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2.  Disclosure of Sexual Intercourse by Teenagers: Agreement Between Telephone Survey Responses and Annual Visit Disclosures 
Clinical pediatrics  2015;54(6):529-533.
Physicians can help guide teenagers in their emerging sexuality; however, teens rarely inform physicians about their sexual activity.
We audio-recorded annual visits between 365 teenagers and 49 physicians. sexual intercourse. Recordings were coded for teenage disclosures about previous sexual intercourse. We measured agreement between telephone survey responses and annual visit disclosures, and examined factors associated with agreement between the two.
Fifty-six teenagers (15%) reported previous sexual intercourse in either the telephone survey or to their physician. Among those who reported sexual intercourse, 57% shared this information to both the telephone survey and their physician (κ = .72, confidence interval = 0.63–0.82).
Although a slight majority of teenagers disclosed their sexual activity to both the telephone survey and their doctor, a significant number disclosed to just one source.
PMCID: PMC4568819  PMID: 25857726
adolescent; patient participation; physician-patient communication; self-disclosure; sexual behavior; telephone
3.  Alcohol consumption among pregnant women in Northern Tanzania 2000–2010: a registry-based study 
Alcohol can be harmful to the development of the foetus. In most developed countries, pregnant women are recommended to abstain from alcohol, however in developing countries, women are less likely to receive these recommendations. With respect to pregnant women in Northern Tanzania, this study aims to 1) describe time trends in level of alcohol consumption, 2) assess socio-demographic predictors of alcohol consumption, and 3) describe associations between alcohol consumption and health-related maternal and foetal outcomes.
Data related to 34,090 births between 2000 and 2010 was obtained from the Medical Birth Registry at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania and analysed. Poisson regression analysis was used to assess associations between potential risk factors and alcohol consumption, and between alcohol consumption during pregnancy and maternal and foetal health outcomes.
From 2000 to 2010, the proportion of women reporting alcohol consumption during pregnancy decreased from 49.5 to 21.5 %. The socio-demographic predictors most strongly related to alcohol consumption were religion (Catholics 53.6 %, Protestants 25.9 %, Muslims 14.8 %) and tribe (Chaggas 45.2 %, Pares 17.3 %, Maasais 6.6 %). Pregnant women consuming alcohol were more likely to be older, taller, and have higher pre-pregnancy body mass index, and were less likely to present with anaemia (Hb < 11.0 g/dl) at last antenatal care (ANC) visit/at admission; adjusted relative risk (ARR) 0.84 (95 % confidence interval 0.79–0.90) for alcohol consumption vs. abstinence. Maternal alcohol consumption during pregnancy was associated with a decreased risk of being small for gestational age (ARR 0.87 (0.80–0.94) and a decreased risk of gestational age less than 37 weeks (ARR 0.89 (0.81–0.99).
The proportion of pregnant women reporting alcohol consumption decreased by 56.5 % from 2000 to 2010. Alcohol intake was strongly associated with socio-demographic factors. The association between alcohol intake and favourable perinatal outcomes remained significant after maternal factors were adjusted for. Information on diet, lifestyle factors and maternal health might give further insight into this unexpected observation. The proportion of pregnant women consuming alcohol in Northern Tanzania is high, and greater awareness of health outcomes associated with alcohol consumption is advised.
PMCID: PMC4559883  PMID: 26337194
4.  The Contribution of Generative Leisure Activities to Cognitive Function among Sri Lankan Elderly 
Although a substantive body of research has shown a protective association between leisure activities and cognitive function, consistent evidence is lacking about which specific types of activities should be promoted. The objective of this analysis was to examine the unique contribution of generative leisure activities, defined as activities motivated by “a concern for others and a need to contribute something to the next generation” (Erikson).
Cross-sectional survey.
Peri-urban and rural area in southern Sri Lanka.
Community dwelling adults aged 60+ (n=252).
Main predictors were leisure activities grouped into generative, social, or solitary. Main outcome was cognitive function assessed with Montreal Cognitive Assessment (MoCA) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).
