTIVES

To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth.

METHODS

To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY).

RESULTS

We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77).

CONCLUSIONS

This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

Development and validation of the Child Oral Health Impact Profile - Preschool version

OBJECTIVE

The Child Oral Health Impact Profile (COHIP) is a validated instrument created to measure the oral health-related quality of life of school-aged children. The purpose of this study was to develop and validate a preschool version of the COHIP (COHIP-PS) for children aged 2-5.

BASIC RESEARCH DESIGN

The COHIP-PS was developed and validated using a multi-stage process consisting of item selection, face validity testing, item impact testing, reliability and validity testing, and factor analysis.

PARTICIPANTS

A cross-sectional convenience sample of caregivers having children 2-5 years old from four groups completed item clarity and impact forms. Groups were recruited from pediatric health clinics or preschools/daycare centers, speech clinics, dental clinics, or cleft/craniofacial centers. Participants had a variety of oral health-related conditions, including caries, congenital orofacial anomalies, and speech/language deficiencies such as articulation and language disorders.

MAIN OUTCOME MEASURE

COHIP-PS.

RESULTS

The COHIP-PS was found to have acceptable internal validity (a = 0.71) and high test-retest reliability (0.87), though internal validity was below the accepted threshold for the community sample. While discriminant validity results indicated significant differences across study groups, the overall magnitude of differences was modest. Results from confirmatory factor analyses support the use of a four-factor model consisting of 11 items across oral health, functional well-being, social-emotional well-being, and self-image domains.

CONCLUSIONS

Quality of life is an integral factor in understanding and assessing children's well-being. The COHIP-PS is a validated oral health-related quality of life measure for preschool children with cleft or other oral conditions.

School-Based Caries Prevention, Tooth Decay, and the Community Environment

The school and community context can contribute to inequity in child oral health. Whether the school and community affect the effectiveness of school-based caries prevention is unknown. The association between the school and community environment and dental caries, as well as their moderating effects with school-based caries prevention, was assessed using multilevel mixed-effects regression. Data were derived from a 6-y prospective cohort study of children participating in a school-based caries prevention program. For the school and community, living in a dental-shortage area and the proportion of children receiving free or reduced lunch were significantly related to an increased risk of dental caries at baseline. Caries prevention was associated with a significant per-visit decrease in the risk of untreated caries, but the rate of total caries experience increased over time. Caries prevention was more effective in children who had prior dental care at baseline and in schools with a higher proportion of low socioeconomic status students. There was significant variation across schools in the baseline prevalence of dental caries and the effect of prevention over time, although effects were modest. The school and community environment have a direct impact on oral health and moderate the association between school-based caries prevention and dental caries. Knowledge Transfer Statement: School-based caries prevention can be an effective means to reduce oral health inequity by embedding dental care within schools. However, the socioeconomic makeup of schools and characteristics of the surrounding community can affect the impact of school-based care.

Challenges in conducting multicentre, multidisciplinary, longitudinal studies in children with chronic conditions

OBJECTIVES

Conducting longitudinal, multicentre, multidisciplinary research for individuals with chronic conditions can be challenging. Despite careful planning, investigative teams must adapt to foreseen and unforeseen problems. Our objective is to identify challenges encountered and solutions sought in a recently completed observational, longitudinal study of youth with cleft lip and palate as well as their caregivers.

METHODS

Data for analysis were derived from a 6-year, multicentre, prospective, longitudinal study of youth with cleft conducted from 2009 to 2015 that examined oral health-related quality of life and other related clinical observations over time in youth who had cleft-related surgery compared to those who did not. Youth and their caregivers participating in this study were followed at one of six geographically diverse, multidisciplinary cleft treatment centres in the USA.

RESULTS

Establishing effective communication, ensuring protocol adherence, safeguarding data quality, recognizing and managing differences across sites, maximizing participant retention, dealing with study personnel turnover, and balancing/addressing clinical and research tasks were particularly exigent issues that arose over the course of the study. Attending to process, ongoing communication within and across sites, and investigator and clinician commitment and flexibility were required to achieve the stated aims of the research.

CONCLUSION

Studying children with cleft and their caregivers over time created both foreseen and unforeseen challenges. Solutions to these challenges are presented to aid in the design of future longitudinal research in individuals with chronic conditions.

Perceived spatial stigma, body mass index and blood pressure: a global positioning system study among low-income housing residents in New York City

