Family Function, Quality of Life, and Well-Being in Parents of Infants With Hypoplastic Left Heart Syndrome.

Survival for hypoplastic left heart syndrome (HLHS) has improved dramatically. Little is known about early family function, quality of life (QOL), or well-being/adjustment for parents of infants with HLHS. Parent/family outcomes over time, predictors, and differences in 143 mothers and 72 fathers were examined. Parents reported better family function compared with published norms, but 26% experienced family dysfunction. QOL and well-being were significantly lower than adult norms. QOL scores generally declined over time, whereas self-reported well-being improved. Responses from mothers and fathers showed different trends, with mothers having worse scores on most measures and at most time points. Being a single parent was a risk factor for poorer family function, but not for lower individual QOL or well-being. Family characteristics, stress, and coping skills were predictive of outcomes. Parents' psychosocial responses to the challenges of life with infants with HLHS change over time. Individually tailored psychosocial support is needed.

Impact of 5α-reductase inhibitor and α-blocker therapy for benign prostatic hyperplasia on prostate cancer incidence and mortality.

OBJECTIVE: To investigate the use of 5α-reductase inhibitors (5ARIs) and α-blockers among men with benign prostatic hyperplasia (BPH) in relation to prostate cancer (PCa) incidence, severity and mortality. PATIENTS AND METHODS: A retrospective 20-year cohort study in men residing in Saskatchewan, aged 40-89 years, with a BPH-coded medical claim between 1995 and 2014, was conducted. Cox proportional hazards regression was used to compare incidence of PCa diagnosis, metastatic PCa, Gleason score 8-10 PCa, and PCa mortality among 5ARI users (n = 4 571), α-blocker users (n = 7 764) and non-users (n = 11 677). RESULTS: In comparison with both non-users and α-blocker users, 5ARI users had a ~40% lower risk of a PCa diagnosis (11.0% and 11.4% vs 5.8%, respectively), and α-blocker users had an 11% lower risk of a PCa diagnosis compared with non-users. Overall, the incidence of metastatic PCa and PCa mortality was not significantly different among 5ARI or α-blocker users compared with non-users (adjusted hazard ratios [HR] of metastatic PCa: 1.12 and 1.13, respectively, and PCa mortality: 1.11 and 1.18, respectively, P > 0.05 for both drugs), but both 5ARI and a-blocker users had ~30% higher risk of Gleason score 8-10 cancer, adjusted HR 1.37, 95% confidence interval [CI] 1.03-1.82, P = 0.03, and adjusted HR 1.28, 95% CI 1.03-1.59, P = 0.02, respectively compared with non-users. CONCLUSION: The use of 5ARIs was associated with lower risk of PCa diagnosis, regardless of comparison group. Risk of high grade PCa was higher among both 5ARI users and α-blocker users compared with non-users; however, this did not translate into higher risk of PCa mortality.

Variation in care for children undergoing the Fontan operation for hypoplastic left heart syndrome.

BACKGROUND: The Single Ventricle Reconstruction Trial randomised neonates with hypoplastic left heart syndrome to a shunt strategy but otherwise retained standard of care. We aimed to describe centre-level practice variation at Fontan completion. METHODS: Centre-level data are reported as median or median frequency across all centres and range of medians or frequencies across centres. Classification and regression tree analysis assessed the association of centre-level factors with length of stay and percentage of patients with prolonged pleural effusion (>7 days). RESULTS: The median Fontan age (14 centres, 320 patients) was 3.1 years (range from 1.7 to 3.9), and the weight-for-age z-score was -0.56 (-1.35 + 0.44). Extra-cardiac Fontans were performed in 79% (4-100%) of patients at the 13 centres performing this procedure; lateral tunnels were performed in 32% (3-100%) at the 11 centres performing it. Deep hypothermic circulatory arrest (nine centres) ranged from 6 to 100%. Major complications occurred in 17% (7-33%). The length of stay was 9.5 days (9-12); 15% (6-33%) had prolonged pleural effusion. Centres with fewer patients (<6%) with prolonged pleural effusion and fewer (<41%) complications had a shorter length of stay (<10 days; sensitivity 1.0; specificity 0.71; area under the curve 0.96). Avoiding deep hypothermic circulatory arrest and higher weight-for-age z-score were associated with a lower percentage of patients with prolonged effusions (<9.5%; sensitivity 1.0; specificity = 0.86; area under the curve 0.98). CONCLUSIONS: Fontan perioperative practices varied widely among study centres. Strategies to decrease the duration of pleural effusion and minimise complications may decrease the length of stay. Further research regarding deep hypothermic circulatory arrest is needed to understand its association with prolonged pleural effusion.