We found that more frequent engagement in generative leisure activities was associated with higher levels of cognitive function, independent of the impact of other social and solitary leisure activities. In a fully adjusted model combining all three leisure activities, generative activities independently predicted cognitive function as measured with the MoCA (β =0.47 (0.11 to 0.83) and the IQCODE (β = -0.81 (-1.54 to -0.09)). In this combined model, solitary activities were also independently associated with slower cognitive decline with the MoCA (β =0.40 (0.16, 0.64), but not with IQCODE (β =-0.38 (-0.88, 0.12)); the association with social activities did not reach statistical significance with either measure. These associations did not differ meaningfully by gender.
Generative leisure activities are a promising area for the development of interventions aimed at reducing cognitive decline among the elderly.
PMCID: PMC4172516  PMID: 25139145
generativity; successful aging; rapidly aging; Sri Lanka
6.  Weight-related SMS texts promoting appropriate pregnancy weight gain: A pilot study 
Patient education and counseling  2014;97(2):256-260.
Excessive gestational weight gain (GWG) puts women and children at risk of obesity. We piloted an SMS-texting intervention to promote healthy GWG among overweight and obese women.
We recruited 35 women and randomized them in a 2:1 fashion to: a tailored SMS-texting intervention (Preg CHAT) vs. a generic texting intervention (Txt4baby). Preg CHAT texts provided personalized feedback based on women's intake of sweetened beverages, fruits and vegetables, fast food, daily steps taken, and weight. We abstracted women's weights from charts and surveyed women at baseline and 32 weeks gestation.
Few women refused the study; many (30%) did not complete the study, however. Of those in the Preg CHAT arm, 86% responded to texts, and 80% said they would recommend this program to a friend. For women who completed the surveys (n=23), those in the Preg CHAT arm had a mean gain of 6 less pounds than women in the Txt4Baby arm (95% CI -15.9, 4.0; p=0.24).
This pilot study shows feasibility, acceptability, and potential efficacy of a low-intensity and disseminable intervention to help overweight and obese women reduce GWG.
Practice implications
An SMS texting program might help overweight women reduce excessive GWG.
PMCID: PMC4512734  PMID: 25153313
7.  Preventing obesity in infants and toddlers in child care: Results from a pilot randomized controlled trial 
Maternal and child health journal  2014;18(5):1246-1257.
Few interventions have focused on very young children for obesity prevention. This study evaluated a pilot intervention to improve the nutrition and physical activity environments of child care centers serving infants and toddlers.
This randomized controlled trial took place in 32 centers in Boston, Massachusetts. The intervention aimed to improve policies and practices related to nutrition and physical activity within the center. For the outcome, observers assessed center environments using the Environment and Policy Assessment and Observation (EPAO) instrument (range 0-320 points) at baseline and the six-month follow-up. We fit linear regression models with change in EPAO score from baseline to follow-up, controlling for potential confounders for total score, nutrition sub-score, and physical activity sub-score.
Intervention centers had a mean (SD) of 98.2 (144.8) children enrolled, while control centers had 59.2 (34.5). In intervention centers, 47.5% of children were white, compared to 46.2% in controls. Fewer intervention centers had outdoor play areas on site (75% vs. 100%) but more had indoor play space (67% vs. 25%). At baseline, intervention centers had a mean (SD) EPAO score of 134.5 (7.0) points and controls had 146.8 (4.8) points. Compared with controls, intervention centers improved their EPAO scores at follow-up by 18.5 points (95% CI 0.1, 37.0; p=0.049), chiefly through greater improvement in physical activity (12.2; 95% CI -1.6, 26.0; p=0.075) and not nutrition (6.4; 95% CI -7.1, 19.8; p=0.385).
The pilot showed promise as an intervention to improve center environments, but future studies should include child-level outcomes.
PMCID: PMC3965661  PMID: 24065371
Child care; infant; nutrition; physical activity; toddler
8.  Depression in Persons with Diabetes by Age and Antidiabetic Treatment: A Cross-Sectional Analysis with Data from the Hordaland Health Study 
PLoS ONE  2015;10(5):e0127161.
Persons with diabetes have increased risk of depression, however, studies addressing whether the risk varies by age and type of antidiabetic treatment have yielded conflicting results. The aim of this study was to investigate if the association between diabetes and depression varied by type of antidiabetic treatment in a large community based sample of middle-aged (40–47 years) and older adults (70–72 years).
