Experience Implementing a Public Health Surveillance System Designed for Fathers of Infants on a South Dakota American Indian Reservation.

INTRODUCTION: Paternal behaviors and attitudes during pregnancy are not known. A health survey for fathers of recently born infants was developed to be administered concurrently with a maternal survey to assess parental behaviors and attitudes before, during and after pregnancy. METHODS: Participants were parents of 149 American Indian infants born from April 1 and Dec. 31, 2015 who were recruited prospectively from data of all births in prespecified reservation counties representing Sisseton Wahpeton Oyate of the Lake Traverse Reservation. Data collection was via hard-copy or online survey. RESULTS: Response rate among mothers was 62 percent (n=92). Of 149 births, 126 listed a father on the birth certificate and 51 percent (n=64) of these completed surveys on average 4.7 months post-birth. Healthwise, 90 percent of fathers reported being overweight or obese, but a small percent visited a health care worker in the previous year to be checked for diabetes (11 percent) or hypertension (14 percent). Among fathers who smoked in the last two years (73 percent), 77 percent of the mothers also smoked compared to 20 percent of mothers smoking if the father did not smoke. Nearly three-fourths of fathers were supportive of breastfeeding (70 percent), and mothers whose partners were supportive were more likely to breastfeed than those with unsupportive partners (91 percent vs. 50 percent, respectively. The majority of fathers attended prenatal visits (57 percent), the delivery (88 percent), and some or all well-baby checks (73 percent) with the main barrier stated as not being able to take time off work. CONCLUSION: Conducting a health survey with both fathers and mothers in a reservation setting is feasible and the father's attitudes and behaviors related to breastfeeding and smoking were associated with maternal health behaviors. Most fathers attended health care visits with the mother, but they were not being screened for health conditions despite a large proportion being overweight and smokers. Prenatal and antenatal visits may provide an opportune time to engage fathers and address paternal health issues.

Safe Sleep Behaviors Among South Dakota Mothers and the Role of the Healthcare Provider.

INTRODUCTION: The purpose of this report was to determine the prevalence of safe sleep practices among South Dakota mothers, and the impact that education from their healthcare provider had on infant safe sleep practices as defined by the American Academy of Pediatrics (AAP). METHOD: A population-based survey was administered to a random sample of mothers delivering in 2017. Data were weighted to obtain statewide and race-specific (white, non-Hispanic; American Indian; other races) prevalence rates. RESULTS: Weighted response rate was 67 percent, with 9.9 percent of mothers giving birth in 2017 completing a survey. Greater than 85 percent of mothers met recommendations regarding placing their infant on their back, breastfeeding, not consuming alcohol or illicit drugs during pregnancy, and attending 80 percent or more of prenatal visits. Less than 85 percent met recommendations regarding infant always sleeping alone on an approved sleep surface (30.8 percent), room-sharing without bed-sharing (44.3 percent), keeping soft objects and loose bed- ding out of crib (47.7 percent), and avoiding smoke exposure during and after pregnancy (82.1 percent). Only 7.7 percent of mothers met all eight recommendations. Healthcare providers talking to the mother about placing the infant to sleep in a crib and placing the crib in the mother's room were associated with a higher percent of mothers meeting these recommendations. Although the health care provider asking the mother if she was going to breastfeed was not associated with ever breastfeeding (p=0.95), if the mother received information from the doctor about breastfeeding she was slightly more likely to breastfeed than if she did not receive information (90.3 vs. 85 percent, p=0.06). CONCLUSIONS: A low percentage of South Dakota mothers met all eight AAP safe sleep recommendations that could be assessed using these data. Health care providers can influence a mother's compliance with some of the safe sleeping recommendations.

Feasibility and Effects on Muscle Function of an Exercise Program for Older Adults.

