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1.  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
2.  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
3.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
15.  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
16.  Under reporting of road traffic injuries in the district of Kandy, Sri Lanka 
BMJ Open  2013;3(11):e003640.
To conduct a community survey to estimate the degree to which road traffic injuries (RTIs) are under reported and to compare the characteristics of RTI reported to the police to those not reported.
A cross-sectional population-based study.
Kandy district, Sri Lanka.
RTIs and deaths during the preceding 12 months were identified through a community-based cross-sectional survey with a sample size of 3080 households. A stratified multistage cluster sampling with population proportion to size was used. ‘Events reported’ to the police were cross checked against events in the police records of the given or adjacent police stations, and either were ‘Events found’ or ‘Not found’. ‘Under reported’ included those ‘Not reported’ and those reported but ‘Not found’ in the police dataset.
Information about 11 724 persons were obtained from 3080 households, identifying 149 persons who suffered an RTI. Of these, 57% were ‘Events reported’, and of these 43.6% (n=65) were ‘Events found’ in police records (95% CI, 36.0 to 51.6). There were 42 events ‘Not reported’ to police while an additional 7 were ‘Not found’ in the police records of the given police station. Although they were claimed to have been reported to the police, 33% (95% CI 25.8 to 40.7) were ‘Under reported’. There were significant differences in age (p=0.02), family income (p<0.001), road user type (p=0.001), injury severity (p<0.001) and injury category (p=0.01) between ‘Events found’ in the police records and ‘Under reported’ events.
In the Kandy district, 33% of RTIs were ‘under reported’. These findings could be used as evidence for policy planning to prevent RTIs, and highlights the need for a nation-wide community-based survey to determine the true rates of RTI for a better understanding of the reasons for under reporting.
PMCID: PMC3822300  PMID: 24213095
17.  Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity? 
Family Practice  2012;29(5):553-560.
Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed.
This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter.
Right after the visit, ∼55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations.
Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.
PMCID: PMC3450433  PMID: 22315467
Counselling; outcome expectations; physicians; weight loss
18.  Parental obesity moderates the relationship between childhood appetitive traits and weight 
Obesity (Silver Spring, Md.)  2013;21(4):815-823.
This study examined the independent and combined associations between childhood appetitive traits and parental obesity on weight gain from 0 to 24 months and body mass index (BMI) z score at 24 months in a diverse community-based sample of dual parent families (n = 213). Participants were mothers who had recently completed a randomized trial of weight loss for overweight/obese post-partum women. As measures of childhood appetitive traits, mothers completed subscales of the Child Eating Behavior Questionnaire, including Desire to Drink (DD), Enjoyment of Food (EF), and Satiety Responsiveness (SR), and a 24-hour dietary recall for their child. Heights and weights were measured for all children and mothers and self-reported for mothers’ partners. The relationship between children’s appetitive traits and parental obesity on toddler weight gain and BMI z score were evaluated using multivariate linear regression models, controlling for a number of potential confounders. Having two obese parents was related to greater weight gain from birth to 24 months independent of childhood appetitive traits, and while significant associations were found between appetitive traits (DD and SR) and child BMI z score at 24 months, these associations were observed only among children who had two obese parents. When both parents were obese, increasing DD and decreasing SR was associated with a higher BMI z-score. The results highlight the importance of considering familial risk factors when examining the relationship between childhood appetitive traits on childhood obesity.
PMCID: PMC3671382  PMID: 23712985
Childhood eating behaviors; parental obesity; childhood obesity; prevention
19.  Parent-Focused Change to Prevent Obesity in Preschoolers: Results from the KAN-DO Study 
Preventive medicine  2012;55(3):188-195.
Present the immediate post-intervention results of Kids and Adults Now - Defeat Obesity!, a randomized controlled trial to enhance healthy lifestyle behaviors in mother-preschooler (2–5 years old) dyads in North Carolina (2007–2011). The outcomes include change from baseline in the child’s diet, physical activity and weight, and in the mother’s parenting behaviors, diet, physical activity, and weight.