Data from 21845 participants in the Hordaland Health Study (HUSK) were analyzed in a cross-sectional design. Diabetes was assessed by self-report and classified as un-medicated, treated by oral antidiabetic agents or by insulin. Depression was defined as a score ≥8 on the depression subscale of the Hospital Anxiety and Depression Scale and/or self-reported use of antidepressant agents. Associations between diabetes and depression were estimated using logistic regression.
Persons in their forties with diabetes had a doubled prevalence of depression (OR: 1.96 (95% C.I.: 1.35, 2.83)) compared to persons without diabetes, while a lower and non-significant association was found among persons in their seventies. Persons in their forties with orally treated diabetes had about three times higher prevalence of depression (OR: 2.92 (95% C.I.: 1.48, 5.77)) after adjustment for gender, BMI, physical activity, alcohol consumption and education, compared to non-diabetic persons in the same age-group. No association between depression and insulin or un-medicated diabetes was found.
Clinicians should be aware that persons in their forties with orally treated diabetes are at a marked increased risk of depression.
PMCID: PMC4444007  PMID: 26010615
9.  Sexuality Talk During Adolescent Health Maintenance Visits 
JAMA pediatrics  2014;168(2):163-169.
Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality.
To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents.
Design, Setting, and Participants
Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area.
Main Outcomes and Measures
Total time per visit during which sexuality issues were discussed.
One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation.
Conclusions and Relevance
Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making.
Trial Registration Identifier: NCT01040975
PMCID: PMC4428666  PMID: 24378686
10.  Short-Term Trajectories of Use of a Caloric-Monitoring Mobile Phone App Among Patients With Type 2 Diabetes Mellitus in a Primary Care Setting 
Self-management plays an important role in maintaining good control of diabetes mellitus, and mobile phone interventions have been shown to improve such self-management. The Health Promotion Board of Singapore has created a caloric-monitoring mobile health app, the “interactive Diet and Activity Tracker” (iDAT).
The objective was to identify and describe short-term (8-week) trajectories of use of the iDAT app among patients with type 2 diabetes mellitus in a primary care setting in Singapore, and identify patient characteristics associated with each trajectory.
A total of 84 patients with type 2 diabetes mellitus from a public primary care clinic in Singapore who had not previously used the iDAT app were enrolled. The app was demonstrated and patients’ weekly use of the app was monitored over 8 weeks. Weekly use was defined as any record in terms of food entry or exercise workout entry in that week. Information on demographics, diet and exercise motivation, diabetes self-efficacy (Diabetes Empowerment Scale-Short Form), and clinical variables (body mass index, blood pressure, and glycosylated hemoglobin/HbA1c) were collected at baseline. iDAT app use trajectories were delineated using latent-class growth modeling (LCGM). Association of patient characteristics with the trajectories was ascertained using logistic regression analysis.
Three iDAT app use trajectories were observed: Minimal Users (66 out of 84 patients, 78.6%, with either no iDAT use at all or use only in the first 2 weeks), Intermittent-Waning Users (10 out of 84 patients, 11.9%, with occasional weekly use mainly in the first 4 weeks), and Consistent Users (8 out of 84 patients, 9.5%, with weekly use throughout all or most of the 8 weeks). The adjusted odds ratio of being a Consistent User, relative to a Minimal User, was significantly higher for females (OR 19.55, 95% CI 1.78-215.42) and for those with higher exercise motivation scores at baseline (OR 4.89, 95% CI 1.80-13.28). The adjusted odds ratio of being an Intermittent-Waning User relative to a Minimal User was also significantly higher for those with higher exercise motivation scores at baseline (OR 1.82, 95% CI 1.00-3.32).
This study provides insight into the nature and extent of usage of a caloric-monitoring app among patients with type 2 diabetes and managed in primary care. The application of LCGM provides a useful framework for evaluating future app use in other patient populations.
PMCID: PMC4342620  PMID: 25648130
type 2 diabetes mellitus; self-management; mobile phone; mobile apps; longitudinal studies
11.  Teen CHAT: Development and Utilization of a Web-Based Intervention to Improve Physician Communication with Adolescents About Healthy Weight 
Patient education and counseling  2013;93(3):10.1016/j.pec.2013.08.017.