INTRODUCTION: Study objective was to determine feasibility and compliance with a 3-month exercise intervention in older adults, and if peripheral quantitative computed tomography muscle measures and jumping mechanography could detect changes in muscle mass and function. METHODS: A parallel group, nonblinded, pilot trial with individuals 70 yr or older randomized to control group of walking-only (WALK) or an intervention group of walking combined with exercises to improve balance and strength (W + EX). Both groups attended similar weekly nutrition education sessions. Body composition, muscle density, intramuscular adipose tissue area, and muscle function were assessed before and after the intervention using dual-energy x-ray, peripheral quantitative computed tomography, functional tests, and mechanography. RESULTS: Eighty-five (90%) of 94 individuals enrolled completed (41WALK, 44W + EX). Eighty-six percent of participants attended seven or more nutrition sessions, and log sheets, used to assess exercise compliance, were returned by 66% of participants, and of those, 88% logged activity on 50%+ days. Sixty-seven percent of participants stated that they increased activity levels, and 82% stated that they felt better overall. Both groups increased lean and lost fat mass, resulting in decreases in fat percentage (all, P < 0.05). Intramuscular adipose tissue area decreased and muscle density increased among WALK (P < 0.05 and P = 0.056, respectively) but were not different between groups. Improvement in force efficiency and chair-rise power were greater among W + EX group than WALK (5.9% ± 1.8% vs -1.2% ± 2.0% [P = 0.01] and 0.25 ± 0.19 W·kg and -0.37 ± 0.23 W·kg [P = 0.04], respectively). Differences in mechanography results became greater in a per-protocol analysis. CONCLUSIONS: A larger trial is feasible, and the program was well accepted. Both groups showed improvements, the program that included strength and balance lead to greater jump force efficiency and power than walking only. Whether these differences lead to differences in fall rates need to be determined in a larger trial.

Cross-Sectional and Longitudinal Association between Glycemic Status and Body Composition in Men: A Population-Based Study.

This study sought to evaluate the associations between changes in glycemic status and changes in total body (TB), trunk, and appendicular fat (FM) and lean mass (LM) in men. A population-based study of men aged 20⁻66 years at baseline were included in cross-sectional (n = 430) and three-year longitudinal (n = 411) analyses. Prediabetes was defined as fasting glucose 100⁻125 mg/dL. Type 2 diabetes (T2D) was determined by: self-reported diabetes, current anti-diabetic drug use (insulin/oral hypoglycemic agents), fasting glucose (≥126 mg/dL), or non-fasting glucose (≥200 mg/dL). Body composition was evaluated by dual-energy X-ray absorptiometry. Longitudinal analyses showed that changes in TB FM and LM, and appendicular LM differed among glycemic groups. Normoglycemic men who converted to prediabetes lost more TB and appendicular LM than men who remained normoglycemic (all, p < 0.05). Normoglycemic or prediabetic men who developed T2D had a greater loss of TB and appendicular LM than men who remained normoglycemic (both, p < 0.05). T2D men had greater gains in TB FM and greater losses in TB and appendicular LM than men who remained normoglycemic (all, p < 0.05). Dysglycemia is associated with adverse changes in TB and appendicular LM.

Pregnancy Survey of Smoking and Alcohol Use in South Dakota American Indian and White Mothers.

INTRODUCTION: American Indian populations are believed to have relatively high tobacco use and alcohol consumption before and during pregnancy compared with other populations despite little evidence. METHODS: Population-based survey distributed 2-6 months postpartum to 1,814 South Dakota mothers having a live birth in 2014. Prevalence of self-reported smoking and alcohol use before and during pregnancy were calculated for American Indian and white mothers and AORs were determined controlling for Hispanic status, marital status, age, education, and income. Analysis was completed in 2017-2018. RESULTS: Smoking among American Indian mothers was similar to white mothers before and during pregnancy (AOR=1.60, 95% CI=0.95, 2.67 and AOR=0.67, 95% CI=0.37, 1.21, respectively). Among smokers, a higher percentage of American Indian mothers smoked less than six cigarettes/day than white mothers (AOR=6.79, 95% CI=3.21, 14.35, before and AOR=4.85, 95% CI=1.08, 21.7, during pregnancy), and American Indian mothers had greater odds of quitting (AOR=3.60, 95% CI=1.74, 7.43). No difference in relapse rates by race were found (AOR=0.57, 95% CI=0.19, 1.72). Alcohol consumption before pregnancy was less among American Indian than white mothers (AOR=0.53 95% CI=0.30, 0.94), and among those who drank no differences by race in drinks/week were observed (AOR for American Indians drinking more than four drinks/week=1.20, 95% CI=0.56, 2.55) or binge drinking (AOR=1.50, 95% CI=0.75, 3.04). Rates of alcohol consumption during pregnancy and topics covered by healthcare providers during prenatal visits did not differ by race. CONCLUSIONS: After adjusting for covariates, no differences by race in smoking rates before or during pregnancy were observed and American Indian mothers who smoked were more likely to smoke fewer cigarettes and quit smoking during pregnancy than white mothers. Lower alcohol consumption among American Indian mothers before pregnancy challenges the commonly held belief of elevated alcohol consumption among American Indians compared with other races.

Longitudinal Growth and pQCT Measures in Hutterite Children and Grandchildren Are Associated With Prevalence of Hip or Knee Replacement Resulting From Osteoarthritis in Parents and Grandparents.

