Myths, presumptions, and facts about obesity.

BACKGROUND: Many beliefs about obesity persist in the absence of supporting scientific evidence (presumptions); some persist despite contradicting evidence (myths). The promulgation of unsupported beliefs may yield poorly informed policy decisions, inaccurate clinical and public health recommendations, and an unproductive allocation of research resources and may divert attention away from useful, evidence-based information. METHODS: Using Internet searches of popular media and scientific literature, we identified, reviewed, and classified obesity-related myths and presumptions. We also examined facts that are well supported by evidence, with an emphasis on those that have practical implications for public health, policy, or clinical recommendations. RESULTS: We identified seven obesity-related myths concerning the effects of small sustained increases in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended during sexual activity. We also identified six presumptions about the purported effects of regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (i.e., human-made) environment. Finally, we identified nine evidence-supported facts that are relevant for the formulation of sound public health, policy, or clinical recommendations. CONCLUSIONS: False and scientifically unsupported beliefs about obesity are pervasive in both scientific literature and the popular press. (Funded by the National Institutes of Health.).

Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD.

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

The impact of the State Children's Health Insurance Program's unborn child ruling expansions on foreign-born Latina prenatal care and birth outcomes, 2000-2007.

The 2002 "unborn child ruling" resulted in State Children's Health Insurance Program (SCHIP) expansion for states to cover prenatal care for low-income women without health insurance. Foreign-born Latinas who do not qualify for Medicaid coverage theoretically should have benefited most from the policy ruling given their documented low rates of prenatal care utilization. This study compares prenatal care utilization and subsequent birth outcomes among foreign-born Latinas in six states that used the unborn child ruling to expand coverage to those in ten states that did not implement the expansion. This policy analysis examines cross-sectional pooled US natality data from the pre-enactment years (2000-2003) versus post-enactment years (2004-2007) to estimate the effect of the UCR on prenatal care utilization and birth outcome measures for foreign-born Latinas. Then using a difference-in-difference estimator, we assessed these differences across time for states that did or did not enact the unborn child ruling. Analyses were then replicated on a high-risk subset of the population (single foreign-born Latinas with lower levels of education). The SCHIP unborn child ruling policy expansion increased PNCU over time in the six enacting states. Foreign-born Latinas in expansion enacting states experienced increases in prenatal care utilization though only the high-risk subset were statistically significant. Birth outcomes did not change. The SCHIP unborn child ruling policy was associated with enhanced PNC for a subset of high-risk foreign-born Latinas.

The effects of breastfeeding exclusivity on early childhood outcomes.

OBJECTIVES: We examined the relationship between breastfeeding exclusivity and duration and children's health and cognitive outcomes at ages 2 and 4 years. METHODS: We used the Early Childhood Longitudinal Study-Birth Cohort, a nationally representative sample of 10,700 children born in the United States in 2001. Parent interviews and child assessments were conducted in measurement waves at 9 months, 2 years, 4 years, and in kindergarten, with the focus on ages 2 and 4 years. We employed propensity scores as a means of adjusting for confounding involving observed characteristics. RESULTS: Outcome analyses using propensity scores showed some small effects of breastfeeding on key outcomes at age 4 years but not at age 2 years. Effects appeared to be concentrated in reading and cognitive outcomes. Overall, we found no consistent evidence for dosage effects of breastfeeding exclusivity. Our sensitivity analyses revealed that a small amount of unobserved confounding could be responsible for the resulting benefits. CONCLUSIONS: Our study revealed little or no effect of breastfeeding exclusivity and duration on key child outcomes.

Economic analysis of a multi-site prevention program: assessment of program costs and characterizing site-level variability.

Programmatic cost analyses of preventive interventions commonly have a number of methodological difficulties. To determine the mean total costs and properly characterize variability, one often has to deal with small sample sizes, skewed distributions, and especially missing data. Standard approaches for dealing with missing data such as multiple imputation may suffer from a small sample size, a lack of appropriate covariates, or too few details around the method used to handle the missing data. In this study, we estimate total programmatic costs for a prevention trial evaluating the Strong African American Families-Teen program. This intervention focuses on the prevention of substance abuse and risky sexual behavior. To account for missing data in the assessment of programmatic costs we compare multiple imputation to probabilistic sensitivity analysis. The latter approach uses collected cost data to create a distribution around each input parameter. We found that with the multiple imputation approach, the mean (95 % confidence interval) incremental difference was $2,149 ($397, $3,901). With the probabilistic sensitivity analysis approach, the incremental difference was $2,583 ($778, $4,346). Although the true cost of the program is unknown, probabilistic sensitivity analysis may be a more viable alternative for capturing variability in estimates of programmatic costs when dealing with missing data, particularly with small sample sizes and the lack of strong predictor variables. Further, the larger standard errors produced by the probabilistic sensitivity analysis method may signal its ability to capture more of the variability in the data, thus better informing policymakers on the potentially true cost of the intervention.