To describe the theoretical basis, use, and satisfaction with Teen CHAT, an online educational intervention designed to improve physician-adolescent communication about healthy weight.
Routine health maintenance encounters between pediatricians and family practitioners and their overweight adolescent patients were audio recorded, and content was coded to summarize adherence with motivational interviewing techniques. An online educational intervention was developed using constructs from social cognitive theory and using personalized audio recordings. Physicians were randomized to the online intervention or not, and completed post-intervention surveys.
Forty-six physicians were recruited, and 22 physicians were randomized to view the intervention website. The educational intervention took an average of 54 minutes to complete, and most physicians thought it was useful, that they would use newly acquired skills with their patients, and would recommend it to others. Fewer physicians thought it helped them address confidentiality issues with their adolescent patients.
The Teen CHAT online intervention shows potential for enhancing physician motivational interviewing skills in an acceptable and time-efficient manner.
Practice Implications
If found to be effective in enhancing motivational interviewing skills and changing adolescent weight-related behaviors, wide dissemination will be feasible and indicated.
PMCID: PMC3851886  PMID: 24021419
Motivational interviewing; obesity; overweight; adolescents; physician-patient communication; tailored intervention
12.  Diet Quality of Overweight and Obese Mothers and Their Preschool Children 
Children of obese parents are more likely to become obese than children of normal weight parents. However, there is little information regarding diet intake of children of obese parents.
To determine diet quality of preschoolers and their overweight/obese mothers; if maternal and child diet quality were correlated; and predictors of child’s diet quality.
Results are from baseline measurements from a randomized controlled behavioral intervention.
Participants were English-literate, postpartum mothers and their preschoolers (n = 177 mother-child dyads) in North Carolina. Visits took place in the Triangle and Triad regions of North Carolina between September 2007 and November 2009.
Main outcome measures
Diet quality of mothers and preschoolers using the Healthy Eating Index (HEI)-2005.
Statistical analyses performed
Descriptive statistics, χ2, analysis of variance, Pearson correlations, and stepwise regression models were used.
Only 11% of children and 7% of mothers had HEI-2005 scores ≥ 80. Most children did not meet recommendations for fruits, vegetables, whole grains, meat and beans, sodium, saturated fat, and energy from solid fat and added sugars. Child diet quality was correlated with maternal diet quality (r = 0.44, p <0.001). However, children and mothers differed in the proportion that met food group recommendations. Children versus mothers: total fruit (50% vs. 14%), whole fruit (46% vs. 28%), total vegetables (6% vs. 18%), dark green and orange vegetables and legumes (7% vs. 19%), total grains (57% vs. 71%), milk (63% vs. 22%), and meat and beans (33% vs. 60%). Maternal diet quality and household income were positively correlated with child diet quality.
Diets of children of overweight/obese mothers need improvement in several areas. Mother’s diet quality and household income are important contributors to child’s diet quality, and should be considered in efforts to improve diets of these children.
PMCID: PMC3805766  PMID: 23871105
Diet quality; Obesity; Preschool diet; HEI-2005
13.  Trends in and socio-demographic factors associated with caesarean section at a Tanzanian referral hospital, 2000 to 2013 
Caesarean section (CS) can prevent maternal or fetal complications. Sub-Saharan Africa has the lowest CS levels in the world but large variations are seen between and within countries. The tertiary hospital, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania has had a high level of CS over years. The aim of this study was to examine trends in the socio-demographic background of babies born at KCMC from year 2000 to 2013, and trends in the CS percentage, and to identify socio-demographic factors associated with CS at KCMC during this period.
This is a registry-based study. The analyses were limited to singletons born by women from Moshi urban and rural districts. The Chi square test for linear trend was used to examine trends in the CS percentage and trends in the socio-demographic background of the baby. The association between different socio-demographic factors and CS was assessed using logistic regression. The analyses were stratified by the mother’s residence.