Relationship between muscle strength and dyslipidemia, serum 25(OH)D, and weight status among diverse schoolchildren: a cross-sectional analysis.

BACKGROUND: The relationship between muscle strength and cardiometabolic risk factors in youth, and the potential influence of vitamin D status on this relationship, is not well understood. This study examined associations between muscle strength and dyslipidemia, serum 25-hydroxyvitamin D [25(OH)D], and weight status in diverse schoolchildren. METHODS: Measures of hand-grip strength (standardized for sex and body weight), anthropometrics (height and weight converted to BMI z-score [BMIz]), sociodemographics, and fasting blood concentrations of plasma HDL-C and triglycerides and serum 25(OH)D were collected from 350 4th-8th grade schoolchildren (11.2 ± 1.3 y, 49.4% female, 56.3% non-white/Caucasian). Logistic regression was used to measure associations between standardized tertiles of grip strength and blood lipids, 25(OH)D, and weight status along with associations between 25(OH)D and dyslipidemia and weight status. RESULTS: Children with higher grip strength had lower odds of overweight/obesity (OR: 0.03, 95% CI: 0.01-0.06, in the highest tertile of grip strength vs. lowest, p for trend< 0.0001), borderline/low HDL-C (OR: 0.28, 95% CI: 0.16-0.50, p for trend< 0.0001), and borderline/high triglycerides (OR: 0.48, 95% CI: 0.25-0.92, p for trend< 0.05), adjusting for covariates. Associations between blood lipids and grip strength became non-significant after further adjustment for BMIz. No association was observed between grip strength and 25(OH)D, nor between 25(OH)D and borderline/low HDL-C or weight status; however, vitamin D sufficiency was associated with lower odds of borderline/high triglycerides compared with vitamin D deficiency (OR: 0.26, 95% CI: 0.09-0.74, p for trend< 0.05) before BMIz adjustment. CONCLUSION: Among racially/ethnically diverse children, muscle strength was associated with lower dyslipidemia. Longitudinal studies are needed to explore whether changes in muscle strength impact this relationship in children, independent of weight status. TRIAL REGISTRATION: This study was registered at www.clinicaltrials.gov (No. NCT01537809 ) on February 17, 2012.

Sun-Exposed Skin Color Is Associated with Changes in Serum 25-Hydroxyvitamin D in Racially/Ethnically Diverse Children.

BACKGROUND: UVB light from the sun increases serum 25-hydroxyvitamin D [25(OH)D] concentration, but this relation may depend on skin pigmentation among different racial/ethnic groups. OBJECTIVE: We used quantitative measures of exposed (facultative) and unexposed (constitutive) skin color to examine relations between serum 25(OH)D concentration, tanning, race/ethnicity, and constitutive skin color over the summer, following winter vitamin D supplementation. METHODS: The subjects (n= 426, mean age 11.7 ± 1.4 y, 51% female) were racially/ethnically diverse schoolchildren (57% non-white/Caucasian) enrolled in a 6-mo vitamin D supplementation trial (October-December to April-June). In this secondary analysis, measures of serum 25(OH)D concentration and skin color, with the use of reflectance colorimetry, were taken over a 6-mo period after supplementation, from pre-summer (April-June) to post-summer (September-December). Multiple linear regression was used to evaluate longitudinal relations. RESULTS: Following supplementation, mean serum 25(OH)D concentration was 29.3 ± 9.5 ng/mL but fell to 25.6 ± 7.9 ng/mL (P< 0.0001) by the end of summer. The decrease in white/Caucasian children was less than in black/African American children (P< 0.01) and tended to be less than in Hispanic/Latino, Asian, and multiracial/other children (P= 0.19-0.50) despite similar changes in sun-exposed skin color among all groups. Tanning was significantly associated with post-summer serum 25(OH)D concentration (ß = -0.15,P< 0.0001), as was race/ethnicity (P= 0.0002), but the later association disappeared after adjusting for constitutive skin color. CONCLUSIONS: Tanning significantly contributed to serum 25(OH)D concentration over the summer, independent of race/ethnicity, but was not sufficient to maintain serum 25(OH)D concentration attained with supplementation. Much of the variation in serum 25(OH)D concentration between racial/ethnic groups may be explained by skin color. This trial was registered atclinicaltrials.govasNCT01537809.

