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To compare the associations between food environment at the individual level, socioeconomic status (SES) and obesity rates in two cities: Seattle and Paris.
Analyses of the SOS (Seattle Obesity Study) were based on a representative sample of 1340 adults in metropolitan Seattle and King County. The RECORD (Residential Environment and Coronary Heart Disease) cohort analyses were based on 7,131 adults in central Paris and suburbs. Data on socio-demographics, health and weight were obtained from a telephone survey (SOS) and from in-person interviews (RECORD). Both studies collected data on and geocoded home addresses and food shopping locations. Both studies calculated GIS network distances between home and the supermarket that study respondents listed as their primary food source. Supermarkets were further stratified into three categories by price. Modified Poisson regression models were used to test the associations among food environment variables, SES and obesity.
Physical distance to supermarkets was unrelated to obesity risk. By contrast, lower education and incomes, lower surrounding property values, and shopping at lower-cost stores were consistently associated with higher obesity risk.
Lower SES was linked to higher obesity risk in both Paris and Seattle, despite differences in urban form, the food environments, and in the respective systems of health care. Cross-country comparisons can provide new insights into the social determinants of weight and health.
PMCID: PMC3955164  PMID: 23736365
Obesity; Socioeconomic Status (SES); Access to Supermarket; Food Environment; Food Shopping
2.  Access to supermarkets and fruit and vegetable consumption 
American journal of public health  2014;104(5):917-923.
Individual-level determinants of diets are well known. Recently, physical proximity to neighborhood supermarkets has been proposed as an environmental determinant of access to healthy foods, diets and health. The present study hypothesized that supermarket choice, conceptualized as the proxy for underlying personal factors, would better predict supermarket accessibility and diet quality than mere physical proximity.
The Seattle Obesity Study geocoded respondents’ home addresses and locations of their primary supermarkets. Primary supermarkets were stratified into low-, medium- and high- cost according to the market basket cost of 100 foods. Data on fruit and vegetable consumption were obtained through telephone surveys. Linear regressions examined associations between physical proximity to primary supermarkets, supermarket choice, and fruit and vegetable consumption. Descriptive analyses examined whether supermarket choice outweighed physical proximity among lower-income and vulnerable groups.
Only one-third of respondents shopped at their nearest supermarket for their primary food supply. Those who shopped at low-cost supermarkets were more likely to travel beyond their nearest supermarket. Fruit and vegetable consumption was not associated with physical distance but, with supermarket choice, after adjusting for covariates.
Mere physical distance may not be the most salient variable to reflect access to supermarkets, particularly among those who shop by car. Studies on food environments need to focus beyond neighborhood geographic boundaries to capture actual food shopping behaviors.
PMCID: PMC3987578  PMID: 24625173
3.  Food price, obesity and climate change 
PMCID: PMC3518359  PMID: 23153157
4.  Following federal guidelines to increase nutrient consumption may lead to higher food costs for consumers 
Health affairs (Project Hope)  2011;30(8):1471-1477.
The 2010 Dietary Guidelines Advisory Committee emphasized the need to increase dietary intakes of potassium, dietary fiber, vitamin D, and calcium. Examining the economic impact of increasing intakes of these nutrients to recommended levels among adults in King County, Washington, we found that each increase in intake of potassium, dietary fiber, and vitamin D equal to 10 percent of the daily target intake significantly increased food costs to consumers. At the same time, each time consumers obtained 1 percent more of their daily calories from added fats and added sugars, their food costs significantly declined. These findings suggest that many consumers, especially those with little budget flexibility, will need assistance to adopt healthier diets consistent with federal goals.
PMCID: PMC4103897  PMID: 21813865
5.  Disseminated Bacillus Calmette Guerin Disease in a Twin Infant with Severe Combined Immunodeficiency Disease 
Fatal-disseminated Bacillus Calmette Guerin (BCG) disease is well known in infants with severe combined immunodeficiency after BCG vaccination. We report a 7 month male infant delivered as a product of in vitro fertilization and twin gestation that presented with fever, cough and multiple nodular skin lesions. A biopsy of skin lesions revealed the presence of acid fast bacilli. Mycobacterium bovis infection was confirmed by polymerase chain reaction (PCR) and molecular studies. Immunological profile confirmed the diagnosis of severe combined immunodeficiency. Only few reports of similar case exist in the literature.