The educational level of mothers and fathers and the age of the mothers of singletons born at KCMC increased significantly from year 2000 to 2013 both among urban and rural residents. Among 29,752 singletons, the overall CS percentage was 28.9%, and there was no clear trend in the overall CS percentage between 2000 and 2013. In the multivariable model, factors associated with higher odds of CS were: having been referred for delivery, maternal age above 25 and no- or primary education level of the baby’s father. Among rural mothers, no- or primary education, being from the Pare tribe and para 2–3 were also associated with higher odds of CS. Being from the Chagga tribe and high parity were associated with lower odds of CS compared to other tribes and parity 1.
The CS percentage remained high but stable over time. Large variations in CS levels between different socio-demographic groups were observed. The educational level of the parents of babies born at KCMC increased over time, possibly reflecting persistent inequitable access to the services offered at the hospital.
PMCID: PMC4206704  PMID: 25319518
The adverse health effects of tobacco and alcohol are well known. Alcohol consumption is increasing in Sri Lanka, but few population studies have been conducted. The objective of this study was to document tobacco and alcohol consumption levels among adults in southern Sri Lanka and to identify the main reasons for using or refraining from alcohol and tobacco products. Tobacco and alcohol use within Sri Lanka is relatively common, particularly among adult males. Reasons given for smoking and drinking frequently relate to social and image-based motivators. Women may be especially susceptible to the influence of peer pressure in social situations. Public health efforts should consider the use of demographic-specific anti-tobacco and anti-alcohol messages, as the motivators driving behavior appear to differ across gender and age groups.
PMCID: PMC4169263  PMID: 24437324
alcohol; attitudes; behavior; tobacco; Sri Lanka
16.  Predictors of and health services utilization related to depressive symptoms among elderly Koreans 
Social science & medicine (1982)  2012;75(1):179-185.
While the prevalence, comorbidity, risk profile and health care utilization for late-life depression have been described for many Western countries, much less is known about the recent epidemiology of late-life depression in East Asian countries such as Korea. We investigated predictors for depressive symptoms and the association between depressive symptoms and the utilization of both medical care and preventive services in elderly Koreans. Data were obtained from a nationally representative sample of Koreans aged 60 and above (2226 men, 2911 women) who participated in the 2008 wave of the Korean Longitudinal Study of Ageing. Depressive symptoms were measured using the 10-item Center for Epidemiological Studies-Depression scale. Risk factors considered included sociodemographics, health behaviors, chronic diseases, and physical function. Health care utilization factors included hospitalization, outpatient clinic use and basic medical checkup. Being female, being unmarried, and having less education, lower household income, physical inactivity and lower weight were associated with depressive symptoms. Presence of chronic diseases and limited physical function also showed a significant association with depressive symptoms. Depressive symptoms were associated with increased odds of hospitalization and outpatient visits, but decreased the odds of utilization of basic medical checkup after controlling for potential confounders. Findings on most risk factors, except lower weight, were consistent with reports from Western countries. It is important to recognize the burden of depressive symptoms in the elderly. The interaction of such symptoms with chronic diseases should be acknowledged and considered in the clinical setting as well as in health care planning and policymaking.
PMCID: PMC4169268  PMID: 22531571
Late-life depression; Korea; Predictors; Health care utilization
17.  Caregiving expectations and challenges among elders and their adult children in Southern Sri Lanka 
Ageing and society  2013;34(5):838-858.
The elderly population in Sri Lanka is growing rapidly. Elders are traditionally cared for in the homes of their adult children, but the shifting socio-economic environment in Sri Lanka challenges this arrangement. This paper describes the dynamics of elder-caregiver relationships in Southern Sri Lanka. Data included 4 focus group discussions and 5 in-depth interviews with elderly, and 10 in-depth interviews with adult children of the elderly. Discussion guide topics included caregiving arrangements, and roles/responsibilities of elders and caregivers. Using a grounded theory approach, a comprehensive analytic memo was developed and discussed to explore emerging themes on the caregiver dynamic. Both elders and caregivers felt that elders should be taken care of in the home by their children. They pointed to a sense of duty and role modeling of parental caregiving that is passed down through generations. Even as elders desired support from their children, they feared losing their independence, and saw financial autonomy as important for maintaining relationship balance. Caregiving challenges included: households where both the adult child and his/her spouse worked outside the home; households where elders had a disproportionate amount of household work; economically stressed households; and lack of direct communication between elders and caregivers regarding conflicts. Results point to strong values around caring for elderly in the home, but identify challenges to this arrangement in the future.