BACKGROUND: Osteoarthritis (OA) is one of the leading causes of disability in the world. Several genes are associated with the development of OA, and previous studies have shown adult children of individuals with OA have higher areal bone mineral density (BMD). Because childhood is an important period of growth and bone development, and body composition is known to be associated with BMD, we speculated that there may be differences in growth and bone measures among young children with a genetic predisposition to OA. QUESTIONS/PURPOSES: (1) Do differences exist at baseline in anthropometric and peripheral quantitative CT (pQCT) measurements between children and grandchildren of individuals with OA and controls? (2) Do children and grandchildren of individuals with OA accrue bone longitudinally at a different rate than controls? METHODS: Longitudinal anthropometric (height, weight) and bone (cortical and trabecular volumetric BMD and cross-sectional area) measurements by pQCT were obtained at baseline and 18 and 36 months on children (n = 178) and grandchildren (n = 230) of 23 individuals with hip or knee arthroplasty resulting from OA and 23 sex-matched controls (16 females each). Grandchildren (age, 8-30 years) were further categorized as growing (premenarcheal or male < 14 years, n = 99) or mature (≥ 2 years postmenarchal or males ≥ 18 years, n = 96). The remaining 35 grandchildren could not be categorized and were excluded. RESULTS: Mature granddaughters and grandsons of individuals with OA had greater trabecular volumetric BMD than controls (236 ± 24 and 222 ± 26 mg/cm, respectively, for granddaughters, difference of 14 [95% confidence interval {CI}, 1-28] mg/cm, p = 0.041 and 270 ± 22 and 248 ± 30 mg/cm, respectively, for grandsons, difference of 22 [95% CI, 1-42] mg/cm, p = 0.040). Greater trabecular volumetric BMD was observed in daughters of individuals with OA compared with daughters of controls (228 ± 28 and 212 ± 33 mg/cm, respectively, difference of 18 [95% CI, 3-30] mg/cm, respectively [p = 0.021]). Growing granddaughters and grandsons of controls had greater decreases in cortical volumetric BMD than grandchildren of individuals with OA (time-by-group [TG] based on mixed model [± standard error] -9.7 ± 4.3 versus -0.8 ± 4.4 mg/cm/year, respectively, for granddaughters, difference of 9.0 [95% CI, 2.4-15.5] mg/cm/year, p = 0.007 and -6.8 ± 3.3 versus 4.5 ± 3.4 mg/cm/year, respectively, for grandsons, difference of 11.3 [95% CI, 4.3-18.3] mg/cm/year, p = 0.002). Cortical volumetric BMD was maintained in sons of individuals with OA, but decreased in sons of controls (-0.0 ± 1.5 versus -4.3 ± 1.0 mg/cm/year, respectively, difference of 4.3 [95% CI, 0.7-7.8] mg/cm/year, p = 0.019 [TG]). There was a greater apparent decrease in cross-sectional area among daughters of individuals with OA than in controls (-4.6 ± 0.9 versus -1.7 ± 0.9 mm/year, respectively, difference of -2.9 [95% CI, -5.3 to -0.6] mm/year, p = 0.015 [TG]). CONCLUSIONS: Several anthropometric and bone differences exist between children and grandchildren of individuals with OA and controls. If these differences are confirmed in additional studies, it would be important to identify the mechanism so that preventive measures could be developed and implemented to slow or reduce OA development. CLINICAL RELEVANCE: Differences in growth and bone development may lead to increased loads on cartilage that may predispose offspring to the development of OA. If these differences are confirmed in additional studies, it would be important to identify the mechanism so that preventive measures could be developed and implemented to slow or reduce OA development.

Sports Participation in High School and College Leads to High Bone Density and Greater Rates of Bone Loss in Young Men: Results from a Population-Based Study.