PMCID: PMC4147425  PMID: 25191057
Disseminated BCG; SCID; TWINS
6.  Are socioeconomic disparities in diet quality explained by diet cost? 
Socioeconomic disparities in nutrition are well documented. This study tested the hypothesis that socioeconomic differences in nutrient intakes can be accounted for, in part, by diet cost.
A representative sample of 1,295 adults in King County (WA) was surveyed in 2008–2009 and usual dietary intakes were assessed based on a food frequency questionnaire (FFQ). Monetary value of individual diets was estimated using local retail supermarket prices for 384 foods. Nutrients of concern as identified by the 2005 Dietary Guidelines Advisory Committee were fiber, vitamins A, C and E, calcium, magnesium and potassium. A nutrient density score based on all seven nutrients was another dependent measure. General linear models and linear regressions were used to examine associations among education and income, nutrient density measure and diet cost. Analyses were conducted in 2009–2010.
Controlling for energy and other covariates, higher-cost diets were significantly higher in all seven nutrients and in overall nutrient density. Higher education and income were positively and significantly associated with the nutrient density measure, but these effects were greatly attenuated with the inclusion of the cost variable in the model.
Socioeconomic differences in nutrient intake can be substantially explained by the monetary cost of the diet. The higher cost of more nutritious diets may contribute to socioeconomic disparities in health and should be taken into account in the formulation of nutrition and public health policy.
PMCID: PMC3951975  PMID: 21148819
food prices; diet cost; nutrient density; diet quality; inequalities
7.  Impact of an Educational Film on Parental Knowledge of Children with Cerebral Palsy 
Parents of children with cerebral palsy (CP) must have knowledge about the disease and its management to improve the outcome. This uncontrolled interventional trial was carried out to evaluate the parental knowledge of CP and assess the impact of an educational programme on it. Preset questionnaires were filled before and 1 week after a single session educational programme using an educational film. Out of a total of 53 subjects, majority (75.5%) were from lower socioeconomic status. Initially, none knew the correct name of child's illness; afterwards 45.3% could name it. When compared to previous status, there occurred significant improvement in the knowledge of parents after viewing the film with regard to knowing the cause of CP, knowing that motor involvement was predominant in CP, knowledge regarding curability of the disease, and knowledge about special schooling (P < 0.05). Change in knowledge was not related to socioeconomic or educational status (P > 0.05). Majority (94.3%) found the film useful and 96.2% learned how they could help in the management of their children. Parental knowledge of CP is inadequate which can be improved by incorporating such educational programmes in special clinics to improve management.
PMCID: PMC3963117  PMID: 24729788
8.  Positive Attitude toward Healthy Eating Predicts Higher Diet Quality at All Cost Levels of Supermarkets☆ 
Shopping at low-cost supermarkets has been associated with higher obesity rates. This study examined whether attitudes toward healthy eating are independently associated with diet quality among shoppers at low-cost, medium-cost, and high-cost supermarkets. Data on socioeconomic status (SES), attitudes toward healthy eating, and supermarket choice were collected using a telephone survey of a representative sample of adult residents of King County, WA. Dietary intake data were based on a food frequency questionnaire. Thirteen supermarket chains were stratified into three categories: low, medium, and high cost, based on a market basket of 100 commonly eaten foods. Diet-quality measures were energy density, mean adequacy ratio, and total servings of fruits and vegetables. The analytical sample consisted of 963 adults. Multivariable regressions with robust standard error examined relations between diet quality, supermarket type, attitudes, and SES. Shopping at higher-cost supermarkets was associated with higher-quality diets. These associations persisted after adjusting for SES, but were eliminated after taking attitudinal measures into account. Supermarket shoppers with positive attitudes toward healthy eating had equally higher-quality diets, even if they shopped at low-, medium-, or high-cost supermarkets, independent of SES and other covariates. These findings imply that shopping at low-cost supermarkets does not prevent consumers from having high-quality diets, as long as they attach importance to good nutrition. Promoting nutrition-education strategies among supermarkets, particularly those catering to low-income groups, can help to improve diet quality.