PMCID: PMC4138525  PMID: 25152553
Sri Lanka; elderly; caregiving; ageing; qualitative methods
18.  Stressful Life Events and Cognitive Decline in Late Life: Moderation by Education and Age The Cache County Study 
Stressful life events (SLE) have been associated with increased dementia risk, but their association with cognitive decline has been inconsistent. In a longitudinal population-based study of elderly individuals, we examined the association between SLE and cognitive decline, and the role of potential effect modifiers.
A total of 2665 non-demented participants of the Cache County Memory Study completed a stress life events questionnaire at Wave 2, and were revisited 4 and 7 years later. The events were represented via several scores: total number, subjective rating (negative, positive, unexpected), and a weighted summary based on their impact. Cognition was assessed at each visit with the modified Mini-Mental State Exam. General linear models were used to examine the association between SLE scores and cognition. Effect modification by age, education, and APOE genotype was tested.
Years of formal education (p = 0.006) modified the effect of number of SLE, and age (p = 0.009) modified the effect of negative SLE on the rate of cognitive decline. Faster decline was observed among those with fewer years of education experiencing more SLE and also among younger participants experiencing more negative SLE. There was no association between other indicators of SLE and cognitive decline. APOE genotype did not modify any of the above associations.
The effects of SLE on cognition in late life are complex and vary by individual factors such as age and education. These results may explain some of the contradictory findings in the literature.
PMCID: PMC3706540  PMID: 23037866
cognition; cognitive decline; memory; stress; life events; stressful life events
19.  Development of the Sri Lankan Early Teenagers' Violence Inventory: An Instrument to Measure Peer Violence in Schools 
BioMed Research International  2014;2014:563143.
This study was designed to develop an inventory to measure peer violence among early teens (13–15 years of age) in schools in Sri Lanka. Development of SLETVI was carried out in two phases. In phase I, development of an operational definition for peer violence, identification, and finalizing violent acts for inventory was done by a combination of qualitative methods: a comprehensive literature review, focus group discussions among 13–15-year-old adolescents, their teachers and parents, and consultative meetings with experts in the field. Inventory was then pretested. In phase II, elaboration of SLETVI was carried out by administering it to a sample of 1700 adolescents (13–15 years old). Exploratory factor analysis using principal component analysis was performed separately for experiences of victimization and perpetration. Test-retest reliability of SLETVI was assessed. SLETVI included 37 items in three factors: “less severe violence,” “severe physical,” and “severe relational” violence. Combined use of qualitative and quantitative methods enabled development of a culturally valid and reliable operational inventory to assess early teenagers' peer violence in Sri Lankan and other South Asian schools.
PMCID: PMC4100445  PMID: 25061607
20.  Baseline Disability in Activities of Daily Living Predicts Dementia Risk Even After Controlling for Baseline Global Cognitive Ability and Depressive Symptoms 
Late-life disability in Activities of Daily Living (ADL) is theorized to be driven by underlying cognitive and/or physical impairment, interacting with psychological and environmental factors. While we expect that cognitive deficits would explain associations between ADL disability and dementia risk, the current study examined ADL as a predictor of future dementia after controlling for global cognitive status.
The population-based Cache County Memory Study (CCMS; N=3547) assessed individuals in four triennial waves (average age 74.9, years of education 13.36; 57.9% were women). Cox proportional hazards regression models assessed whether baseline ADL disability (presence of 2+ Instrumental ADL and/or 1+ Personal ADL) predicted incident dementia after controlling for APOE status, gender, age, baseline cognitive ability (Modified Mini-mental State Exam, 3MS-R; adjusted for education level), and baseline depressive symptoms (Diagnostic Interview Schedule).
Over the course of study, 571 cases of incident dementia were identified through in-depth cognitive assessment, ending in expert consensus diagnosis. Results from Cox models suggest that ADL disability is a statistically significant predictor of incident dementia (adjusted Hazard Ratio=1.83, p<.001), even after controlling for covariate.
Findings suggest that ADL disability offers unique contributions in risk for incident dementia, even after controlling for global cognitive status. We discuss how physical impairment and executive function may play important roles in this relationship, and how ADL is useful, not just a diagnostic tool at, or after dementia onset, but as a risk factor for future dementia, even in individuals not impaired on global cognitive tests.