Sugar-Sweetened Beverage Intake Is Positively Associated with Baseline Triglyceride Concentrations, and Changes in Intake Are Inversely Associated with Changes in HDL Cholesterol over 12 Months in a Multi-Ethnic Sample of Children.

BACKGROUND: Intake of sugar-sweetened beverages (SSBs) is linked to greater cardiometabolic risk in adults. Although longitudinal evidence is sparse among children, SSB intake reduction is targeted to reduce cardiometabolic risk factors in this group. OBJECTIVE: We investigated characteristics associated with consumption of SSBs in a multi-ethnic sample of children/adolescents and measured cross-sectional and longitudinal associations between SSB intake and plasma HDL cholesterol and triglycerides (TGs) over 12 mo. METHODS: In a diverse cohort of children aged 8-15 y, cross-sectional associations (n = 613) between baseline SSB intake and blood lipid concentrations and longitudinal associations (n = 380) between mean SSB intake, changes in SSB intake, and lipid changes over 12 mo were assessed with multivariable linear regression. RESULTS: Greater SSB intake was associated with lower socioeconomic status, higher total energy intake, lower fruit/vegetable intake, and more sedentary time. In cross-sectional analysis, greater SSB intake was associated with higher plasma TG concentrations among consumers (62.4, 65.3, and 71.6 mg/dL in children who consumed >0 but <2, ≥2 but <7, and ≥7 servings/wk, respectively; P-trend: 0.03); plasma HDL cholesterol showed no cross-sectional association. In the longitudinal analysis, mean SSB intake over 12 mo was not associated with lipid changes; however, the 12-mo increase in plasma HDL-cholesterol concentration was greater among children who decreased their intake by ≥1 serving/wk (4.6 ± 0.8 mg/dL) compared with children whose intake stayed the same (2.0 ± 0.8 mg/dL) or increased (1.5 ± 0.8 mg/dL; P = 0.02). CONCLUSIONS: In a multi-ethnic sample of children, intake of SSBs was positively associated with TG concentrations among consumers, and changes in SSB intake were inversely associated with HDL cholesterol concentration changes over 12 mo. Further research in large diverse samples of children is needed to study the public health implications of reducing SSB intake among children of different racial/ethnic groups. The Daily D Health Study was registered at clinicaltrials.gov as NCT01537809.

Recruitment and retention of urban schoolchildren into a randomized double-blind vitamin D supplementation trial.

BACKGROUND: While rarely used for supplementation trials in the United States, schools present a practical alternative to a clinical setting. PURPOSE: We describe the successful recruitment and retention of urban schoolchildren into a 6-month randomized, double-blind vitamin D3 supplementation trial. METHODS: Boston-area urban schoolchildren, aged 8-15 years, were recruited in 2011-2012 through classroom and auditorium presentations. Informed consent forms in five languages were sent home to parents. Retention methods included regular telephone calls and gift cards for completed study visits. RESULTS: In total, 691 schoolchildren enrolled. Their mean (standard deviation) age was 11.7 (1.4) years; 59% were racial/ethnic minorities and 68% qualified for free or reduced-price school meals. Multi-level, culturally sensitive, creative approaches contributed to success in recruitment and retention. Of 691 participants, 81% completed the 6-month intervention period. Reasons for attrition included missed appointments and fear of a blood draw. More children from households with higher incomes were retained than those from households with lower incomes (85% vs 79%, respectively, P = 0.04). LIMITATIONS: The need for three fasting blood draws over the 6-month supplementation period was a limiting factor in the recruitment and retention of children in this study. CONCLUSION: Recruitment of urban children into a school-based randomized controlled trial represents a feasible approach for a supplementation study. Particular attention to children of lower socioeconomic status may enhance participation and retention when conducting intervention studies among diverse populations.