A Person-Centered Examination of Adolescent Religiosity Using Latent Class Analysis.

Empirical studies of religion's role in society, especially those focused on individuals and analyzing survey data, conceptualize and measure religiosity on a single measure or a summary index of multiple measures. Other concepts, such as "lived religion," "believing without belonging," or "fuzzy fidelity," emphasize what scholars have noted for decades: humans are rarely consistently low, medium, or high across dimensions of religiosity including institutional involvement, private practice, salience, or belief. A method with great promise for identifying population patterns in how individuals combine types and levels of belief, practice, and personal religious salience is latent class analysis. In this paper, we use data from the first wave of the National Study of Youth and Religion's telephone survey to discuss how to select indicators of religiosity in an informed manner, as well as the implications of the number and types of indicators used for model fit. We identify five latent classes of religiosity among adolescents in the United States and their socio-demographic correlates. Our findings highlight the value of a person-centered approach to understanding how religion is lived by American adolescents.

Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study.

Never or curtailed lactation has been associated with an increased risk for incident hypertension, but the effect of exclusive breastfeeding is unknown. The authors conducted an observational cohort study of 55,636 parous women in the US Nurses' Health Study II. From 1991 to 2005, participants reported 8,861 cases of incident hypertension during 660,880 person-years of follow-up. Never or curtailed lactation was associated with an increased risk of incident hypertension. Compared with women who breastfed their first child for ≥12 months, women who did not breastfeed were more likely to develop hypertension (hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.18, 1.36), adjusting for family history and lifestyle covariates. Women who never breastfed were more likely to develop hypertension than women who exclusively breastfed their first child for ≥6 months (HR = 1.29, 95% CI: 1.20, 1.40). The authors found similar results for women who had never breastfed compared with those who had breastfed each child for an average of ≥12 months (HR = 1.22, 95% CI: 1.13, 1.32). In conclusion, never or curtailed lactation was associated with an increased risk of incident maternal hypertension, compared with the recommended ≥6 months of exclusive or ≥12 months of total lactation per child, in a large cohort of parous women.

Deployment and the citizen soldier: need and resilience.

BACKGROUND: The wars in Iraq and Afghanistan have made unprecedented demands on the nation's citizen soldiers, the National Guard and Reserve. A major concern involves the repeated deployment of these forces overseas. OBJECTIVES: Using data from the Department of Defense Survey of Health Related Behaviors among the Guard and Reserve Force, we examined the effects of deployment on 6 health outcomes. SUBJECTS: The Department of Defense Survey of Health Related Behaviors among the Guard and Reserve Force is a sample (n = 17,754) of all Reserve component personnel (including full time and/or activated Guard and Reservists) serving in all pay grades throughout the world. RESEARCH DESIGN: We relied on inverse probability of treatment weights to adjust for observed confounders and used sensitivity analyses to examine the sensitivity of our findings to potential unobserved confounding. RESULTS: Observed confounders explain much of the apparent effect of deployment. For men, the adjusted relationships could very well reflect further confounding involving unobserved factors. However, for women, effects of deployment on marijuana use, symptoms of post-traumatic stress disorder, and suicidal ideation are robust to adjustments for multiple testing and possible unobserved confounding. CONCLUSIONS: These effects are large in practical terms and troubling but suggest that media reports of the harm caused by deployment may be overstated. Such exaggerations run the risk of stigmatizing those who serve.

Breastfeeding and the child cognitive outcomes: a propensity score matching approach.

To estimate the effect of breastfeeding initiation and duration on child development outcomes. 3,271 children and their mothers participating in the Child Development Supplement of the Panel Study of Income Dynamics provide data for these analyses. Main outcomes include Woodcock Johnson Psycho-Educational Battery-Revised (WJ-R) test score (letter word, passage comprehension, applied problem, and broad reading), and Wechsler Intelligence Scale for Children-Revised (WISC-R) test score at the 2002 survey. Controlled variables include family, maternal, and child characteristics, many of which can be traced back to the year the child was born. The analytic technique is propensity score matching with multiple imputations. After using propensity scores to adjust for confounding factors, breastfeeding initiation showed statistically significant effects but the practical scale remains small. Breastfeeding duration showed a non-linear effect on those outcomes and most of the effects are not significant. The effects of breastfeeding on child's cognitive outcomes are modest in practical terms. The non-linear effects suggest that selection into breastfeeding may account for the increased score of children who are breastfed.