PMCID: PMC3565032  PMID: 22968965
Activities of Daily Living; Dementia risk; Disability
21.  Do High-Risk Preschoolers or Overweight Mothers Meet AAP-Recommended Behavioral Goals for Reducing Obesity? 
Academic pediatrics  2013;13(3):243-250.
The American Academy of Pediatrics (AAP) has issued specific behavioral recommendations to prevent obesity. It is unclear how often high-risk preschoolers and overweight mothers meet recommended behavior-goals, and whether meeting these goals is negatively associated with overweight/obesity.
Describe the proportion of preschoolers and mothers that meet AAP-recommended behavior-goals, and examine the associations of meeting goals with weight-status, and mothers meeting goals and children meeting corresponding goals.
Secondary analysis of baseline data (prior to an intervention) from mother-preschooler dyads in a weight-control study. Mothers were overweight or obese. Preschoolers were 2–5 years old. Dietary and feeding practices were assessed using questionnaires. Activity was measured directly using accelerometry. Outcomes included preschooler overweight and maternal obesity.
The respective proportions of children and mothers that met behavior-goals were: 17% and 13% for ≥5 fruits/vegetables/day, 46% and 33% for zero sugar-sweetened beverages/day, 41% and 13% for fast-food <1x/week, and 46% and 13% for screentime ≤2 hours/day. Moderate-to-vigorous physical activity did not exceed 60 minutes/day in any participant. 49% ate family meals together 7x/week. For each additional goal met, the adjusted odds for preschooler overweight was 0.9 (95% CI, 0.8–1.1), and for maternal obesity, 0.8 (95% CI, 0.6–0.9). Preschoolers had significantly greater odds of meeting each goal when mothers met the corresponding goal.
Few high-risk preschoolers or overweight mothers meet AAP-recommended behavior-goals. Meeting a greater number of behavior-goals may be particularly important for maternal weight. Preschoolers have greater odds of meeting behavior-goals when mothers meet behavior-goals.
PMCID: PMC3658466  PMID: 23491583
childhood obesity; behavioral modification; obesity prevention; maternal child health
22.  Changes in Physical Activity Among Postpartum Overweight and Obese Women: Results from the KAN-DO Study 
Women & health  2013;53(3):317-334.
Few studies have assessed physical activity at multiple time points in the postpartum period or used both self-reported and objective measures of assessment. The purpose of this study was to describe physical activity and sedentary behavior at two time points in a cohort of overweight or obese postpartum women using both self-reported and objective measures. In total, 132 women completed physical activity assessments at a median of 24 weeks postpartum and again approximately 10 months later. At both time points, women wore an Actical accelerometer for one week and completed the Kaiser Physical Activity Survey at both time points. Adjusted Poisson regression models were used to determine whether physical activity changed over time for the cohort. Overall counts per minute and moderate to vigorous physical activity increased from baseline to 10-months later, although the absolute levels were modest (median 6.9 to 8.8 minutes/day). A median of 64–71% at baseline and 63–67% at follow-up of their monitored time was sedentary. More intensive interventions are needed to help postpartum women integrate physical activity and reduce sedentary behavior.
PMCID: PMC3670793  PMID: 23705761
exercise; leisure activities; obesity; pregnancy; sedentary
23.  The Effect of the Home Environment on Physical Activity and Dietary Intake in Preschool Children 
The effects of the home environment on child health behaviors related to obesity are unclear.
To examine the role of the home physical activity (PA) and food environment on corresponding outcomes in young children, and assess maternal education/work status as a moderator.
Overweight or obese mothers reported on the home PA and food environment (accessibility, role modeling and parental policies). Outcomes included child moderate-vigorous PA (MVPA) and sedentary time derived from accelerometer data and two dietary factors (“junk” and healthy food intake scores) based on factor analysis of mother-reported food intake. Linear regression models assessed the net effect (controlling for child demographics, study arm, supplemental timepoint, maternal education/work status, child body mass index and accelerometer wear-time (for PA outcomes)) of the home environment on the outcomes and moderation by maternal education/work status. Data was collected in North Carolina from 2007–2011.
