Parental childhood growth and offspring birthweight: pooled analyses from four birth cohorts in low and middle income countries.

OBJECTIVE: Associations between parental and offspring size at birth are well established, but the relative importance of parental growth at different ages as predictors of offspring birthweight is less certain. Here we model parental birthweight and postnatal conditional growth in specific age periods as predictors of offspring birthweight. METHODS: We analyzed data from 3,392 adults participating in four prospective birth cohorts and 5,506 of their offspring. RESULTS: There was no significant heterogeneity by study site or offspring sex. 1SD increase in maternal birthweight was associated with offspring birthweight increases of 102 g, 1SD in maternal length growth 0-2 year with 46 g, and 1SD in maternal height growth Mid-childhood (MC)-adulthood with 27 g. Maternal relative weight measures were associated with 24 g offspring birth weight increases (2 year- MC) and 49 g for MC-adulthood period but not with earlier relative weight 0-2 year. For fathers, birthweight, and linear/length growth from 0-2 year were associated with increases of 57 and 56 g in offspring birthweight, respectively but not thereafter. CONCLUSIONS: Maternal and paternal birthweight and growth from birth to 2 year each predict offspring birthweight. Maternal growth from MC-adulthood, relative weight from 2-MC and MC-adulthood also predict offspring birthweight. These findings suggest that shared genes and/or adequate nutrition during early life for both parents may confer benefits to the next generation, and highlight the importance of maternal height and weight prior to conception. The stronger matrilineal than patrilineal relationships with offspring birth weight are consistent with the hypothesis that improving the early growth conditions of young females can improve birth outcomes in the next generation.

Prenatal famine, birthweight, reproductive performance and age at menopause: the Dutch hunger winter families study.

STUDY QUESTION: Is there an association between acute prenatal famine exposure or birthweight and subsequent reproductive performance and age at menopause? SUMMARY ANSWER: No association was found between intrauterine famine exposure and reproductive performance, but survival analysis showed that women exposed in utero were 24% more likely to experience menopause at any age. WHAT IS KNOWN ALREADY: Associations between prenatal famine and subsequent reproductive performance have been examined previously with inconsistent results. Evidence for the effects of famine exposure on age at natural menopause is limited to one study of post-natal exposure. STUDY DESIGN, SIZE, DURATION: This cohort study included men and women born around the time of the Dutch famine of 1944-1945. The study participants (n = 1070) underwent standardized interviews on reproductive parameters at a mean age of 59 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: The participants were grouped as men and women with prenatal famine exposure (n = 407), their same-sex siblings (family controls, n = 319) or other men and women born before or after the famine period (time controls, n = 344). Associations of famine exposure with reproductive performance and menopause were analysed using logistic regression and survival analysis with competing risk, after controlling for family clustering. MAIN RESULTS AND THE ROLE OF CHANCE: Gestational famine exposure was not associated with nulliparity, age at birth of first child, difficulties conceiving or pregnancy outcome (all P> 0.05) in men or women. At any given age, women were more likely to experience menopause after gestational exposure to famine (hazard ratio 1.24; 95% CI 1.03, 1.51). The association was not attenuated with an additional control for a woman's birthweight. In this study, there was no association between birthweight and age at menopause after adjustment for gestational famine exposure. LIMITATIONS, REASON FOR CAUTION: Age at menopause was self-reported and assessed retrospectively. The study power to examine associations with specific gestational periods of famine exposure and reproductive function was limited. WIDER IMPLICATIONS OF THE FINDINGS: Our findings support previous results that prenatal famine exposure is not related to reproductive performance in adult life. However, natural menopause occurs earlier after prenatal famine exposure, suggesting that early life events can affect organ function even at the ovarian level. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the NHLBI/NIH (R01 HL-067914). TRIAL REGISTRATION NUMBER: Not applicable.

Associations between maternal prepregnancy body mass index and child neurodevelopment at 2 years of age.

