Cardiovascular disease risk factors in congenital heart disease survivors are associated with heart failure.

BACKGROUND: Despite advances in treatment and survival, individuals with congenital heart defects (CHD) have a higher risk of heart failure (HF) compared to the general population. OBJECTIVE: To evaluate comorbidities associated with HF in patients with CHD with a goal of identifying potentially modifiable risk factors that may reduce HF-associated morbidity and mortality. METHODS: Five surveillance sites in the United States linked population-based healthcare data and vital records. Individuals with an ICD-9-CM code for CHD aged 11-64 years were included and were stratified by presence of HF diagnosis code. Prevalence of death and cardiovascular risk factors based on diagnosis codes were compared by HF status using log-linear regression. RESULTS: A total of 25,343 individuals met inclusion/exclusion criteria. HF was documented for 2.2% of adolescents and 12.9% of adults with CHD. Adolescents and adults with HF had a higher mortality than those without HF. In both age groups, HF was positively associated with coronary artery disease, hypertension, obesity, diabetes, and increased healthcare utilization compared to those without HF. CONCLUSIONS: Within this population-based cohort, over 1 in 50 adolescents and 1 in 8 adults with CHD had HF, which was associated with increased mortality. Modifiable cardiovascular comorbidities were associated with HF. IMPACT: Five sites in the United States linked population-based healthcare data and vital records to establish surveillance network for identifying the factors which influence congenital heart disease (CHD) outcomes. Survivors of CHD frequently develop heart failure across the lifespan. Over 1 in 50 adolescent and 1 in 8 adult survivors of CHD have heart failure which is associated with increased mortality compared to CHD survivors without heart failure. Heart failure development is associated with potentially modifiable cardiovascular risk factors such as hypertension, coronary artery disease, and diabetes. Controlling modifiable cardiovascular risk factors may serve to lower the risk of heart failure and mortality in survivors of congenital heart disease of all ages.

Longitudinal Assessment of Multimorbidity Medication Patterns among Smokers in the COPDGene Cohort.

Background and objectives: Chronic obstructive pulmonary disease (COPD) is usually comorbid with other chronic diseases. We aimed to assess the multimorbidity medication patterns and explore if the patterns are similar for phase 1 (P1) and 5-year follow-up phase 2 (P2) in the COPDGene cohort. Materials and Methods: A total of 5564 out of 10,198 smokers from the COPDGene cohort who completed 2 visits, P1 and P2 visits, with complete medication use history were included in the study. We conducted latent class analysis (LCA) among the 27 categories of chronic disease medications, excluding COPD treatments and cancer medications at P1 and P2 separately. The best number of LCA classes was determined through both statistical fit and interpretation of the patterns. Results: We found four classes of medication patterns at both phases. LCA showed that both phases shared similar characteristics in their medication patterns: LC0: low medication; LC1: hypertension (HTN) or cardiovascular disease (CVD)+high cholesterol (Hychol) medication predominant; LC2: HTN/CVD+type 2 diabetes (T2D) +Hychol medication predominant; LC3: Hychol medication predominant. Conclusions: We found similar multimorbidity medication patterns among smokers at P1 and P2 in the COPDGene cohort, which provides an understanding of how multimorbidity medication clustered and how different chronic diseases combine in smokers.

Individuals aged 1-64 years with documented congenital heart defects at healthcare encounters, five U.S. surveillance sites, 2011-2013.