The intervention targeted parenting through maternal emotion regulation, home environment, feeding practices, and modeling of healthy behaviors. 400 Mother-child dyads were randomized.
Mothers in the intervention arm, compared to the control arm, reduced instrumental feeding (−0.24 vs. 0.01, p<0.001) and TV snacks (−.069 vs. −0.24, p=0.001). There were also improvements in emotional feeding (p=0.03), mother’s sugary beverage (p=0.03) and fruit/vegetable (p=0.04) intake, and dinners eaten in front of TV (p=0.01); these differences were not significant after adjustment for multiple comparisons.
KAN-DO, designed to maximize the capacity of mothers as agents of change, improved several channels of maternal influence. There were no group differences in the primary outcomes, but differences were observed in the parenting and maternal outcomes and there were trends toward improvement in the preschoolers’ diets. Long-term follow-up will address whether these short-term trends ultimately improve weight status.
PMCID: PMC3439558  PMID: 22705016
Obesity; randomized controlled trial; parenting; emotion regulation; physical activity; dietary intake
20.  The Accuracy of Medicare Claims as an Epidemiological Tool: The Case of Dementia Revisited 
Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993–2005 to clinical dementia assessments carried out in 2001–2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.
PMCID: PMC3697480  PMID: 19542620
Dementia costs; medicare; sensitivity; specificity
21.  Identifying Trajectories of Depressive Symptoms for Women Caring for Their Husbands with Dementia 
To use an innovative statistical method, Latent Class Trajectory Analysis (LCTA), to identify and describe subgroups (called trajectories) of caregiver depressive symptoms in a national sample of wives providing informal care for their husbands with dementia.
Respondents to the National Longitudinal Caregiver Survey were wife caregivers of veterans with dementia who were identified through Veterans Affairs hospitals nationally.
Mean number of depressive symptoms as measured using the Center for Epidemiologic Studies Depression scale (CES-D, 20-item scale).
Overall mean depressive symptoms of wife caregivers were 6.2 of 20, below the cutpoint (8 or 9/20) associated with clinical depression. Four distinct trajectories of caregiver depressive symptoms were identified. The trajectory with the highest number of symptoms (11.9 of 20), contained one-third of the sample. Another third had mean depressive symptoms virtually identical to the overall sample mean. The final third were divided between two trajectories, low depressive symptoms (mean CES-D, 3.0/ 20, 22% of sample) and very low (mean CES-D, 0.8/20, 14% of sample). Approximately two-thirds of the sample members were in a depressive symptom trajectory, with substantially higher or lower numbers of symptoms than the overall mean. Two subjective measures asked of wife caregivers (desire for more help, life satisfaction) were significantly associated with membership in the highest depressive symptom trajectory.
LCTA identified important depressive symptom subgroups of wife caregivers. A population-averaging method identified a mean effect that was similar to the effect in one-third of the cases but substantially different from that in two-thirds of the cases.
PMCID: PMC3679900  PMID: 18179488
depression; caregiving; Latent Class Trajectory Analysis; dementia; spouses
22.  Trajectories of Caregiving Time Provided by Wives to Their Husbands With Dementia 
Spouses are often the first providers of informal care when their partners develop dementia. We used The National Longitudinal Caregiver Study (NLCS, 4 annual surveys, 1999 to 2002) and identified 3 distinct longitudinal patterns (trajectory classes) of total daily caregiving time provided by the wife to her husband using Generalized growth mixture models (GGMM). About 56.4% of the sample (N=828) was found to have an increase in the trajectory of total daily caregiving time (mean 252 min/d at baseline, rising to 471 min/d at time 4). Four hundred forty-four (30.3%) caregivers had a trajectory described by a moderate increase in caregiving time (an increase from a mean of 464 min/d at baseline to 533 at wave 4), whereas 195 (13.3%) had a sharply declining trajectory (a decline from a mean of 719 min/d at baseline to 421 at wave 4). There was no significant difference in the duration (time since onset) of caregiving at baseline for these 3 trajectories. GGMM are well suited for the identification of distinct trajectory classes. Here they show that there are large differences in caregiving time provided to persons with dementia, who seem to be quite similar.