PMCID: PMC3947012  PMID: 23916974
Attitude toward healthy eating; Supermarket access and food environment; Cost level of supermarkets; Diet quality; Fruit and vegetable intake
9.  Giant primary cerebral hydatid cyst: A rare cause of childhood seizure 
We report a 9-year-old girl who presented with focal seizures, hemiparesis, headache, vomiting and bilateral optic atrophy. CT scan revealed a giant solitary cyst in the left parietal lobe. Serology and histopathology of the excised cyst confirmed the diagnosis of neurohydatidosis which is a rare cause of childhood seizure.
PMCID: PMC4040043  PMID: 24891913
Childhood seizures; hydatid cyst; neurohydatidosis
10.  Neuroimaging in Cerebral Palsy – Report from North India 
Only few Indian reports exist on neuroimaging abnormalities in children with cerebral palsy (CP) from India.
Materials & Methods
We studied the clinico-radiological profile of 98 children diagnosed as CP at a tertiary centre in North India. Relevant investigations were carried out to determine the etiology.
Among the 98 children studied, 80.5% were males and 22.2% were premature. History of birth asphyxia was present in 41.9%. Quadriplegic CP was seen in 77.5%, hemiplegic in 11.5%, and diplegic in 10.5%. Other abnormalities were microcephaly (60.5%), epilepsy (42%), visual abnormality (37%), and hearing abnormality (20%). Neuroimaging was abnormal in 94/98 (95.91%).
Abnormalities were periventricular white matter abnormalities (34%), deep grey matter abnormalities (47.8%), malformations (11.7%), and miscellaneous lesions (6.4%). Neuroimaging findings did not relate to the presence of birth asphyxia, sex, epilepsy, gestation, type of CP, or microcephaly.
Neuroimaging is helpful for etiological diagnosis, especially malformations.
PMCID: PMC3943052  PMID: 24665317
Cerebral Palsy; Neuroimaging; Birth asphyxia; Children
11.  Clinical profile of children with developmental delay and microcephaly 
To study the profile of children with developmental delay and microcephaly.
Materials and Methods:
Children attending child development clinic with developmental delay were evaluated as per protocol. Z scores of head circumference were calculated using WHO charts. Clinical, radiological and etiological profile of those with microcephaly and those without was compared.
Of the 414 children with developmental delay 231 had microcephaly (z score ≤ -3). Mean age of children with microcephaly was 35.1 ± 27.9 months (range 4-184), males (72.7%). Comorbidities were epilepsy (42.9%), visual abnormality (26.4%), hearing abnormality (16.9%). Mean DQ was 29.75 + 17.8 in those with microcephaly was significantly lower compared to the rest (P = 0.002). Secondary microcephaly was associated with cerebral palsy in 69.7%. Other causes were congenital infections (4), inborn error of metabolism (3), post-meningoencephalitis (5), malformations (12), and syndromic (13). Neuroimaging was done in 118 (51.1%) cases of which 104 (88.1%) were abnormal. On comparison children with microcephaly had more epilepsy, lower developmental quotient, vision abnormalities findings as compared to normocephalic children with developmental delay (P > 0.05).
Microcephaly was associated with lower, DQ, higher comorbidities in children with developmental delay. Spastic CP is commonly associated with microcephaly.
PMCID: PMC3821414  PMID: 24250161
Cerebral palsy; developmental delay; etiology; microcephaly
12.  Subdural effusion in infantile tremor syndrome 
PMCID: PMC3680910  PMID: 23772258
13.  Nutrient Intakes Linked to Better Health Outcomes Are Associated with Higher Diet Costs in the US 
PLoS ONE  2012;7(5):e37533.
Degrees of nutrient intake and food groups have been linked to differential chronic disease risk. However, intakes of specific nutrients may also be associated with differential diet costs and unobserved differences in socioeconomic status (SES). The present study examined degrees of nutrient intake, for every key nutrient in the diet, in relation to diet cost and SES.
Socio-demographic data for a stratified random sample of adult respondents in the Seattle Obesity Study were obtained through telephone survey. Dietary intakes were assessed using food frequency questionnaire (FFQ) (n = 1,266). Following standard procedures, nutrient intakes were energy-adjusted using the residual method and converted into quintiles. Diet cost for each respondent was estimated using Seattle supermarket retail prices for 384 FFQ component foods.
Higher intakes of dietary fiber, vitamins A, C, D, E, and B12, beta carotene, folate, iron, calcium, potassium, and magnesium were associated with higher diet costs. The cost gradient was most pronounced for vitamin C, beta carotene, potassium, and magnesium. Higher intakes of saturated fats, trans fats and added sugars were associated with lower diet costs. Lower cost lower quality diets were more likely to be consumed by lower SES.