BACKGROUND: Many individuals born with congenital heart defects (CHD) survive to adulthood. However, population estimates of CHD beyond early childhood are limited in the U.S. OBJECTIVES: To estimate the percentage of individuals aged 1-to-64 years at five U.S. sites with CHD documented at a healthcare encounter during a three-year period and describe their characteristics. METHODS: Sites conducted population-based surveillance of CHD among 1 to 10-year-olds (three sites) and 11 to 64-year-olds (all five sites) by linking healthcare data. Eligible cases resided in the population catchment areas and had one or more healthcare encounters during the surveillance period (January 1, 2011-December 31, 2013) with a CHD-related ICD-9-CM code. Site-specific population census estimates from the same age groups and time period were used to assess percentage of individuals in the catchment area with a CHD-related ICD-9-CM code documented at a healthcare encounter (hereafter referred to as CHD cases). Severe and non-severe CHD were based on an established mutually exclusive anatomic hierarchy. RESULTS: Among 42,646 CHD cases, 23.7% had severe CHD and 51.5% were male. Percentage of CHD cases among 1 to 10-year-olds, was 6.36/1,000 (range: 4.33-9.96/1,000) but varied by CHD severity [severe: 1.56/1,000 (range: 1.04-2.64/1,000); non-severe: 4.80/1,000 (range: 3.28-7.32/1,000)]. Percentage of cases across all sites in 11 to 64-year-olds was 1.47/1,000 (range: 1.02-2.18/1,000) and varied by CHD severity [severe: 0.34/1,000 (range: 0.26-0.49/1,000); non-severe: 1.13/1,000 (range: 0.76-1.69/1,000)]. Percentage of CHD cases decreased with age until 20 to 44 years and, for non-severe CHD only, increased slightly for ages 45 to 64 years. CONCLUSION: CHD cases varied by site, CHD severity, and age. These findings will inform planning for the needs of this growing population.

The relationship between traffic-related air pollution exposures and allostatic load score among youth with type 1 diabetes in the SEARCH cohort.

OBJECTIVE: We investigated the effects of chronic exposures to particulate and traffic-related air pollution on allostatic load (AL) score, a marker of cumulative biological risk, among youth with type 1 diabetes. RESEARCH DESIGN AND METHODS: Participants were drawn from five clinical sites of the SEARCH for Diabetes in Youth (SEARCH) study (n = 2338). Baseline questionnaires, anthropometric measures, and a fasting blood test were taken at a clinic visit between 2001 and 2005. AL was operationalized using 10 biomarkers reflecting cardiovascular, metabolic, and inflammatory risk. Annual residential exposures to PM2.5 and proximity to heavily-trafficked major roadways were estimated for each participant. Poisson regression models adjusted for sociodemographic and lifestyle factors were conducted for each exposure. RESULTS: No significant associations were observed between exposures to PM2.5 or proximity to traffic and AL score, however analyses were suggestive of effect modification by race for residential distance to heavily-trafficked major roadways (p = 0.02). In stratified analyses, residing <100, 100-<200 and 200-<400 m compared to 400 m or more from heavily-trafficked major roadways was associated with 11%, 26% and 14% increases in AL score, respectively (95% CIs: -4, 29; 9, 45; -1, 30) for non-white participants compared to 6%, -2%, and -2% changes (95% CIs: -2, 15; -10, 7; -8, 6) for white participants. CONCLUSIONS: Among this population of youth with type 1 diabetes, we did not observe consistent relationships between chronic exposures to particulate and traffic-related air pollution and changes in AL score, however associations for traffic-related pollution exposures may differ by race/ethnicity and warrant further examination.

Estimating the prevalence of congenital heart disease among adolescents and adults in Colorado adjusted for incomplete case ascertainment.

BACKGROUND: Congenital heart defects (CHDs), the most common type of birth defect in the United States, are increasing in prevalence in the general population. Though CHD prevalence at birth has been well described in the United States at about 1%, little is known about long-term survival and prevalence of CHDs beyond childhood. This study aimed to estimate the prevalence of CHDs among adolescents and adults in Colorado. METHODS: The prevalence of CHDs among adolescents and adults residing in Colorado during 2011 to 2013 was estimated using log-linear capture-recapture methods to account for incomplete case ascertainment. Five case-finding data sources were used for this analysis including electronic health record data from 4 major health systems and a state-legislated all payer claims database. RESULTS: Twelve thousand two hundred ninety-three unique individuals with CHDs (2481 adolescents and 9812 adults) were identified in one or more primary data sources. We estimated the crude prevalence of CHDs in adolescents and adults in Colorado to be 3.22 per 1000 individuals (95% CI 3.19-3.53). After accounting for incomplete case ascertainment, the final capture-recapture model yielded an estimated total adolescent and adult CHD population of 23,194 (95% CI 22,419-23,565) and an adjusted prevalence of 6.07 per 1000 individuals (95% CI 5.86-6.16), indicating 47% of the cases in the catchment area were not identified in the case-identifying data sources. CONCLUSION: This statewide study yielded new information on the prevalence of CHDs in adolescents and adults. These high prevalence rates underscore the need for additional specialized care facilities for this population with CHDs.