A spoonful of math helps the medicine go down: an illustration of how healthcare can benefit from mathematical modeling and analysis.

OBJECTIVES: A recent joint report from the Institute of Medicine and the National Academy of Engineering, highlights the benefits of--indeed, the need for--mathematical analysis of healthcare delivery. Tools for such analysis have been developed over decades by researchers in Operations Research (OR). An OR perspective typically frames a complex problem in terms of its essential mathematical structure. This article illustrates the use and value of the tools of operations research in healthcare. It reviews one OR tool, queueing theory, and provides an illustration involving a hypothetical drug treatment facility. METHOD: Queueing Theory (QT) is the study of waiting lines. The theory is useful in that it provides solutions to problems of waiting and its relationship to key characteristics of healthcare systems. More generally, it illustrates the strengths of modeling in healthcare and service delivery.Queueing theory offers insights that initially may be hidden. For example, a queueing model allows one to incorporate randomness, which is inherent in the actual system, into the mathematical analysis. As a result of this randomness, these systems often perform much worse than one might have guessed based on deterministic conditions. Poor performance is reflected in longer lines, longer waits, and lower levels of server utilization.As an illustration, we specify a queueing model of a representative drug treatment facility. The analysis of this model provides mathematical expressions for some of the key performance measures, such as average waiting time for admission. RESULTS: We calculate average occupancy in the facility and its relationship to system characteristics. For example, when the facility has 28 beds, the average wait for admission is 4 days. We also explore the relationship between arrival rate at the facility, the capacity of the facility, and waiting times. CONCLUSIONS: One key aspect of the healthcare system is its complexity, and policy makers want to design and reform the system in a way that affects competing goals. OR methodologies, particularly queueing theory, can be very useful in gaining deeper understanding of this complexity and exploring the potential effects of proposed changes on the system without making any actual changes.

The value of reanalysis: TV viewing and attention problems.

Using data from the National Longitudinal Survey of Youth (N = 1,159), this study reexamines the link between maternal reports of television viewing at ages 1 and 3 and attention problems at age 7. This work represents a reanalysis and extension of recent research suggesting young children's television viewing causes subsequent attention problems. The nonlinear specification reveals the association between television watching and attention problems exists-if at all-only at very high levels of viewing. Adding 2 covariates to the regression model eliminated even this modest effect. The earlier findings are not robust. This study also considers whether its own findings are sensitive to unobserved confounding using fixed-effects estimation. In general, it finds no meaningful relation between television viewing and attention problems.

Costs and effectiveness of the fast track intervention for antisocial behavior.

BACKGROUND: Antisocial behavior is enormously costly to the youth involved, their families, victims, taxpayers and other members of society. These costs are generated by school failure, delinquency and involvement in the juvenile justice system, drug use, health services and other services. For prevention programs to be cost effective, they must reduce these costly behaviors and outcomes. AIM: The Fast Track intervention is a 10-year, multi-component prevention program targeting antisocial behavior. The intervention identified children at school entry and provided intervention services over a 10-year period. This study examined the intervention's impact on outcomes affecting societal costs using data through late adolescence. METHODOLOGY: The intervention is being evaluated through a multi-cohort, multi-site, multi-year randomized control trial of program participants and comparable children and youth in similar schools, and that study provides the data for these analyses. Schools within four sites (Durham, NC; Nashville, TN; Seattle, WA; and rural central Pennsylvania) were selected as high-risk based on crime and poverty statistics of the neighborhoods they served. Within each site, schools were divided into multiple sets matched for demographics (size, percentage free/reduced lunch, ethnic composition); one set within each pair was randomly assigned to the intervention and one to the control condition. Within participating schools, high-risk children were identified using a multiple-gating procedure. For each of three annual cohorts, all kindergarteners (9,594 total) in 54 schools were screened for classroom conduct problems by teachers. Those children scoring in the top 40% within cohort and site were then solicited for the next stage of screening for home behavior problems by the parents, and 91% agreed (n = 3,274). The teacher and parent screening scores were then standardized within site and combined into a sum score. These summed scores represented a total severity-of-risk screen score. Children were selected for inclusion into the study based on this screen score, moving from the highest score downward until desired sample sizes were reached within sites, cohorts, and conditions. RESULTS AND DISCUSSION: The intervention lacked both the breadth and depth of effects on costly outcomes to demonstrate cost-effectiveness or even effectiveness. LIMITATIONS: The outcomes examined here reflect effects observed during measurement windows that are not complete for every outcome. Data are lacking on some potential outcomes, such as the use of mental health services before year 7. CONCLUSION AND IMPLICATIONS: The most intensive psychosocial intervention ever fielded did not produce meaningful and consistent effects on costly outcomes. The lack of effects through high school suggests that the intervention will not become cost-effective as participants progress through adulthood. FUTURE RESEARCH: Future research should consider alternative approaches to prevention youth violence.