Estimated lifetime risk of an osteoporotic fracture in men over the age of 50 years is substantial and lifestyle factors such as physical activity may explain variation in bone mass and bone loss associated with aging. Men (n = 253) aged 20-66 years were followed for 7.5 years and factors that influence changes in means and rates of change in bone mass, density, and size using dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) were investigated; in particular, seasons of sports participation during high school and college. Men with greater sports participation had higher total hip bone mineral content (BMC) (48.4 ± 0.9 and 48.6 ± 0.9 g for 7-12 and 13+ seasons vs. 45.6 ± 0.8 and 45.4 ± 0.7 g for 0 and 1-6 seasons, respectively p < 0.05) and areal bone mineral density (aBMD) (1.082 ± 0.015 and 1.087 ± 0.015 g/cm2 for 7-12 and 13+ seasons vs. 1.011 ± 0.015 and 1.029 ± 0.013 g/cm2 for 0 and 1-6 seasons, respectively p < 0.05) than men who participated in less sport-seasons. However, men with higher sports participation also had greater rates of bone loss in their mid-twenties at the hip (BMC - 0.8 and - 1.2% and aBMD - 0.8 and - 0.9% for 7-12 and 13+ seasons of sport participation, respectively) compared to those with 0 seasons of sport participation (BMC - 0.6% and aBMD - 0.6%) (all p < 0.05). Similar results were observed for femoral neck aBMD. Men with 7+ seasons of sport participation had higher cross-sectional area at the 20% distal radius site than those with no sports participation (all p < 0.05). These findings support significant effects of high school and/or college sports participation on bone mass and geometry in men throughout adulthood.

Response to an Online Version of a PRAMS-like Survey in South Dakota.

Objectives Increasing response rates for research surveys is challenging, especially in minority populations. A unique minority group in South Dakota is the American Indian (AI) representing about 9 % of the state's population and 15 % of the births. The purpose of this study was to determine race differences among White, AI, and Other Races (OR) in contact, participation, and response rates in the South Dakota Pregnancy Risk Assessment Monitoring System (SDPRAMS). We determined response rates of an online version and evaluated demographic characteristics associated with online response. Methods The SDPRAMS was sent to 1814 mothers randomly sampled from 2014 birth certificate files. Results The weighted response rate was 71.3 %, and varied significantly among the three races: 79.1 % for White race, 48.6 % for AI race, and 60.6 % for OR (p < 0.01). A higher percent of White mothers responded online than AI and OR (35, 25 and 26 %, respectively; p = 0.001); no difference between AI and OR. Online responders were more likely to be married, educated beyond high school and having annual incomes ≥$25,000 (p ≤ 0.01 for all), but only education (p < 0.001) and income (p = 0.05) remained significant in the logistic models. 26 % of White, 43 % of AI, and 46 % of OR online respondents used a smartphone to respond (p = 0.01). Conclusions Response rates differed among races. An online version of the PRAMS is a viable method of response to offer participants. Response to the online version via smartphone may increase response from minority populations, emphasizing the importance of mobile friendly formats.

Rural vs. non-rural differences and longitudinal bone changes by DXA and pQCT in men aged 20-66 years: A population-based study.

The purpose of this research was to determine whether there were differences in estimated means and rates of change in BMC, bone area, BMD and measures of bone geometry among men (n=544) from three distinct populations (Hutterite [rural], rural non-Hutterite, non-rural), and whether activity levels or calcium intake explain these population differences. Men were enrolled in the South Dakota Rural Bone Health Study and followed for 7.5 years to estimate means and rates of change in bone mass, density, size and geometry. Femoral neck (FN) and spine measurements were obtained every 18 months by DXA and distal radius (4% and 20%) measurements by pQCT. Activity measurements and calcium intake were obtained quarterly for the first 3 years and at 54, 72, and 90 months. Rural men had greater percent time in moderate plus vigorous activity (mean ± SD: 22 ± 10 vs. 15 ± 8%, p<0.001) and greater lean mass (69 ± 9 vs. 66 ± 10 kg, p=0.05) than non-rural men. Both rural populations (Hutterite and rural men) had larger femoral neck (FN) bone area and greater 20% radius cross-sectional area than non-rural men ([least square means ± SE] FN area: 5.90 ± 0.02 and 5.86 ± 0.02 vs. 5.76 ± 0.03 cm(2), p<0.001 and p=0.03 respectively and cross-sectional area: 171.0 ±1.3 and 165.5 ± 1.5 vs. 150.3 ± 1.6mm(2), both p<0.001). Despite lower cortical vBMD in Hutterite and rural men compared to non-rural men (1182 ± 2 and 1187 ± 2 vs. 1192 ± 2 mm(2), p<0.001 and p=0.06 respectively), bone strength (pSSI) was greater (429 ± 5 and 422 ± 5 vs. 376 ± 6 mm(3), both p<0.001). The rates of change in femoral neck BMC and aBMD and trabecular vBMD also differed by rural lifestyle, with greater losses among non-rural men in their 20s and 60s compared to both Hutterite and rural populations (time-by-age-by-group interactions, both p<0.01). Physical activity was not found to be a potential mediator of population differences. Baseline calcium intake was associated with FN aBMD (p=0.04), and increases in calcium intake were associated with spine BMC (p=0.04) and inversely associated with cortical area (p=0.02). There was some evidence for mediation by either baseline calcium intake or changes in calcium intake over the study period, but the influence on population differences were negligible. We speculate that rural-non-rural differences in bone occur earlier in life or are a result of factors that have not yet been identified.