Population-level surveillance of congenital heart defects among adolescents and adults in Colorado: Implications of record linkage.

BACKGROUND: The objective was to describe the design of a population-level electronic health record (EHR) and insurance claims-based surveillance system of adolescents and adults with congenital heart defects (CHDs) in Colorado and to evaluate the bias introduced by duplicate cases across data sources. METHODS: The Colorado CHD Surveillance System ascertained individuals aged 11-64 years with a CHD based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic coding between 2011 and 2013 from a diverse network of health care systems and an All Payer Claims Database (APCD). A probability-based identity reconciliation algorithm identified duplicate cases. Logistic regression was conducted to investigate bias introduced by duplicate cases on the relationship between CHD severity (severe compared to moderate/mild) and adverse outcomes including all-cause mortality, inpatient hospitalization, and major adverse cardiac events (myocardial infarction, congestive heart failure, or cerebrovascular event). Sensitivity analyses were conducted to investigate bias introduced by the sole use or exclusion of APCD data. RESULTS: A total of 12,293 unique cases were identified, of which 3,476 had a within or between data source duplicate. Duplicate cases were more likely to be in the youngest age group and have private health insurance, a severe heart defect, a CHD comorbidity, and higher health care utilization. We found that failure to resolve duplicate cases between data sources would inflate the relationship between CHD severity and both morbidity and mortality outcomes by ~15%. Sensitivity analyses indicate that scenarios in which APCD was excluded from case finding or relied upon as the sole source of case finding would also result in an overestimation of the relationship between a CHD severity and major adverse outcomes. DISCUSSION: Aggregated EHR- and claims-based surveillance systems of adolescents and adults with CHD that fail to account for duplicate records will introduce considerable bias into research findings. CONCLUSION: Population-level surveillance systems for rare chronic conditions, such as congenital heart disease, based on aggregation of EHR and claims data require sophisticated identity reconciliation methods to prevent bias introduced by duplicate cases.

The accuracy of provider diagnosed diabetes type in youth compared to an etiologic criteria in the SEARCH for Diabetes in Youth Study.

BACKGROUND: Although surveillance for diabetes in youth relies on provider-assigned diabetes type from medical records, its accuracy compared to an etiologic definition is unknown. METHODS: Using the SEARCH for Diabetes in Youth Registry, we evaluated the validity and accuracy of provider-assigned diabetes type abstracted from medical records against etiologic criteria that included the presence of diabetes autoantibodies (DAA) and insulin sensitivity. Youth who were incident for diabetes in 2002-2006, 2008, or 2012 and had complete data on key analysis variables were included (n = 4001, 85% provider diagnosed type 1). The etiologic definition for type 1 diabetes was ≥1 positive DAA titer(s) or negative DAA titers in the presence of insulin sensitivity and for type 2 diabetes was negative DAA titers in the presence of insulin resistance. RESULTS: Provider diagnosed diabetes type correctly agreed with the etiologic definition of type for 89.9% of cases. Provider diagnosed type 1 diabetes was 96.9% sensitive, 82.8% specific, had a positive predictive value (PPV) of 97.0% and a negative predictive value (NPV) of 82.7%. Provider diagnosed type 2 diabetes was 82.8% sensitive, 96.9% specific, had a PPV and NPV of 82.7% and 97.0%, respectively. CONCLUSION: Provider diagnosis of diabetes type agreed with etiologic criteria for 90% of the cases. While the sensitivity and PPV were high for youth with type 1 diabetes, the lower sensitivity and PPV for type 2 diabetes highlights the value of DAA testing and assessment of insulin sensitivity status to ensure estimates are not biased by misclassification.

Metabolomics-related nutrient patterns at seroconversion and risk of progression to type 1 diabetes.