Nutrients commonly associated with a lower risk of chronic disease were associated with higher diet costs. By contrast, nutrients associated with higher disease risk were associated with lower diet costs. The cost variable may help somewhat explain why lower income groups fail to comply with dietary guidelines and have highest rates of diet related chronic disease.
PMCID: PMC3360788  PMID: 22662168
14.  Dengue encephalitis in children 
PMCID: PMC3410015  PMID: 22865995
15.  Does diet cost mediate the relation between socioeconomic position and diet quality? 
Socioeconomic disparities in diet quality are well established. This study tested the hypothesis that such disparities are mediated, in part, by diet cost.
The Seattle Obesity Study (S.O.S.) was a cross sectional study based on a representative sample of 1266 adults of King County, WA conducted in 2008–09. Demographic and socioeconomic variables were obtained through telephone survey. Income and education were used as indicators of socioeconomic position (SEP). Dietary intake data were obtained using a food frequency questionnaire (FFQ). Diet cost was calculated based on retail prices for FFQ component foods. Energy density (KJ/g) and Mean Adequacy Ratio (MAR) were used as two indices of overall diet quality.
Higher income and education were each associated with lower energy density and higher MAR scores, adjusting for covariates. Higher income and education were also associated with higher energy adjusted diet cost. Higher quality diets were in turn associated with higher diet costs. All these associations were significant (P<0.0001). In formal mediation analyses, diet cost significantly mediated the pathway between income and diet quality measures, adjusting for covariates (p <0.05 each). Further, income – diet cost – diet quality pathway was found to be moderated by education level.
The social gradient in diet quality may be explained by diet cost. Strategies to improve diet quality among lower socioeconomic strata may need to take food prices and diet cost along with nutrition education into account.
PMCID: PMC3157585  PMID: 21559042
socioeconomic position; diet cost; energy density; MAR; diet quality; mediation analyses
16.  Immunization Status of Children Admitted to a Tertiary-care Hospital of North India: Reasons for Partial Immunization or Non-immunization 
Reasons for the low coverage of immunization vary from logistic ones to those dependent on human behaviour. The study was planned to find out: (a) the immunization status of children admitted to a paediatric ward of tertiary-care hospital in Delhi, India and (b) reasons for partial immunization and non-immunization. Parents of 325 consecutively-admitted children aged 12–60 months were interviewed using a semi-structured questionnaire. A child who had missed any of the vaccines given under the national immunization programme till one year of age was classified as partially-immunized while those who had not received any vaccine up to 12 months of age or received only pulse polio vaccine were classified as non-immunized. Reasons for partial/non-immunization were recorded using open-ended questions. Of the 325 children (148 males, 177 females), 58 (17.84%) were completely immunized, 156 (48%) were partially immunized, and 111 (34.15%) were non-immunized. Mothers were the primary respondents in 84% of the cases. The immunization card was available with 31.3% of the patients. All 214 partially- or completely-immunized children received BCG, 207 received OPV/DPT1, 182 received OPV/DPT2, 180 received OPV/DPT3, and 115 received measles vaccines. Most (96%) received pulse polio immunization, including 98 of the 111 non-immunized children. The immunization status varied significantly (p<0.05) with sex, education of parents, urban/rural background, route and place of delivery. On logistic regression, place of delivery [odds ratio (OR): 2.3, 95% confidence interval (CI) 1.3–4.1], maternal education (OR=6.94, 95% CI 3.1–15.1), and religion (OR=1.75, 95% CI 1.2–3.1) were significant (p<0.05). The most common reasons for partial or non-immunization were: inadequate knowledge about immunization or subsequent dose (n=140, 52.4%); belief that vaccine has side-effects (n=77, 28.8%); lack of faith in immunization (n=58, 21.7%); or oral polio vaccine is the only vaccine required (n=56, 20.9%. Most (82.5%) children admitted to a tertiary-care hospital were partially immunized or non-immunized. The immunization status needs to be improved by education, increasing awareness, and counselling of parents and caregivers regarding immunizations and associated misconceptions as observed in the study.
PMCID: PMC2980896  PMID: 20635642
Child; Immunization; Vaccination; India

Results 1-16 (16)