OBJECTIVE: Both underweight and obese mothers have an increased risk for adverse offspring outcomes. Few studies have examined the association between prepregnancy body mass index (BMI) and children's neurodevelopment. SUBJECTS: We used data from the nationally representative Early Childhood Longitudinal Study-Birth Cohort (ECLS-B; n=6850). Children were classified according to their mother's prepregnancy BMI (kg m(-2)) status: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese class I (BMI 30.0-34.9), and obese class II and III (BMI ≥35.0). Children's age-adjusted mental development index (MDI) and psychomotor development index (PDI) T-scores (mean 50, s.d. 10) were obtained using a validated shortened version of the Bayley Scales of Infant Development-II at approximately 2 years of age. While adjusting for sociodemographics, we estimated the average MDI and PDI scores or the risk of delayed (<-1 s.d. vs >1 s.d.) mental or motor development, relative to children of normal weight mothers. RESULTS: Compared with children of normal weight mothers, MDI scores were lower among children of mothers of all other prepregnancy BMI categories, with the greatest adjusted difference among children of class II and III obese mothers (-2.13 (95% CI -3.32, -0.93)). The adjusted risk of delayed mental development was increased among children of underweight (risk ratio (RR) 1.36 (95% CI 1.04, 1.78)) and class II and III obese (RR 1.38 (95% CI 1.03, 1.84)) mothers. Children's PDI scores or motor delay did not differ by maternal prepregnancy BMI. CONCLUSION: In this nationally representative sample of 2-year-old US children, low and very-high maternal prepregnancy BMI were associated with increased risk of delayed mental development but not motor development.

Differential influences of early growth and social factors on young children's cognitive performance in four low-and-middle-income birth cohorts (Brazil, Guatemala, Philippines, and South Africa).

BACKGROUND: Studies relating childhood cognitive development to poor linear growth seldom take adequate account of social conditions related to both, leading to a focus on nutrition interventions. We aimed to assess the roles of both biological and social conditions in determining early childhood cognition, mediated by birthweight and early linear growth. METHODS: After exploratory structural equation modelling to identify determining factors, we tested direct and indirect paths to cognitive performance through birthweight and child height-for-age at 2 years, assessed between 4 and 8.5 years of age among 2448 children in four birth cohort studies in low-and-middle-income countries (Brazil, Guatemala, Philippines and South Africa). Determinants were compared across the cohorts. FINDINGS: Three factors yielded excellent fit, comprising birth endowment (primarily maternal age and birth order), household resources (crowding, dependency) and parental capacity (parental education). We estimated their strength together with maternal height in determining cognitive performance. Percentage shares of total effects of the four determinants show a marked transition from mainly biological determinants of birth weight (birth endowment 34%) and maternal height (30%) compared to household resources (25%) and parental capacity (11%), through largely economic determinants of height at 2 years (household resources (60%) to cognitive performance being predominantly determined by parental capacity (64%) followed by household resources (29%). The largely biological factor, birth endowment (maternal age and birth order) contributed only 7% to childhood cognitive performance and maternal height was insignificant. In summary, the combined share of social total effects (household resources and parental capacity) rises from 36∙2% on birth weight, to 78∙2% on height for age at 24 m, and 93∙4% on cognitive functioning. INTERPRETATION: Across four low- and middle-income contexts, cognition in childhood is influenced more by the parental capacity of families and their economic resources than by birth weight and early linear growth. Improving children's cognitive functioning requires multi-sectoral interventions to improve parental education and enhance their economic wellbeing, interventions that are known to improve also early childhood growth.

Size at birth, infant, early and later childhood growth and adult body composition: a prospective study in a stunted population.