OBJECTIVE: Our aim was to elucidate the role of diet in type 1 diabetes (T1D) by examining combinations of nutrient intake in the progression from islet autoimmunity (IA) to T1D. METHODS: We measured 2457 metabolites and dietary intake at the time of seroconversion in 132 IA-positive children in the prospective Diabetes Autoimmunity Study in the Young. IA was defined as the first of two consecutive visits positive for at least one autoantibody (insulin, GAD, IA-2, or ZnT8). By December 2018, 40 children progressed to T1D. Intakes of 38 nutrients were estimated from semiquantitative food frequency questionnaires. We tested the association of each metabolite with progression to T1D using multivariable Cox regression. Nutrient patterns that best explained variation in candidate metabolites were identified using reduced rank regression (RRR), and their association with progression to T1D was tested using Cox regression adjusting for age at seroconversion and high-risk HLA genotype. RESULTS: In stepwise selection, 22 nutrients significantly predicted at least two of the 13 most significant metabolites associated with progression to T1D, and were included in RRR. A nutrient pattern corresponding to intake lower in linoleic acid, niacin, and riboflavin, and higher in total sugars, explained 18% of metabolite variability. Children scoring higher on this metabolite-related nutrient pattern at seroconversion had increased risk for progressing to T1D (HR = 3.17, 95%CI = 1.42-7.05). CONCLUSIONS: Combinations of nutrient intake reflecting candidate metabolites are associated with increased risk of T1D, and may help focus dietary prevention efforts.

Effect of environmental conditions on injury rates at a Colorado ski resort.

OBJECTIVE: To determine the effect of daily environmental conditions on skiing and snowboarding-related injury rates. METHODS: Injury information was collected from a mountainside clinic at a large Colorado ski resort for the 2012/2013 through 2016/2017 seasons. Daily environmental conditions including snowfall, snow base depth, temperature, open terrain and participant visits were obtained from historical resort records. Snowpack and visibility information were obtained for the 2013/2014 through 2014/2015 seasons and included in a subanalysis. Negative binomial regression was used to estimate injury rate ratios (IRRs) and 95% CIs. RESULTS: The overall injury rate among skiers and snowboarders was 1.37 per 1000 participant visits during 2012/2013 through 2016/2017. After adjustment for other environmental covariates, injury rates were 22% higher (IRR=1.22, 95% CI 1.14 to 1.29) on days with <2.5 compared with ≥2.5 cm of snowfall, and 14% higher on days with average temperature in the highest quartile (≥-3.1°C) compared with the lowest (<-10.6°C; IRR=1.14, 95% CI 1.03 to 1.26). Rates decreased by 8% for every 25 cm increase in snow base depth (IRR=0.92, 95% CI 0.88 to 0.95). In a subanalysis of the 2013/2014 and 2014/2015 seasons including the same covariates plus snowpack and visibility, only snowpack remained significantly associated with injury rates. Rates were 71% higher on hardpack compared with powder days (IRR=1.71, 95% CI 1.18 to 2.49) and 36% higher on packed powder compared with powder days (IRR 1.36, 95% CI 1.12 to 1.64). CONCLUSIONS: Environmental conditions, particularly snowfall and snowpack, have a significant impact on injury rates. Injury prevention efforts should consider environmental factors to decrease injury rates in skiers and snowboarders.

Impact of an incentive-based prenatal smoking cessation program for low-income women in Colorado.