Carbohydrate nutrition differs by diabetes status and is associated with dyslipidemia in Boston Puerto Rican adults without diabetes.

Puerto Rican adults have a greater prevalence of type 2 diabetes (T2D) and lower HDL-cholesterol (HDL-C) than the general U.S. population. Carbohydrate nutrition may play a role in this disparity. Cross-sectional analyses included data from 1219 Puerto Ricans aged 45-75 y enrolled in the Boston Puerto Rican Health Study. Using the Pearson chi-square test and ANCOVA, lifestyle characteristics and dietary intake, as assessed by semiquantitative FFQ, were compared by T2D status based on fasting plasma glucose concentration and medication use. Food source rankings for carbohydrate, dietary glycemic load (GL), and fiber were obtained using the SAS procedure PROC RANK. Geometric mean plasma HDL-C and TG concentrations were compared across quintiles of dietary carbohydrate, glycemic index (GI), GL, and fiber by using ANCOVA and tests for linear trend. In multivariable analyses, individuals with T2D (39.5%) had lower dietary carbohydrate, GL, and total sugar intake from lower intake of sugar, fruit drinks, and soda compared with those without T2D. In individuals without T2D, dietary carbohydrate and GL were inversely associated with HDL-C (P < 0.0001). Associations between dietary fiber and HDL-C were confounded by carbohydrate intake, apparently from concurrent consumption of legumes with white rice, a refined carbohydrate food. No associations were observed between carbohydrate, dietary GI, GL, or fiber and TG. In conclusion, individuals with T2D showed evidence of dietary modification. Among those without diabetes, a high intake of refined carbohydrates was associated with decreased HDL-C. Longitudinal research on carbohydrate nutrition in relation to diabetes risk factors and blood lipids in Puerto Ricans is warranted.

Vitamin D supplementation and cardiometabolic risk factors among diverse schoolchildren: a randomized clinical trial.

BACKGROUND: There remains a lack of evidence demonstrating a potential relationship between vitamin D and cardiometabolic risk among children. OBJECTIVES: We examined the effect of 3 different dosages of vitamin D on cardiometabolic risk factors among children at risk of deficiency. METHODS: Racially diverse schoolchildren aged 8-15 y were randomly assigned in a double-blind fashion to supplementation with 600, 1000, or 2000 IU vitamin D3/d for 6 mo. Changes in HDL cholesterol, triglycerides, LDL cholesterol, total cholesterol, and blood glucose over 6 mo and at 12 mo (6 mo post-supplementation) were assessed. Subgroup analyses were also performed by weight status and race. RESULTS: Among 604 children, 40.9% were vitamin D-inadequate at baseline (<20 ng/mL; mean ± SD: 22.0 ± 6.8 ng/mL), 46.4% were overweight/obese, and 60.9% had ≥1 suboptimal blood lipids or glucose. Over 6 mo, serum 25-hydroxyvitamin D increased in all 3 dosage groups from baseline (mean ± SE change: 4.4 ± 0.6 ng/mL, 5.7 ± 0.7 ng/mL, and 10.7 ± 0.6 ng/mL for 600, 1000, and 2000 IU/d, respectively; P < 0.001). Whereas HDL cholesterol and triglycerides increased in the 600 IU group (P = 0.002 and P = 0.02, respectively), LDL cholesterol and total cholesterol decreased across dosage groups. At 6 mo post-supplementation, HDL cholesterol remained elevated in the 600 and 1000 IU groups ( P < 0.001 and P = 0.02, respectively) whereas triglycerides remained elevated in the 1000 and 2000 IU groups (P = 0.04 and P = 0.006, respectively). The suppression of LDL cholesterol and total cholesterol persisted in the 2000 IU group only (P = 0.04 and P < 0.001, respectively). There were no significant changes in blood glucose and similar responses were observed overall by weight status and racial groups across dosages. CONCLUSIONS: Vitamin D supplementation demonstrated generally positive effects on HDL cholesterol, LDL cholesterol, and total cholesterol, especially at the lower dosage of 600 IU/d, with several significant changes persisting during the post-supplementation period. Increases in triglycerides across dosage groups may be due to natural changes during adolescence warranting further study.This trial was registered at clinicaltrials.gov as NCT01537809.

Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease.

BACKGROUND: Many factors affect outcomes after congenital cardiac surgery. OBJECTIVES: The RLS (Residual Lesion Score) study explored the impact of severity of residual lesions on post-operative outcomes across operations of varying complexity. METHODS: In a prospective, multicenter, observational study, 17 sites enrolled 1,149 infants undergoing 5 common operations: tetralogy of Fallot repair (n = 250), complete atrioventricular septal defect repair (n = 249), arterial switch operation (n = 251), coarctation or interrupted arch with ventricular septal defect (VSD) repair (n = 150), and Norwood operation (n = 249). The RLS was assigned based on post-operative echocardiography and clinical events: RLS 1 (trivial or no residual lesions), RLS 2 (minor residual lesions), or RLS 3 (reintervention for or major residual lesions before discharge). The primary outcome was days alive and out of hospital within 30 post-operative days (60 for Norwood). Secondary outcomes assessed post-operative course, including major medical events and days in hospital. RESULTS: RLS 3 (vs. RLS 1) was an independent risk factor for fewer days alive and out of hospital (p ≤ 0.008) and longer post-operative hospital stay (p ≤ 0.02) for all 5 operations, and for all secondary outcomes after coarctation or interrupted arch with VSD repair and Norwood (p ≤ 0.03). Outcomes for RLS 1 versus 2 did not differ consistently. RLS alone explained 5% (tetralogy of Fallot repair) to 20% (Norwood) of variation in the primary outcome. CONCLUSIONS: Adjusting for pre-operative factors, residual lesions after congenital cardiac surgery impacted in-hospital outcomes across operative complexity with greatest impact following complex operations. Minor residual lesions had minimal impact. These findings may provide guidance for surgeons when considering short-term risks and benefits of returning to bypass to repair residual lesions.

The Pediatric Heart Network Residual Lesion Score Study: Design and objectives.

OBJECTIVES: The Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively. METHODS: The study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation. CONCLUSIONS: This is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.

Prostate cancer incidence and mortality among men using statins and non-statin lipid-lowering medications.

BACKGROUND: Statins have demonstrated protection against aggressive/late-stage and/or lethal prostate cancer (PC), but prior studies are limited by small populations, short follow-up and unequal health-care access. Research has not demonstrated that non-statin lipid-lowering medications (NSLLMs) provide a similar benefit, which would support a cholesterol-based mechanism. We sought to rigorously test the hypothesis that cholesterol-lowering drugs affect PC incidence and severity. METHODS: A retrospective cohort study was conducted by abstracting prescription and health service records for 249,986 Saskatchewan men aged ≥40 years between January 1, 1990 and December 31, 2014 and comparing first-time statin and NSLLM users with age-matched non-users and glaucoma medication (GM) users for PC incidence, metastases at diagnosis and PC mortality using Cox proportional hazards regression. RESULTS: In comparing statin users to non-users, a weak association was detected with increased PC incidence (hazard ratio [HR] 1.07, 95% confidence interval [CI]: 1.02-1.12) that disappeared when compared with GM users. Substantial protective associations were observed between statin use and metastatic PC and PC mortality (HRs 0.69, 95% CI: 0.61-0.79 and 0.73, 95% CI: 0.66-0.81, respectively), which were stronger when compared with GM use (HRs 0.52, 95% CI: 0.40-0.68 and 0.51, 95% CI: 0.41-0.63, respectively). Similar associations were found for NSLLM versus GM for metastatic PC (HR 0.57, 95% CI: 0.41-0.79) and PC mortality (HR 0.66, 95% CI: 0.51-0.85). CONCLUSIONS: Our analyses provide one of the more comprehensive findings to date that statins may reduce risk of metastatic PC and PC mortality, and the first to demonstrate that NSLLM have similar effects, supporting a cholesterol-based mechanism.

Investigation of the C-3-epi-25(OH)D3 of 25-hydroxyvitamin D3 in urban schoolchildren.