BACKGROUND: Pre-natal and post-natal growth are associated with adult body composition, but the relative importance of growth in different periods of childhood is still unclear, particularly in stunted populations. METHODS: We studied 358 women and 352 men measured as children in 1969-77 in four villages in Guatemala, and re-measured as adults in 2002-04 (mean age 32.7 years). We determined the associations of body mass index (BMI) and length at birth, and changes in BMI and length during infancy (0-1.0 year) and early (1.0-3.0 years) and later (3.0-7.0 years) childhood, with adult BMI ((a)BMI), percentage of body fat ((a)PBF), abdominal circumference ((a)AC) and fat-free mass ((a)FFM). RESULTS: Prevalence of stunting was high (64% at 3 years; HAZ < -2SD). Obesity (WHZ > 2SD) prevalence in childhood was <2%, while overweight prevalence in adulthood was 52%. BMI at birth was positively associated with (a)BMI and (a)FFM while length at birth was positively associated with (a)AC and (a)FFM. Increased BMI in infancy and later childhood were positively associated with all four adult body composition measures; associations in later childhood with fatness and abdominal fatness were stronger than those with (a)FFM. Change in length during infancy and early childhood was positively associated with all four adult body composition outcomes; the associations with (a)FFM were stronger than those with fat mass. CONCLUSIONS: Increases in BMI between 3.0 and 7.0 years had stronger associations with adult fat mass and abdominal fat than with (a)FFM; increases in length prior to age 3.0 years were most strongly associated with increases in (a)FFM.

Nutrition status of children in Latin America.

The prevalence of overweight and obesity is rapidly increasing among Latin American children, posing challenges for current healthcare systems and increasing the risk for a wide range of diseases. To understand the factors contributing to childhood obesity in Latin America, this paper reviews the current nutrition status and physical activity situation, the disparities between and within countries and the potential challenges for ensuring adequate nutrition and physical activity. Across the region, children face a dual burden of undernutrition and excess weight. While efforts to address undernutrition have made marked improvements, childhood obesity is on the rise as a result of diets that favour energy-dense, nutrient-poor foods and the adoption of a sedentary lifestyle. Over the last decade, changes in socioeconomic conditions, urbanization, retail foods and public transportation have all contributed to childhood obesity in the region. Additional research and research capacity are needed to address this growing epidemic, particularly with respect to designing, implementing and evaluating the impact of evidence-based obesity prevention interventions.

Risk factors affecting child cognitive development: a summary of nutrition, environment, and maternal-child interaction indicators for sub-Saharan Africa.

An estimated 200 million children worldwide fail to meet their development potential due to poverty, poor health and unstimulating environments. Missing developmental milestones has lasting effects on adult human capital. Africa has a large burden of risk factors for poor child development. The objective of this paper is to identify scope for improvement at the country level in three domains--nutrition, environment, and mother-child interactions. We used nationally representative data from large-scale surveys, data repositories and country reports from 2000 to 2014. Overall, there was heterogeneity in performance across domains, suggesting that each country faces distinct challenges in addressing risk factors for poor child development. Data were lacking for many indicators, especially in the mother-child interaction domain. There is a clear need to improve routine collection of high-quality, country-level indicators relevant to child development to assess risk and track progress.

Sex differences in obesity incidence: 20-year prospective cohort in South Africa.

BACKGROUND: Prospective data spanning childhood and adolescence are needed to better understand obesity incidence among children and to identify important periods for intervention. OBJECTIVE: To describe gender differences in overweight and obesity from infancy to late adolescence in a South African cohort. METHODS: We analysed body mass index at 1-2 years, 4-8 years, 11-12 years, 13-15 years and 16-18 years among 1172 participants in the South African Birth-to-Twenty cohort. RESULTS: Among boys, overweight and obesity prevalence declined from age 1-2 years to 16-18 years. Among girls, overweight and obesity prevalence increased from 4-8 years to 16-18 years. Obesity incidence was highest from 4-8 years to 11-12 years in boys (6.8 cases per 1000 person-years) and from 11-12 years to 13-15 years in girls (11.2 cases per 1000 person-years). Among girls, obesity at 16-18 years was associated with overweight (odds ratio [OR] = 3.6; 95% confidence interval [CI] 1.8-7.2) or obesity (OR = 8.0; 95% CI 3.7-17.6) at 1-2 years and overweight (OR = 6.8; 95% CI 3.3-13.9) or obesity (OR = 42.3; 95% CI 15.0-118.8) at 4-8 years; for boys, obesity at 16-18 years was associated with overweight at 1-2 years (OR = 5.6; 95% CI 1.7-18.0) and obesity at 4-8 years (OR = 19.7; 95% CI 5.1-75.9). CONCLUSIONS: Among girls, overweight and obesity increased throughout childhood. Overweight and obesity were not widely prevalent among boys. Early childhood and post-puberty may be important periods for intervention among girls.