Parental policies supporting PA increased MVPA time, and limiting access to unhealthy foods increased the healthy food intake score. Role modeling of healthy eating behaviors increased the healthy food intake score among children of mothers with no college education. Among children of mothers with no college education and not working, limiting access to unhealthy foods and role modeling reduced “junk” food intake scores while parental policies supporting family meals increased “junk” food intake scores.
To promote MVPA, parental policies supporting child PA are warranted. Limited access to unhealthy foods and role modeling of healthy eating may improve the quality of the child’s food intake.
PMCID: PMC3786032  PMID: 23736357
Childhood obesity; home environment; parenting; physical activity; dietary intake
Postpartum weight retention is a significant risk factor for long-term weight gain. Encouraging new mothers to consume a healthy diet may result in weight loss.
To assess predictors of diet quality during the early postpartum period; to determine if diet quality, energy intake, and lactation status predicted weight change from five to 15 months postpartum; and to determine whether an intervention improved diet quality, reduced energy intake, and achieved greater weight loss compared to usual care.
Randomized clinical trial (KAN-DO: Kids and Adults Now - Defeat Obesity), a family and home-based, ten-month, behavioral intervention to prevent childhood obesity, with secondary aims to improve diet and physical activity habits of mothers, in order to promote postpartum weight loss.
Overweight/obese, postpartum women (n=400), recruited from 14 counties in the Piedmont region of North Carolina.
Eight education kits, each mailed monthly; motivational counseling; and one group class.
Anthropometric measurements and 24-hour dietary recalls collected at baseline (approximately five months postpartum) and follow-up (approximately ten months later). Diet quality was determined using the Healthy Eating Index-2005 (HEI-2005). 3
Statistical analyses
Descriptive statistics, chi-square, analysis of variance, bi-and multivariate analyses were performed.
At baseline, mothers consumed a low quality diet (HEI-2005 score = 64.4 ± 11.4). Breastfeeding and income were positive, significant predictors of diet quality; while BMI was a negative predictor. Diet quality did not predict weight change. However, total energy intake, not working outside of the home, and breastfeeding duration/intensity were negative predictors of weight loss. There were no significant differences in changes in diet quality, decreases in energy intake or weight loss between the intervention (2.3 ± 5.4 kg) and control (1.5 ± 4.7 kg) arms.
The family-based intervention did not promote postpartum weight loss. Reducing energy intake, rather than improving diet quality, should be the focus of weight loss interventions for overweight/obese postpartum women.
PMCID: PMC3529806  PMID: 23146549
Diet quality; HEI-2005; Postpartum weight loss; Obesity
25.  Chikungunya as a Cause of Acute Febrile Illness in Southern Sri Lanka 
PLoS ONE  2013;8(12):e82259.
Chikungunya virus (CHIKV) re-emerged in Sri Lanka in late 2006 after a 40-year hiatus. We sought to identify and characterize acute chikungunya infection (CHIK) in patients presenting with acute undifferentiated febrile illness in unstudied rural and semi-urban southern Sri Lanka in 2007.
Methodology/Principal Findings
We enrolled febrile patients ≥ 2 years of age, collected uniform epidemiologic and clinical data, and obtained serum samples for serology, virus isolation, and real-time reverse-transcriptase PCR (RT-PCR). Serology on paired acute and convalescent samples identified acute chikungunya infection in 3.5% (28/797) patients without acute dengue virus (DENV) infection, 64.3% (18/28) of which were confirmed by viral isolation and/or real-time RT-PCR. No CHIKV/DENV co-infections were detected among 54 patients with confirmed acute DENV. Sequencing of the E1 coding region of six temporally distinct CHIKV isolates (April through October 2007) showed that all isolates posessed the E1-226A residue and were most closely related to Sri Lankan and Indian isolates from the same time period. Except for more frequent and persistent musculoskeletal symptoms, acute chikungunya infections mimicked DENV and other acute febrile illnesses. Only 12/797 (1.5%) patients had serological evidence of past chikungunya infection.
Our findings suggest CHIKV is a prominent cause of non-specific acute febrile illness in southern Sri Lanka.
PMCID: PMC3846738  PMID: 24312651

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