The physiological relevance C-3 epimer of 25-hydroxyvitamin D (3-epi-25(OH)D) is not well understood among youth. The objective of this study was to assess whether demographic/physiologic characteristics were associated with 3-epi-25(OH)D3 concentrations in youth. Associations between 3-epi-25(OH)D3 and demographics and between 3-epi-25(OH)D3, total 25-hydroxyvitamin (25(OH)D) (25(OH)D2 + 25(OH)D3), total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were examined in racially/ethnically diverse schoolchildren (n = 682; age, 8-15 years) at Boston-area urban schools. Approximately 50% of participants had detectable 3-epi-25(OH)D3 (range 0.95-3.95 ng/mL). The percentage of 3-epi-25(OH)D3 of total 25(OH)D ranged from 2.5% to 17.0% (median 5.5%). Males were 38% more likely than females to have detectable 3-epi-25(OH)D3 concentrations. Both Asian and black race/ethnicity were associated with lower odds of having detectable 3-epi-25(OH)D3 compared with non-Hispanic white children (Asian vs. white, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.14-0.53; black vs. white, OR 0.38, 95%CI 0.23-0.63, p < 0.001). Having an adequate (20-29 ng/mL) or optimal (>30 ng/mL) 25(OH)D concentration was associated with higher odds of having detectable 3-epi-25(OH)D3 than having an inadequate (<20 ng/mL) concentration (OR 4.78, 95%CI 3.23-6.94 or OR 14.10, 95%CI 7.10-28.0, respectively). There was no association between 3-epi-25(OH)D3 and blood lipids. However, when considering 3-epi-25(OH)D3 as a percentage of total 25(OH)D, total cholesterol was lower in children with percent 3-epi-25(OH)D3 above the median (mean difference -7.1 mg/dL, p = 0.01). In conclusion, among schoolchildren, sex, race/ethnicity, and total serum 25(OH)D concentration is differentially associated with 3-epi-25(OH)D. The physiological relevance of 3-epi-25(OH)D3 may be related to the 3-epi-25(OH)D3 as a percentage of total 25(OH)D and should be considered in future investigations.

Impact of Three Doses of Vitamin D3 on Serum 25(OH)D Deficiency and Insufficiency in At-Risk Schoolchildren.

Objective: We investigated the daily dose of vitamin D needed to achieve serum 25-hydroxyvitamin D [25(OH)D] sufficiency among schoolchildren at risk for deficiency. Study Design: The Daily D Health Study was a randomized double-blind vitamin D supplementation trial among racially/ethnically diverse schoolchildren (n = 685) in the northeastern United States. Children were supplemented with vitamin D3 at 600, 1000, or 2000 IU/d for 6 months. Measurements included serum 25(OH)D at baseline (October to December), 3 months (January to March), 6 months (April to June), and 12 months (6 months after supplementation). Results: At baseline, mean ± standard deviation serum 25(OH)D level was 22.0 ± 6.8 ng/mL, with 5.5% severely vitamin D deficient (<12 ng/mL), 34.1% deficient (12 to 19 ng/mL), 49.0% insufficient (20 to 29 ng/mL), and 11.4% sufficient (≥30 ng/mL). The lowest levels of serum 25(OH)D were found among black (17.9 ± 6.7 ng/mL) and Asian children (18.9 ± 4.8 ng/mL), with no baseline differences by weight status. Serum 25(OH)D increased over 6 months in all three dose groups. The 2000 IU/d group achieved a higher mean serum 25(OH)D level than the other two dose groups (33.1 vs 26.3 and 27.5 ng/mL; P < 0.001), with 59.9% of this group attaining sufficiency at 3 months and only 5.3% remaining severely deficient/deficient at 6 months. All dose groups demonstrated a fall in 25(OH)D at 12 months. Conclusions: Children at risk for vitamin D deficiency benefited from daily sustained supplementation of 2000 IU/d compared with lower doses closer to the current recommended daily allowance for vitamin D intake. This benefit occurred over the winter months, when serum 25(OH)D level tend to fall.

Credentialing complementary and alternative medical providers.