Is there a relationship between dietary fat and stature or growth in children three to five years of age?

STUDY OBJECTIVE: To determine whether a moderately reduced fat diet affects the stature or growth of healthy preschool children. DESIGN: Cohort study with mean of 25 months of follow-up. SETTING: Primary care pediatrics practice at a large urban medical center. SUBJECTS: A predominantly Hispanic group of 215 children aged 3 to 4 years at baseline. MEASUREMENTS AND MAIN RESULTS: The children's diet was assessed using four 24-hour recalls and three Willett semiquantitative food-frequency questionnaires administered to the children's mothers over a 1-year baseline period. Stature was defined in terms of height, weight, and body mass index at baseline. Growth was defined in terms of change during follow-up in height, weight, and body mass index. Total fat provided a mean of 27.1% of caloric intake in the lowest quintile of intake compared with 38.4% in the highest quintile. There were no differences in stature or growth across quintiles of children defined by consumption of total fat, saturated fat, or cholesterol. These findings were consistent across the two methods of diet assessment. Children who consumed a smaller percentage of total calories from fat consumed significantly less total calories, saturated fat, cholesterol, calcium, and phosphorus, as well as more carbohydrates, iron, thiamine, niacin, vitamin A, and vitamin C. CONCLUSIONS: These data support the safety of a moderately reduced fat diet in healthy preschool children. Maintenance of calcium and phosphorus intake should be part of any program of dietary fat reduction. Substitution of low-fat milk for whole milk, rather than elimination of whole milk, is one such strategy.

Variability and self-regulation of energy intake in young children in their everyday environment.

Recent data from small numbers of children studied under controlled protocols indicate that intraindividual variation in energy consumption over 24 hours is smaller than variation from eating occasion to eating occasion, implying that children self-regulate their energy consumption. This hypothesis was tested in children living in their everyday environment. Between 1986 and 1989, 24-hour recalls were administered on seven occasions (four times in 1986 through 1987 and three times in 1988 through 1989) to the mothers of 181 preschool children in New York City. Each 24-hour period was divided into six meals or snacks. The coefficient of variation (standard deviation divided by the mean) was calculated for each child for energy consumption at each eating occasion and for the day as a whole. Coefficients of variation for energy consumption at the six eating occasions ranged from 46.5% to 165.8%, compared with 30.3% for the whole day. This coefficient of variation for the observed whole-day energy consumption was significantly less (P < .001) than would be expected if no autoregulation of energy intake (no meal-to-meal correlation) occurred. These findings in children living in their everyday environment are consistent with observations under more controlled study conditions. These data suggest that children who eat less at one meal compensate at another, although the data do not address the issues of longer term energy self-regulation, overall energy balance, or diet quality.

The rate of increase in blood pressure in children 5 years of age is related to changes in aerobic fitness and body mass index.