OBJECTIVE: To assess birth outcomes and cost-savings of an incentive-based prenatal smoking cessation program targeting low-income women in Colorado. DESIGN: Prospective observational cohort with nonequivalent population control groups. SAMPLE: Program participants (n = 2,231) linked to the birth certificate to ascertain birth outcomes compared to two reference populations from Pregnancy Risk Assessment Monitoring System (PRAMS) and Colorado live births based on the birth certificate. MEASUREMENTS: Tobacco cessation metrics in the third trimester of pregnancy, neonatal low birth weight (<2,500 g), preterm birth (birth at <37 weeks gestation), neonatal intensive care unit (NICU) admission and maternal gestational hypertension. Cost-savings and return on investment (ROI) were projected using average Medicaid reimbursement. RESULTS: Infants of mothers enrolled in the program had a lower risk of low birthweight (RR = 0.86; 95% CI = 0.75, 0.97), preterm birth (PTB) (RR = 0.76; 95% CI = 0.65, 0.88) and neonatal intensive care unit (NICU) admission (RR = 0.76; 95% CI = 0.66, 0.88) compared to the birth certificate population, corresponding to a ROI of $7.73 and an individual cost savings of $6,040. Compared to PRAMS, infants of enrolled mothers had a lower risk of PTB (RR = 0.72; 95% CI = 0.53, 0.99) and NICU admission (RR = 0.45; 95% CI = 0.32, 0.62), corresponding to an ROI of $2.79 and an individual cost savings of $2,182. CONCLUSIONS: We found a reduction of adverse birth outcomes, and cost savings.

A comparison of recreational skiing- and snowboarding-related injuries at a Colorado ski resort, 2012/13-2016/17.

The purpose of this study was to compare injury patterns between recreational skiers and snowboarders. Injured skiers (n = 3,961) and snowboarders (n = 2,428) presented to a mountainside medical clinic, 2012/13-2016/17. Variables investigated for analysis included demographics/characteristics, injury event information, and injury information. Skiers were older than snowboarders (34.3 ± 19.3 vs. 23.2 ± 10.5 years, p < 0.001); a greater proportion of skiers were female (46.3% vs. 27.8%, p < 0.001). Most skiers (84.4%) and snowboarders (84.5%) were helmeted at the time of injury (p = 0.93). Snowboarders were most frequently beginners (38.9%), skiers were intermediates (37.8%). Falls to snow (skiers = 72.3%, snowboarders = 84.8%) and collisions with natural objects (skiers = 9.7%, snowboarders = 7.4%) were common injury mechanisms. Common skiing injuries were knee sprains (20.5%) and head trauma (8.9%); common snowboarding injuries were wrist fractures (25.7%), shoulder separations (9.1%), and head trauma (9.0%). Given that injury patterns significantly differ between sports, it is important for clinicians, ski patrollers, and resorts to develop and deliver sport-specific injury prevention interventions to most effectively decrease injury burden.

Exposure to Diabetes in Utero Is Associated with Earlier Pubertal Timing and Faster Pubertal Growth in the Offspring: The EPOCH Study.

OBJECTIVE: To examine the associations of in utero exposure to maternal diabetes with surrogate measures of offspring pubertal timing (age at peak height velocity [APHV]) and speed of pubertal growth (peak height velocity [PHV]). STUDY DESIGN: Data from 77 exposed and 340 unexposed youth followed from age 2 to 19 years (51% non-Hispanic white, 50% female) were analyzed using the Exploring Perinatal Outcomes among Children study, a historical prospective cohort. Maternal diabetes status was collected from obstetric records, and child heights from 2 years to current age from pediatric records. Other covariates were collected during research visits. The superimposition by translation and rotation method, using height measurements (4-52 per participant), modeled APHV and PHV. Accelerated failure time analyses were used to test whether exposure to maternal diabetes was associated with younger APHV and faster PHV. RESULTS: Adjusting for child's sex, race/ethnicity, and socioeconomic status, median APHV was reached ~3 months earlier in youth exposed to maternal diabetes compared with unexposed youth (P < .03). Youth exposed to maternal diabetes had a faster PHV than unexposed youth: exposed girls had 10.5% greater median PHV compared with unexposed girls and exposed boys had a 4.0% greater median PHV compared with unexposed boys (P < .001 for exposure by sex interaction). CONCLUSIONS: Our findings provide evidence that exposure to maternal diabetes in utero is associated with earlier pubertal timing and faster pubertal growth. Whether earlier puberty or faster speed of pubertal growth mediates the association between maternal diabetes exposure and later chronic disease risk remains to be studied.

Trends in prevalence of cardiovascular risk factors from 2002 to 2012 among youth early in the course of type 1 and type 2 diabetes. The SEARCH for Diabetes in Youth Study.