Since the late 19th century, state legislatures and professional medical organizations have developed mechanisms to license physicians and other conventional nonphysician providers, establish standards of practice, and protect health care consumers by establishing standardized credentials as markers of competence. The popularity of complementary and alternative medical (CAM) therapies presents new challenges. This article describes the current status of, and central issues in, efforts to create models for health care credentialing of chiropractors, acupuncturists, naturopaths, massage therapists, and other CAM practitioners. It also suggests a strategy of CAM provider credentialing for use by physicians, health care administrators, insurance companies, and national professional organizations. The credentialing debate reflects fundamental questions about who determines which providers and therapies will be accepted as safe, effective, appropriate, and reimbursable. More nationally uniform credentialing mechanisms are necessary to ensure high standards of care and more generalizable clinical research. However, the result of more uniform licensure and credentialing may be excessive standardization and a decrease in individualization of services. Thus, increased standardization of credentialing for CAM practitioners may alter CAM practice substantially. Furthermore, even credentialed providers can deliver ineffective therapy. The suggested framework balances the desire to protect the public from dangerous practices against the wish to grant patients access to reasonably safe and effective therapies.

Acculturation and sociocultural influences on dietary intake and health status among Puerto Rican adults in Massachusetts.

BACKGROUND: Previous studies have shown negative consequences of acculturation on lifestyle factors, health status, and dietary intake of Hispanic immigrants in the US. Despite prevalent type 2 diabetes and low socioeconomic status (SES) among Puerto Rican adults living on the US mainland, little is known about acculturation in this group. OBJECTIVE: We investigated associations among acculturation, lifestyle characteristics, health status, and carbohydrate nutrition in Puerto Rican adults. A secondary objective was to investigate possible confounding and/or effect modification on these associations by SES. DESIGN: Cross-sectional data from the Boston Puerto Rican Health Study, which included 1219 Puerto Ricans in the Boston area, aged 45-75 years. STATISTICAL ANALYSES: Characteristics were compared using ANCOVA, linear trend and Pearson's chi-square tests across quartiles of acculturation. Tests for interaction by poverty status were conducted. Proportional contributions of foods to intake of total carbohydrate and fiber were assessed using SAS RANK. RESULTS: Levels of acculturation were low, despite young age at first arrival to the US mainland (25.4 ± 12.3 y) and long length of stay (34.2 ± 12.2 y). Greater English language use was associated with higher SES, alcohol consumption, physical activity, better perceived health, and less central obesity. Acculturation was associated with lower legume fiber and greater cereal fiber intake. Among those above the poverty threshold, acculturation was associated with lower dietary glycemic index and starch intake, and greater fruit and non-starchy vegetable intake. CONCLUSIONS: In contrast to studies with Mexican Americans, the association of acculturation with dietary quality in these Puerto Rican adults was mixed, but tended toward better carbohydrate quality. Dietary recommendations should include maintenance of traditional, healthful dietary practices including consumption of legumes, but also reduction in refined grains, and greater inclusion of fruit, non-starchy vegetables, and whole grains. Interventions to improve access to better quality carbohydrate sources are necessary for this group disproportionately affected by diabetes.

Prevalence of cardiovascular disease risk factors among older Puerto Rican adults living in Massachusetts.

There remains limited research on cardiovascular disease (CVD) risk factors in Puerto Rican adults. We compared lifestyle and CVD risk factors in Puerto Rican men and women with normal fasting glucose (NFG), impaired fasting glucose (IFG), or type 2 diabetes (T2D), and investigated achievement of American Diabetes Association (ADA) treatment goals in those with T2D. Baseline data from the Boston Puerto Rican Health Study were analyzed, which included 1,287 adults aged 45-75 years. Obesity, hyperglycemia, and dyslipidemia were prevalent and increased from NFG to IFG and T2D. In individuals without T2D, fasting insulin correlated significantly with body mass index. Achievement of ADA goals was poor; LDL cholesterol was most achieved (59.4%), followed by blood pressure (27.2%) and glycosylated hemoglobin (27.0%). Poverty, female sex, current alcohol use, and diabetes or anti-hypertensive medication use were associated with not meeting goals. Puerto Rican adults living in the Boston area showed several metabolic abnormalities and high CVD risk, likely due to pervasive obesity and socio-economic disparities.