OBJECTIVE: To determine whether changes in aerobic fitness and body mass index are related to the age-related rise in blood pressure in healthy preschool children. STUDY DESIGN: Longitudinal analyses of 196 free-living children aged 5 years at baseline who were followed over a mean of 19.7 months. Aerobic fitness was assessed using a treadmill. All measures were obtained on multiple occasions at scheduled visits as part of a longitudinal cohort study. SETTING: An inner-city medical center. OUTCOME MEASURES: Blood pressure was measured using an automated Dinamap device. RESULTS: Mean systolic blood pressure was 95.3 mmHg (SD 8.38) at baseline and increased by 4.46 mmHg per year. Mean diastolic blood pressure was 53.9 mmHg (SD 5.81) at baseline and did not change significantly. Children in the highest quintile of increase in fitness had a significantly smaller increase in systolic blood pressure compared to children in the lowest quintile (2.92 vs 5.10 mmHg/year; P = .03). Children in the lowest quintile of increase in body mass index did not differ significantly in rate of increase in systolic blood pressure compared to children in the highest quintile (3.92 vs 4.96 mmHg/year). In a multiple regression model including baseline systolic blood pressure, fitness, height, body mass index, and other covariates, greater increase in fitness (P = .03) and lesser increase in body mass index (P < .01) were associated with lower rates of increase in systolic blood pressure. In a similar multivariate analysis, an increase in fitness was also associated with a lower rate of increase in diastolic blood pressure (P = .02). CONCLUSION: Young children who increase their aerobic fitness or decrease their body mass index reduce the rate of the age-related increase in blood pressure. These observations may have implications for development of interventions directed at the primary prevention of hypertension.

Reproducibility of the women's module of the Behavioral Risk Factor Surveillance System questionnaire.

The Behavioral Risk Factor Surveillance System (BRFSS) is designed to provide statewide estimates of the prevalence of preventive health practices, including screening. We assessed the reproducibility of responses to the women's health module, which covers breast and cervical cancer screening, hysterectomy, and pregnancy. A random sample of women in Massachusetts (n = 91; response rate for the repeat interview, 70.0%) and a separate random sample of minority women in the state (n = 179; response rate for the repeat interview, 69.4%) were interviewed by telephone twice, 21 to 94 days apart. Differences across administrations in mean prevalence of screening were small. Concordance exceeded 85% for almost all the variables examined, but tended to be lower for nonwhite respondents. After correction for agreement occurring by chance, moderate to excellent values of kappa (range, 0.41 to 0.86) were observed. The women's health module of the BRFSS questionnaire yields highly consistent group mean estimates of prevalence when administered repeatedly to the same individuals. Individual reproducibility is excellent, but may be reduced among minority respondents.

Familial and sporadic human renal cell carcinoma: evidence against a double-loss mechanism of carcinogenesis.

It has been speculated that renal cell carcinoma (RCC) is an example of a double-loss mutation. We analyzed the age distribution of 71 cases of familial RCC and of 11 population-based cancer registries [German Democratic Republic, Denmark, Finland, Norway, Sweden, U.S.A. Whites, U.S.A. Blacks, Miyagi and Osaka Prefectures (Japan), Hong Kong, and Israeli Jews] according to the multi-hit and clonal growth models of carcinogenesis. The analysis rules out a double-loss mechanism for RCC. On both of the two models analyzed, carcinogenesis in the familial cases of RCC arises as a result of a three- to ten-fold increase in the average rate of mutation at the susceptible loci, as compared with the sporadic cases. In general, the clonal growth model provides a somewhat better fit to the age-distribution of RCC incidence than does the multi-hit model.

Prevention-oriented life styles and diffusion of cholesterol screening and awareness: Massachusetts behavioral risk factor survey, 1987-1991.

Universal screening of the adult population for detection of elevated serum cholesterol has been recommended. We examined the relation of eight risk factors for morbidity and mortality (hypertension, overweight, inactivity, tobacco use, safety belt nonuse, binge alcohol consumption, driving after alcohol consumption, and chronic alcohol consumption) to adoption of cholesterol screening and to awareness of cholesterol level. Data were collected through the Massachusetts Behavioral Risk Factor Surveillance System between 1987 and 1991 (mean number of respondents interviewed annually, 1240). We compared trends in prevalence of cholesterol screening and awareness within risk groups defined on the basis of the presence or absence of each risk factor. Cholesterol screening prevalence increased from 46.8% in 1987 to 67.9% in 1991. Overweight and hypertensive respondents were more likely to have been screened than nonoverweight or normotensive respondents; for the other six risk factors, individuals at increased risk were less likely to have been screened. The difference in cholesterol screening prevalence between increased-risk and lower-risk respondents increased between 1987-1988 and 1990-1991 for four risk factors. Prevalence of awareness of cholesterol level increased from 7.8% in 1987 to 35.4% in 19991. Trends by risk status were comparable to those observed for cholesterol screening. Individuals already motivated toward a preventive life style appear to be those most likely to avail themselves of a new prevention possibility.