Old wine in new skins: the sensitivity of established findings to new methods.

Findings from an evaluation of a model system for delivering mental health services to youth were reassessed to determine the robustness of key findings to the use of methodologies unavailable to the original analysts. These analyses address a key concern about earlier findings-that the quasi-experimental design involved the comparison of two noncomparable groups. The authors employed propensity score methodology to reconsider between-group baseline differences in observed characteristics of participating families. The authors also considered the possible effect of unobserved between-group differences. The data support previous studies that show few differences in outcomes, but the findings are sensitive to unobserved heterogeneity.

New methods for new questions: obstacles and opportunities.

Two forces motivate this special section, "New Methods for New Questions in Developmental Psychology." First are recent developments in social science methodology and the increasing availability of those methods in common software packages. Second, at the same time psychologists' understanding of developmental phenomena has continued to grow. At their best, these developments in theory and methods work in tandem, fueling each other. Newer methods make it possible for scientists to better test their ideas; better ideas lead methodologists to techniques that better reflect, capture, and quantify the underlying processes. The articles in this special section represent a sampling of these new methods and new questions. The authors describe common themes in these articles and identify barriers to future progress, such as the lack of data sharing by and analytical training for developmentalists.

Preventing Serious Conduct Problems in School-Age Youths: The Fast Track Program.

Children with early-starting conduct Problems have a very poor prognosis and exact a high cost to society. The Fast Track project is a multisite, collaborative research project investigating the efficacy of a comprehensive, long-term, multicomponent intervention designed to prevent the development of serious conduct problems in high-risk children. In this article, we (a) provide an overview of the development model that serves as the conceptual foundation for the Fast Track intervention and describe its integration into the intervention model; (b) outline the research design and intervention model, with an emphasis on the elementary school phase of the intervention; and (c) summarize findings to dale concerning intervention outcomes. We then provide a case illustration, and conclude with a discussion of guidelines for practitioners who work with children with conduct problems.

"The Costs of a Public Health Infrastructure for Delivering Parenting and Family Support".

Objectives: To estimate the costs of building a public health infrastructure for delivering a population-wide evidence-based multi-level system of parenting interventions to strengthen parenting; reduce risk for child maltreatment and coercive parenting practices; and reduce the prevalence of early child behavioral and emotional problems. Methods: Using data from 9 South Carolina counties, this study examines the costs to service agencies of training a wide range of providers. Using data on the number of children and families served, the paper estimates the total costs of training providers sufficient to treat all children and families in a hypothetical community. Results: The costs of the universal media and communication component totaled less than $1.00 per child in the population. The costs of training service providers to deliver at other intervention levels were quite modest ($11.74 on a per child basis). Conclusions: This study shows that a population-wide system of efficacious parenting programs aimed at reducing child behavioral and emotional problems and promoting effective parenting is quite feasible. Rough estimates suggest that these costs could be recovered in a single year by as little as a 10% reduction in the rate of abuse and neglect.

Is stacking intervention components cost-effective? An analysis of the Incredible Years program.

OBJECTIVE: Research demonstrates that interventions targeting multiple settings within a child's life are more effective in treating or preventing conduct disorder. One such program is the Incredible Years Series, which comprises three treatment components, each focused on a different context and type of daily social interaction that a child encounters. This article explores the cost-effectiveness of stacking multiple intervention components versus delivering single intervention components. METHOD: The data involved 459 children, ages 3 to 8, who participated in clinical trials of the Incredible Years Series. Children randomized to one of six treatment conditions received one or more of the three following program components: a child-based program, a parent training program, and a teacher-based program instructing teachers in classroom management and in the delivery of a classroom-based social skills curriculum. RESULTS: Per-child treatment costs and child behavior outcomes (observer and teacher reported) were used to generate cost-effectiveness acceptability curves; results suggest that stacking intervention components is likely cost-effective, at least for willingness to pay above $3,000 per child treated. CONCLUSIONS: Economic data may be used to compare competing intervention formats. In the case of this program, providing multiple intervention components was cost-effective.