BACKGROUND: Given diabetes is an important risk factor for cardiovascular disease (CVD), we examined temporal trends in CVD risk factors by comparing youth recently diagnosed with type 1 diabetes (T1D) and type 2 diabetes (T2D) from 2002 through 2012. METHODS: The SEARCH for Diabetes in Youth Study identified youth with diagnosed T1D (n = 3954) and T2D (n = 706) from 2002 to 2012. CVD risk factors were defined using the modified Adult Treatment Panel III criteria for metabolic syndrome: (a) hypertension; (b) high-density lipoprotein cholesterol ≤40 mg/dL; (c) triglycerides ≥110 mg/dL; and (d) waist circumference (WC) >90th percentile. Prevalence of CVD risk factors, stratified by diagnosis year and diabetes type, was reported. Univariate and multivariate logistic models and Poisson regression were fit to estimate the prevalence trends for CVD risk factors individually and in clusters (≥2 risk factors). RESULTS: The prevalence of ≥2 CVD risk factors was higher in youth with T2D than with T1D at each incident year, but the prevalence of ≥2 risk factors did not change across diagnosis years among T1D or T2D participants. The number of CVD risk factors did not change significantly in T1D participants, but increased at an annual rate of 1.38% in T2D participants. The prevalence of hypertension decreased in T1D participants, and high WC increased in T2D participants. CONCLUSION: The increase in number of CVD risk factors including large WC among youth with T2D suggests a need for early intervention to address these CVD risk factors. Further study is needed to examine longitudinal associations between diabetes and CVD.

Tobacco Use During Pregnancy.

Smoking during pregnancy is the most common preventable cause of infant morbidity and mortality. Cessation by the third trimester has consistently been associated with improved birth outcomes; however, the majority of women who obtain cessation during pregnancy, relapse in the first year postpartum. The majority of women who smoke during pregnancy developed their addiction to tobacco in early life, thus the need to intervene in the familial transmission of nicotine dependence is clear. This review discusses the epidemiology of tobacco use amongst pregnant women and factors associated with cessation. Specific intervention strategies are discussed and recommendations are provided to clinicians.

Cannabis Use During the Perinatal Period in a State With Legalized Recreational and Medical Marijuana: The Association Between Maternal Characteristics, Breastfeeding Patterns, and Neonatal Outcomes.

OBJECTIVES: To evaluate state-level prevalence estimates of prenatal and early postnatal cannabis use in a state with legalized medical and recreational marijuana and the association with adverse neonatal outcomes. STUDY DESIGN: We conducted a cross-sectional study on 3,207 respondents from the 2014-2015 Colorado Pregnancy Risk Assessment Monitoring System with state-developed questions on cannabis use. Differences in perinatal cannabis use were evaluated according to maternal characteristics, breastfeeding patterns, and pregnancy intendedness. Multiple logistic regression models evaluated the relationship between prenatal cannabis use and adverse neonatal outcomes including low birth weight, small for gestational age, preterm birth, and admission to the neonatal intensive care unit. RESULTS: The self-reported prevalence of cannabis use at any time during pregnancy was 5.7 ± 0.5% and the prevalence of early postnatal cannabis use among women who breastfed was 5.0% (95% CI, 4.1%-6.2%). Prenatal cannabis use was associated with a 50% increased likelihood of low birth weight, independent of maternal age, race/ethnicity, level of education, and tobacco use during pregnancy (OR, 1.5; 95% CI, 1.1-2.1; P = .02). Small for gestational age, preterm birth, and neonatal intensive care unit admission were not associated with prenatal cannabis use, independent of prenatal tobacco use. CONCLUSIONS: Our findings underscore the importance of screening for cannabis use during prenatal care and the need for provider counselling about the adverse health consequences of continued use during pregnancy and lactation.

Maternal dietary intake during pregnancy and offspring body composition: The Healthy Start Study.