Maternal recall of birthweights of adult children: validation by hospital and well baby clinic records.

BACKGROUND: Several studies have suggested that maternal recall of offspring birthweight compares well to data from birth certificates or medical records. However, these studies describe relatively short recall periods and pertain to populations where hospitalized childbirth is the norm. Accuracy of maternal recall has not been confirmed after long recall periods or in populations where non-hospitalized childbirth is common. METHODS: Accuracy of recalled birthweights is assessed among 626 women interviewed at an average age of 43.3 years (standard deviation [SD] 1 year), at which time the average age of their 1297 offspring was 17.9 years (range 1-29 years, SD 4.8 years). One-third of these infants were delivered at home. Recalled birthweight was compared to hospital or Well Baby clinic records, available for 66% (861/1297) of all births. RESULTS: Record availability was not related to birthweight. For the 861 infants for whom both sources were available mean recorded birthweight was 3342 g (SD 586 g) and mean recalled birthweight 3340 g (SD 675 g). Recalled weights overestimated recorded weights by 109 g (95% Cl: 68-151) among infants weighing > 3750 g and underestimated recorded weights by 83 g (95% Cl: 54-111) among infants weighing < or = 3250 g. CONCLUSIONS: As an outcome variable recalled birthweights were unbiased, but less precise than recorded birthweights. Use of recalled birthweight does not sacrifice study power however and may increase generalizability provided recalled weights are available for 30% more infants than recorded weights. For individual birthweight assessment and for use as an independent variable recalled weights are biased and may have to be adjusted using recorded data as available.

A survey of doctors' and nurses' knowledge, attitudes and compliance with infection control guidelines in Birmingham teaching hospitals.

This study investigated knowledge about infection control amongst doctors and nurses through a cross-sectional survey conducted between March and May 2001 in three Birmingham, UK teaching hospitals. Seventy-five doctors and 143 nurses, representing 7% and 4%, respectively, of potential respondents, participated in the study measuring knowledge of, attitudes towards, and compliance with universal precautions. Overall knowledge of risks of blood-borne virus (BBV) transmission from an infected patient after needlestick injury was low [44.0% for hepatitis B virus (HBV), 38.1% for hepatitis C virus (HCV), 54.6% for human immunodeficiency virus (HIV)]. There were significant differences between doctors and nurses concerning the estimations of HBV (e-antigen +) (P=0.006) and HIV (P<0.001) transmission risks. Eighty-six percent of nurses stated that they treat each patient as if they are carrying a BBV compared with 41% of doctors. Doctors and nurses differed significantly in their attitudes about and reported compliance with washing hands before and after patient contact and with wearing gloves when taking blood (P<0.001 for all). Doctors consistently de-emphasized the importance of, and reported poor compliance with, these procedures. Doctors were also more likely to state that they re-sheath used needles manually than were nurses (P<0.001). Thirty-seven percent of respondents reported that they had suffered a needlestick injury with a used needle, with doctors more likely to be injured than nurses (P=0.005). Twenty-eight percent of these doctors and 2% of the nurses did not report their needlestick injuries (P=0.004). Education, monitoring, improved availability of resources, and disciplinary measures for poor compliance are necessary to improve infection control in hospitals, especially amongst doctors.

Financial incentives, participation in employer-sponsored health promotion, and changes in employee health and productivity: HealthPlus Health Quotient Program.