Can a costly intervention be cost-effective?: An analysis of violence prevention.

OBJECTIVES: To examine the cost-effectiveness of the Fast Track intervention, a multi-year, multi-component intervention designed to reduce violence among at-risk children. A previous report documented the favorable effect of intervention on the highest-risk group of ninth-graders diagnosed with conduct disorder, as well as self-reported delinquency. The current report addressed the cost-effectiveness of the intervention for these measures of program impact. DESIGN: Costs of the intervention were estimated using program budgets. Incremental cost-effectiveness ratios were computed to determine the cost per unit of improvement in the 3 outcomes measured in the 10th year of the study. RESULTS: Examination of the total sample showed that the intervention was not cost-effective at likely levels of policymakers' willingness to pay for the key outcomes. Subsequent analysis of those most at risk, however, showed that the intervention likely was cost-effective given specified willingness-to-pay criteria. CONCLUSIONS: Results indicate that the intervention is cost-effective for the children at highest risk. From a policy standpoint, this finding is encouraging because such children are likely to generate higher costs for society over their lifetimes. However, substantial barriers to cost-effectiveness remain, such as the ability to effectively identify and recruit such higher-risk children in future implementations.

Treatment for ADHD: is more complex treatment cost-effective for more complex cases?

OBJECTIVE: To determine the cost-effectiveness of three alternative high-quality treatments for attention deficit hyperactivity disorder (ADHD) relative to community care (CC) and to determine whether cost-effectiveness varies with the presence of comorbid disorders. DATA SOURCES/COLLECTION: The study included 579 children ages 7-9.9 with diagnosed ADHD at six sites. Data for the study were distilled from administrative data and from interviews with parents, including estimates of the child's functional impairment. These analyses focus on changes in functional impairment over 14 months. STUDY DESIGN: The study involved a large clinical trial that randomized participants to one of four arms: routine CC, intensive medication management (MedMgt), multicomponent behavioral treatment, and a combination of behavioral treatment and medication. PRINCIPAL FINDINGS: We assessed the cost-effectiveness of the alternatives using costs measured from a payer perspective. The preferred cost-effective treatment varies as a function of the child's comorbidity and of the policy maker's willingness to pay. For pure (no comorbidity) ADHD, high-quality MedMgt appears likely to be cost-effective at all levels of willingness to pay. In contrast, for some comorbid conditions, willingness to pay is critical: the policy maker with low willingness to pay likely will judge MedMgt most cost-effective. On the other hand, a policy maker willing to pay more now in expectation of future costs savings (involving, for example, juvenile justice), will recognize that the most cost-effective choice for comorbid conditions likely involves behavior therapy, with or without medication. CONCLUSIONS: Analyses of costs and effectiveness of treatment for ADHD must consider the role of comorbidities.

The economic impact of attention-deficit/hyperactivity disorder in children and adolescents.

Using a cost of illness (COI) framework, this article examines the economic impact of attention-deficit/hyperactivity disorder (ADHD) in childhood and adolescence. Our review of published literature identified 13 studies, most conducted on existing databases by using diagnostic and medical procedure codes and focused on health care costs. Two were longitudinal studies of identified children with ADHD followed into adolescence. Costs were examined for ADHD treatment-related and other health care costs (all but 1 study addressed some aspect of health care), education (special education, 2 studies; disciplinary costs: 1 study), parental work loss (2 studies), and juvenile justice (2 studies). Based on this small and as yet incomplete evidence base, we estimated annual COI of ADHD in children and adolescents at $14,576 per individual (2005 dollars). Given the variability of estimates across studies on which that number is based, a reasonable range is between $12,005 and $17,458 per individual. Using a prevalence rate of 5%, a conservative estimate of the annual societal COI for ADHD in childhood and adolescence is $42.5 billion, with a range between $36 billion and $52.4 billion. Estimates are preliminary because the literature is incomplete; many potential costs have not been assessed in extant studies. Limitations of the review and suggestions for future research on COI of ADHD are provided.