Previous research has highlighted the salience of spatial stigma on the lives of low-income residents, but has been theoretical in nature and/or has predominantly utilised qualitative methods with limited generalisability and ability to draw associations between spatial stigma and measured cardiovascular health outcomes. The primary objective of this study was to evaluate relationships between perceived spatial stigma, body mass index (BMI), and blood pressure among a sample of low-income housing residents in New York City (NYC). Data come from the community-based NYC Low-income Housing, Neighborhoods and Health Study. We completed a crosssectional analysis with survey data, which included the four items on spatial stigma, as well objectively measured BMI and blood pressure data (analytic n=116; 96.7% of the total sample). Global positioning systems (GPS) tracking of the sample was conducted for a week. In multivariable models (controlling for individual-level age, gender, race/ethnicity, education level, employment status, total household income, neighborhood percent non-Hispanic Black and neighborhood median household income) we found that participants who reported living in an area with a bad neighborhood reputation had higher BMI (B=4.2, 95%CI: -0.01, 8.3, P=0.051), as well as higher systolic blood pressure (B=13.2, 95%CI: 3.2, 23.1, P=0.01) and diastolic blood pressure (B=8.5, 95%CI: 2.8, 14.3, P=0.004). In addition, participants who reported living in an area with a bad neighborhood reputation had increased risk of obesity/overweight [relative risk (RR)=1.32, 95%CI: 1.1, 1.4, P=0.02) and hypertension/pre-hypertension (RR=1.66, 95%CI: 1.2, 2.4, P=0.007). However, we found no differences in spatial mobility (based GPS data) among participants who reported living in neighborhoods with and without spatial stigma (P>0.05). Further research is needed to investigate how placebased stigma may be associated with impaired cardiovascular health among individuals in stigmatised neighborhoods to inform effective cardiovascular risk reduction interventions.

Application of global positioning system methods for the study of obesity and hypertension risk among low-income housing residents in New York City: a spatial feasibility study

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.

Posttraumatic stress disorder and new-onset diabetes among adult survivors of the World Trade Center disaster

OBJECTIVE

To explore the temporal relationship between 9/11-related posttraumatic stress disorder (PTSD) and new-onset diabetes in World Trade Center (WTC) survivors up to 11 years after the attack in 2001.

METHODS

Three waves of surveys (conducted from 2003 to 2012) from the WTC Health Registry cohort collected data on physical and mental health status, sociodemographic characteristics, and 9/11-related exposures. Diabetes was defined as self-reported, physician-diagnosed diabetes reported after enrollment. After excluding prevalent cases, there were 36,899 eligible adult enrollees. Logistic regression and generalized multilevel growth models were used to assess the association between PTSD measured at enrollment and subsequent diabetes.

RESULTS

We identified 2143 cases of diabetes. After adjustment, we observed a significant association between PTSD and diabetes in the logistic model [adjusted odds ratio (AOR) 1.28, 95% confidence interval (CI) 1.14-1.44]. Results from the growth model were similar (AOR 1.37, 95% CI 1.23-1.52).

CONCLUSION

This exploratory study found that PTSD, a common 9/11-related health outcome, was a risk factor for self-reported diabetes. Clinicians treating survivors of both the WTC attacks and other disasters should be aware that diabetes may be a long-term consequence.

By Ounce or By Calorie: The Differential Effects of Alternative Sugar-Sweetened Beverage Tax Strategies

The obesity epidemic and excessive consumption of sugar-sweetened beverages have led to proposals of economics-based interventions to promote healthy eating in the United States. Targeted food and beverage taxes and subsidies are prominent examples of such potential intervention strategies. This paper examines the differential effects of taxing sugar-sweetened beverages by calories and by ounces on beverage demand. To properly measure the extent of substitution and complementarity between beverage products, we developed a fully modified distance metric model of differentiated product demand that endogenizes the cross-price effects. We illustrated the proposed methodology in a linear approximate almost ideal demand system, although other flexible demand systems can also be used. In the empirical application using supermarket scanner data, the product-level demand model consists of 178 beverage products with combined market share of over 90%. The novel demand model outperformed the conventional distance metric model in non-nested model comparison tests and in terms of the economic significance of model predictions. In the fully modified model, a calorie-based beverage tax was estimated to cost $1.40 less in compensating variation than an ounce-based tax per 3,500 beverage calories reduced. This difference in welfare cost estimates between two tax strategies is more than three times as much as the difference estimated by the conventional distance metric model. If applied to products purchased from all sources, a 0.04-cent per kcal tax on sugar-sweetened beverages is predicted to reduce annual per capita beverage intake by 5,800 kcal.

Associations between building design, point-of-decision stair prompts, and stair use in urban worksites

OBJECTIVE

Incidental forms of physical activity such as stair use offer frequent opportunities for energy expenditure and may contribute to the prevention and control of chronic diseases. This study analyzes the associations between building characteristics, stair prompts, and stair use in large urban worksites.

METHODS

Bootstrapped generalized mixed models were used to analyze self-reported stair use, using data from 1348 surveys of city employees and fourteen building assessments conducted in New York City in 2012.

RESULTS

57% of respondents reported climbing ≥1 flights of stairs daily at the workplace. Model results show that stair prompts were associated with a 3.21 increased likelihood of stair use. Naturally lit stairwells and stairwell visibility were also positively associated. Higher floor residency and BMI were negatively related, as were gender, stairwell distance from lobby entrances, the total number of floors in each building, and building averages for BMI and gender. Residual heterogeneity measured by adjusted median odds ratios indicates that buildings can have a moderate effect on the likelihood of stair use beyond those of individual characteristics.

CONCLUSIONS

Specific building features and stair prompts may potentially be leveraged to positively influence rates of incidental physical activity and contribute to improvements in population health.