Employer-sponsored health promotion can improve employee health and morale and reduce medical claims and absenteeism. Effectiveness depends on the participation of those employees who are at increased risk of ill health. HealthPlus Health Quotient is an incentive/disincentive approach to health promotion. The employer's contribution to the employee cafeteria-plan benefit package is adjusted on the basis of an annual health risk appraisal. We evaluated whether this financial incentive/disincentive predicted participation in health promotion activities, and whether participation improved future health risk and productivity. In the first year, participation was proportional to overall health risk (P < 0.01). Participation in targeted programs was proportional to levels of body fat, cholesterol, and blood pressure. Participation in activity-related health promotion was proportional to prior-year activity or fitness scores. Health promotion participants improved their subsequent-year health risk more than did non-participants. Participation was associated with reduced illness-related absenteeism and (although inconsistently) with medical claims paid and short-term disability.

Pre-pregnant body size and spontaneous abortion of known karyotype.

We examined the relation of pre-pregnancy body size to chromosomally normal and chromosomally aberrant spontaneous abortion. Data derive from a hospital based case-control study of spontaneous abortion in the public and private facilities of three New York City hospitals. Chromosomally normal (n = 1265) and chromosomally aberrant (n = 872) spontaneous abortions (cases) were compared with 3795 women attending prenatal care before 22 weeks of gestation and delivering at 28 weeks or later (controls). Data on height and pre-pregnant weight were obtained by interview and Body Mass Index (BMI, weight/height squared) was computed. Associations were consistent across payment strata with disparate sociodemographic characteristics. BMI was similar in chromosomally normal cases and controls (pooled adjusted mean difference = 0.21 kg/m squared, 95% CI -0.06, 0.48) and reduced in chromosomally aberrant cases compared with controls (pooled adjusted mean difference = -0.29 kg/m squared, 95% CI -0.58, 0.00). These associations are unlikely to be due to reporting bias. However, they were of small magnitude and the association with chromosomally aberrant loss did not differ from that with chromosomally normal loss, nor was it specific to one, or even two, types of aberration. We therefore infer that, in relatively well nourished populations, low pre-pregnant body size does not increase the risk of either chromosomally normal or chromosomally aberrant spontaneous abortion.

Carrots and sticks: impact of an incentive/disincentive employee flexible credit benefit plan on health status and medical costs.

PURPOSE: Employee wellness programs aim to assist in controlling employer costs by improving the health status and fitness of employees, potentially increasing productivity, decreasing absenteeism, and reducing medical claims. Most such programs offer no disincentive for nonparticipation. We evaluated an incentive/disincentive program initiated by a large teaching hospital in western Michigan. METHODS: The HealthPlus Health Quotient program is an incentive/disincentive approach to health promotion. The employer's contribution to the cafeteria plan benefit package is adjusted based on results of an annual appraisal of serum cholesterol, blood pressure, tobacco use, body fat, physical fitness, motor vehicle safety, nutrition, and alcohol consumption. The adjustment (health quotient [HQ]) can range from -$25 to +$25 per pay period. We examined whether appraised health improved between 1993 and 1996 and whether the HQ predicted medical claims. RESULTS: Mean HQ increased slightly (+$0.47 per pay period in 1993 to +$0.89 per pay period in 1996). Individuals with HQs of less than -$10 per pay period incurred approximately twice the medical claims of the other groups (test for linear trend, p = .003). After adjustment, medical claims of employees in the worst category (HQ < -$10 per pay period) were $1078 (95% confidence interval $429-$1728) greater than those for the neutral (HQ between -$2 and +$2 per pay period) category. A decrease in HQ of at least $6 per pay period from 1993 to 1995 was associated with $956 (95% confidence interval $264-$1647) greater costs in 1996 than was a stable HQ. CONCLUSIONS: The HealthPlus Health Quotient program is starting to yield benefits. Most employees are impacted minimally, but savings are accruing to the employer from reductions in medical claims paid and in days lost to illness and disability.