BACKGROUND: Consistent evidence of an influence of maternal dietary intake during pregnancy on infant body size and composition in human populations is lacking, despite robust evidence in animal models. OBJECTIVE: We sought to evaluate the influence of maternal macronutrient intake and balance during pregnancy on neonatal body size and composition, including fat mass and fat-free mass. STUDY DESIGN: The analysis was conducted among 1040 mother-offspring pairs enrolled in the prospective prebirth observational cohort: the Healthy Start Study. Diet during pregnancy was collected using repeated 24-hour dietary recalls (up to 8). Direct measures of body composition were obtained using air displacement plethysmography. The National Cancer Institute measurement error model was used to estimate usual dietary intake during pregnancy. Multivariable partition (nonisocaloric) and nutrient density (isocaloric) linear regression models were used to test the associations between maternal dietary intake and neonatal body composition. RESULTS: The median macronutrient composition during pregnancy was 32.2% from fat, 15.0% from protein, and 47.8% from carbohydrates. In the partition multivariate regression model, individual macronutrient intake values were not associated with birthweight or fat-free mass, but were associated with fat mass. Respectively, 418 kJ increases in total fat, saturated fat, unsaturated fat, and total carbohydrates were associated with 4.2-g (P = .03), 11.1-g (P = .003), 5.9-g (P = .04), and 2.9-g (P = .02) increases in neonatal fat mass, independent of prepregnancy body mass index. In the nutrient density multivariate regression model, macronutrient balance was not associated with fat mass, fat-free mass, or birthweight after adjustment for prepregnancy body mass index. CONCLUSION: Neonatal adiposity, but not birthweight, is independently associated with increased maternal intake of total fat, saturated fat, unsaturated fat, and total carbohydrates, but not protein, suggesting that most forms of increased caloric intake contribute to fetal fat accretion.

Testing the fuel-mediated hypothesis: maternal insulin resistance and glucose mediate the association between maternal and neonatal adiposity, the Healthy Start study.

AIMS/HYPOTHESIS: In women who are overweight or obese before or during pregnancy there is an associated risk of increased fetal growth and higher birthweight. The metabolic phenotype of the overweight/obese pregnant woman, characterised by higher than normal insulin resistance (IR) and increased circulating fuels, suggests a mechanism resulting in fetal overnutrition and subsequent increased adiposity. We tested the fuel-mediated hypothesis in an observational pre-birth cohort of 951 mother-offspring pairs, the Healthy Start study. METHODS: We conducted a path analysis to estimate the simultaneous effects of maternal IR and maternal fuels (fasting glucose, triacylglycerol [TG] and NEFA levels) in late pregnancy in mediating the relationship between maternal pre-pregnancy BMI and neonatal adiposity (per cent fat mass [%FM]). RESULTS: The total effect of maternal BMI on neonatal %FM was significant (total effect 0.16, 95% CI 0.08, 0.22, p < 0.001). The mediated path including maternal IR and glucose levels together accounted for 21% (p < 0.01) of the total effect of maternal BMI on neonatal %FM while the mediating effects of all other fuels were non-significant. CONCLUSIONS/INTERPRETATION: Using a novel application of path analysis our data implicate maternal IR and glucose levels as important mediators of the association between maternal and infant adiposity.

Sugar-sweetened beverage intake and cardiovascular risk factor profile in youth with type 1 diabetes: application of measurement error methodology in the SEARCH Nutrition Ancillary Study.

The SEARCH Nutrition Ancillary Study aims to investigate the role of dietary intake on the development of long-term complications of type 1 diabetes in youth, and capitalise on measurement error (ME) adjustment methodology. Using the National Cancer Institute (NCI) method for episodically consumed foods, we evaluated the relationship between sugar-sweetened beverage (SSB) intake and cardiovascular risk factor profile, with the application of ME adjustment methodology. The calibration sample included 166 youth with two FFQ and three 24 h dietary recall data within 1 month. The full sample included 2286 youth with type 1 diabetes. SSB intake was significantly associated with higher TAG, total and LDL-cholesterol concentrations, after adjusting for energy, age, diabetes duration, race/ethnicity, sex and education. The estimated effect size was larger (model coefficients increased approximately 3-fold) after the application of the NCI method than without adjustment for ME. Compared with individuals consuming one serving of SSB every 2 weeks, those who consumed one serving of SSB every 2 d had 3.7 mg/dl (0.04 mmol/l) higher TAG concentrations and 4.0 mg/dl (0.10 mmol/l) higher total cholesterol and LDL-cholesterol concentrations, after adjusting for ME and covariates. SSB intake was not associated with measures of adiposity and blood pressure. Our findings suggest that SSB intake is significantly related to increased lipid levels in youth with type 1 diabetes, and that estimates of the effect size of SSB on lipid levels are severely attenuated in the presence of ME. Future studies in youth with diabetes should consider a design that will allow for the adjustment for ME when studying the influence of diet on health status.