Do Sex Differences Exist in Rates of Falls and Fractures in Hutterite, Rural, and Nonrural Populations, Aged 20 to 66 Years?

BACKGROUND: Falls and fractures are a major public health concern with an economic impact of more than USD 19 billion per year. Extensive research into the risk of falls and fractures in elderly populations has been performed; however, little is known about fall or fracture risk in younger populations. Additionally, sex- and population-specific (rural versus nonrural) fall and fracture risk may be important in identifying groups most at risk in an effort to develop preventive measures. QUESTIONS/PURPOSES: The purpose of this study was to determine whether sex and population (rural versus nonrural) differences exist in fall and fracture rates. METHODS: Data from 1256 (538 men) participants of the South Dakota Rural Bone Health Study, a population-based cohort study, including those living a rural lifestyle (n=349 non-Hutterites and 572 Hutterites) and a nonrural lifestyle (n=335), were used to address our a priori hypotheses. Health histories, physical activity recall, anthropometric measurements, and dual-energy xray absorptiometry measurements of body composition were obtained longitudinally from participants every 18 months for 7.5 years. Falls and fractures were self-reported and fractures were confirmed through medical record review. Incidence rates were calculated as the number of falls or fractures per 1000 person-years and generalized estimating equations determined the association of sex and population group with fall and fractures rates while accounting for the repeated longitudinal measurements on the same person. All models adjusted for age group, percent time in moderate and vigorous physical activity, lean and fat mass, grip strength, and previous diagnosis of osteoarthritis. RESULTS: Males aged 39 years and younger had a 135% greater fall risk than females in the same age category (p=0.03), but there was no differences between males and females 40 years of age or older (p=0.26; age-by-sex interaction, p=0.05). No sex differences were observed for fracture risk. After controlling for covariates, rural and nonrural individuals fell at higher rates than Hutterites (84% and 50%, respectively, p<0.001). Additionally, rural individuals fractured at a 72% greater rate than Hutterites after controlling for covariates (p=0.03). CONCLUSIONS: Sex differences in fall risk among younger individuals along with population differences in fall and fracture rates suggest that sex and lifestyle factors may have an impact on fall and fracture risk. Future studies focusing on sex- and population-specific risk factors are necessary to develop prevention strategies tailored to specific populations. LEVEL OF EVIDENCE: Level III, prospective study.

Odd-impact loading results in increased cortical area and moments of inertia in collegiate athletes.

PURPOSE: The purpose of this study was to investigate tibial changes in volumetric bone mineral density and geometry that take place in athletes from pre- to post-season. METHODS: Female college athletes (n = 36) and ten controls recruited from the student population were included in the study. Participants had their left tibia scanned by pQCT at 4, 20, and 66 % of the overall length from the distal end before and after their competitive seasons. Subjects were divided into four groups: non-athlete (controls, n = 10), moderate-impact (cross-country runners, n = 13), high-impact (volleyball and basketball, n = 11), and odd-impact (soccer, n = 12). RESULTS: Anterior-posterior and medial-lateral diameter increased at the 4 % site in control subjects. In the moderate-impact group, medial-lateral moment of inertia (MOI) increased by 1.2 ± 1.8 (mean ± SD) percent at the 20 % site. In high-impact group, anterior-posterior MOI increased by 1.6 ± 2.0 percent at the 66 % site. In odd-impact group, cortical area (1.4 ± 2.3 %) and cortical thickness (1.8 ± 2.8 %) increased at the 20 % site increased, as did the polar MOI (1.8 ± 2.2 %) at the 66 % site. CONCLUSIONS: Load-specific changes resulting in improved measures of bone strength take place in athletes during a competitive season. These changes may result in improved resistance to fractures and stress fractures.

Can physical activity improve peak bone mass?

The pediatric origin of osteoporosis has led many investigators to focus on determining factors that influence bone gain during growth and methods for optimizing this gain. Bone responds to bone loading activities by increasing mass or size. Overall, pediatric studies have found a positive effect of bone loading on bone size and accrual, but the types of loads necessary for a bone response have only recently been investigated in human studies. Findings indicate that responses vary by sex, maturational status, and are site-specific. Estrogen status, body composition, and nutritional status also may influence the bone response to loading. Despite the complex interrelationships among these various factors, it is prudent to conclude that increased physical activity throughout life is likely to optimize bone health.