PMCID: PMC3679901  PMID: 18525284
informal caregiving; longitudinal methods; burden of Alzheimer disease/dementia
23.  Parenting Styles and Body Mass Index Trajectories From Adolescence to Adulthood 
Parenting styles such as authoritarian, disengaged, or permissive are thought to be associated with greater adolescent obesity risk than an authoritative style. This study assessed the relationship between parenting styles and changes in body mass index (BMI) from adolescence to young adulthood.
The study included self-reported data from adolescents in the National Longitudinal Study of Adolescent Health. Factor mixture modeling, a data-driven approach, was used to classify participants into parenting style groups based on measures of acceptance and control. Latent growth modeling (LGM) identified patterns of developmental changes in BMI. After a number of potential cofounders were controlled for, parenting style variables were entered as predictors of BMI trajectories. Analyses were also conducted for males and females of three racial/ethnic groups (Hispanic, black, white) to assess whether parenting styles were differentially associated with BMI trajectories in these 6 groups.
Parenting styles were classified into 4 groups: authoritarian, disengaged, permissive, and balanced. Compared with the balanced parenting style, authoritarian and disengaged parenting styles were associated with a less steep average BMI increase (linear slope) over time, but also less leveling off (quadratic) of BMI over time. Differences in BMI trajectories were observed for various genders and races, but the differences did not reach statistical significance.
Adolescents who reported having parents with authoritarian or disengaged parenting styles had greater increases in BMI as they transitioned to young adulthood despite having a lower BMI trajectory through adolescence.
PMCID: PMC3616616  PMID: 22545979
24.  Postpartum Physical Activity in Overweight and Obese Women 
Low physical activity (PA) during the postpartum period is associated with weight retention. While patterns of PA have been examined in normal weight women during this period, little is known about PA among overweight and obese women. The aim of this cross-sectional study was to investigate PA and determine the proportion of women meeting recommendations for PA.
Women (n = 491), with a body mass index (BMI) ≥ 25 kg/m2 were enrolled in a behavioral intervention. PA was assessed at six weeks postpartum using the Seven-Day PA Recall.
Women averaged 923 ± 100 minutes/day of sedentary/light and 33 ± 56 minutes/day of combined moderate, hard, and very hard daily activity. Women with a BMI ≥ 40 kg/m2 reported more time in sedentary/light activities and less hours of sleep than those with a lower BMI. Only 34% met national PA guidelines; this proportion was significantly lower among blacks (OR 0.5, CI 0.3–0.9).
These overweight and obese postpartum women reported a large percentage of time spent in sedentary/light activity, and a high proportion failed to meet minimal guidelines for PA. Promotion of PA in the postpartum period should focus on reducing sedentary behaviors and increasing moderate PA.
PMCID: PMC3613777  PMID: 21885890
physical activity assessment; obesity; epidemiology
25.  Predictors of Postpartum Weight Change Among Overweight and Obese Women: Results from the Active Mothers Postpartum Study 
Journal of Women's Health  2012;21(2):215-222.
The postpartum period may be critical for the development of midlife obesity. Identifying factors associated with postpartum weight change could aid in targeting women for healthy lifestyle interventions.
Data from Active Mothers Postpartum (AMP), a study of overweight and obese postpartum women (n=450), were analyzed to determine the effect of baseline characteristics, breastfeeding, diet, physical activity, and contraception on weight change from 6 weeks to 12, 18, and 24 months postpartum. The repeated measures mixed model was used to test the association of these effects with weight change.
Although mean weight loss was modest (0.49 kg by 24 months), the range of weight change was striking (+21.5 kg to −24.5 kg, standard deviation [SD] 7.4). Controlling only for baseline weight, weight loss was associated with breastfeeding, hormonal contraception, lower junk food and greater healthy food intake, and greater physical activity. Only junk food intake and physical activity were significant after controlling for all other predictors.
Eating less healthy foods and being less physically active put overweight and obese women at risk of gaining more weight after a pregnancy.
PMCID: PMC3525888  PMID: 22092110

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