Longitudinal association between television watching and computer use and risk markers in diabetes in the SEARCH for Diabetes in Youth Study.

BACKGROUND: The study provides evidence of the longitudinal association between screen time with hemoglobin A1c (HbA1c) and cardiovascular risk markers among youth with type 1 diabetes (T1D) and type 2 diabetes (T2D). OBJECTIVE: To examine the longitudinal relationship of screen time with HbA1c and serum lipids among youth with diabetes. SUBJECTS: Youth with T1D and T2D. METHODS: We followed up 1049 youth (≥10 yr old) with recently diagnosed T1D and T2D participating in the SEARCH for Diabetes in Youth Study. RESULTS: Increased television watching on weekdays and during the week over time was associated with larger increases in HbA1c among youth with T1D and T2D (p-value <0.05). Among youth with T1D, significant longitudinal associations were observed between television watching and TG (p-value <0.05) (week days and whole week), and low-density lipoprotein cholesterol (LDL-c, p-value <0.05) (whole week). For example, for youth who watched 1 h of television per weekday at the outset and 3 h per weekday 5 yr later, the longitudinal model predicted greater absolute increases in HbA1c (2.19% for T1D and 2.16% for T2D); whereas for youth who watched television 3 h per weekday at the outset and 1 h per weekday 5 yr later, the model predicted lesser absolute increases in HbA1c (2.08% for T1D and 1.06% for T2D). CONCLUSIONS: Youth with T2D who increased their television watching over time vs. those who decreased it had larger increases in HbA1c over 5 yr. Youth with T1D who increased their television watching over time had increases in LDL-c, TG, and to a lesser extent HbA1c.

The Association Between Stimulant, Opioid, and Multiple Drug Use on Behavioral Health Care Utilization in a Safety-Net Health System.

BACKGROUND: Prior studies show an association between drug use and health care utilization. The relationship between specific drug type and emergent/urgent, inpatient, outpatient, and behavioral health care utilization has not been examined. We aimed to determine if multiple drug use was associated with increased utilization of behavioral health care. METHODS: To assess health care utilization, we conducted a retrospective cohort study of patients who accessed health care at a safety-net medical center and affiliated clinics. Using electronic health records, we categorized patients who used stimulants, opioids, or multiple drugs based on urine toxicology screening tests and/or International Classification of Diseases, 9th Revision (ICD-9). Remaining patients were categorized as patients without identified drug use. Health care utilization by drug use group and visit type was determined using a negative binomial regression model. Associations were reported as incidence rate ratios. Utilization was described by rates of health care-related visits for inpatient, emergent/urgent, outpatient, and behavioral health care among patients who used drugs, categorized by drug types, compared with patients without identified drug use. RESULTS: Of 95,198 index visits, 4.6% (n=4340) were by patients who used drugs. Opioid and multiple drug users had significantly higher rates of behavioral health care visits than patients without identified drug use (opioid incidence rate ratio [IRR]=7.2; 95% confidence interval [CI]: 3.8-13.8; multiple drug use IRR=5.6, 95% CI: 3.3-9.7). Patients who used stimulants were less likely to use behavioral health services (IRR=1.3, 95% CI: 0.9-2.0) when compared with opioid and multiple drug users, but were more likely to use inpatient (IRR=1.6, 95% CI: 1.4-1.8) and emergent/urgent care (IRR=1.4, 95% CI: 1.3-1.5) services as compared with patients without identified drug use. CONCLUSIONS: Integrated medical and mental health care and drug treatment may reduce utilization of costly health care services and improve patient outcomes. How to capture and deliver primary care and behavioral health care to patients who use stimulants needs further investigation.