Diabetes trends in the U.S.: 1990-1998.

OBJECTIVE: To examine trends in diabetes prevalence in the U.S. RESEARCH DESIGN AND METHODS: This study was conducted via telephone surveys in states that participated in the Behavioral Risk Factor Surveillance System between 1990 and 1998. The participants consisted of noninstitutionalized adults aged 18 years or older. The main outcome measure was self-reported diabetes. RESULTS: The prevalence of diabetes rose from 4.9% in 1990 to 6.5% in 1998--an increase of 33%. Increases were observed in both sexes, all ages, all ethnic groups, all education levels, and nearly all states. Changes in prevalence varied by state. The prevalence of diabetes was highly correlated with the prevalence of obesity (r = 0.64, P<0.001). CONCLUSIONS: The prevalence of diabetes continues to increase rapidly in the U.S. Because the prevalence of obesity is also rising, diabetes will become even more common. Major efforts are needed to alter these trends.

Cost-benefit analysis of preconception care for women with established diabetes mellitus.

OBJECTIVE: To determine whether the additional costs of preconception care are balanced by the savings from averted complications. Several studies have demonstrated the efficacy of preconception care in reducing congenital anomalies in infants born of mothers with pre-existing diabetes mellitus. RESEARCH DESIGN AND METHODS: This study used literature review, consensus development among an expert panel of physicians, and surveys of medical care personnel to obtain information about the costs and consequences of preconception plus prenatal care compared with prenatal care only for women with established diabetes. Preconception care involves close interaction between the patient and an interdisciplinary health-care team as well as intensified evaluation, follow-up, testing, and monitoring. The outcome measures assessed in this study are the medical costs of preconception care versus prenatal care only and the benefit-cost ratio. RESULTS: The costs of preconception plus prenatal care are $17,519/delivery, whereas the costs of prenatal care only are $13,843/delivery. Taking into account maternal and neonatal adverse outcomes, the net savings of preconception care are $1720/enrollee over prenatal care only and the benefit-cost ratio is 1.86. The preconception care program remained cost saving across a wide range of assumptions regarding incidence of adverse outcomes and program cost components. CONCLUSIONS: Despite significantly higher per delivery costs for participants in a hypothetical preconception care program, intensive medical care before conception resulted in cost savings compared with prenatal care only. Third-party payers can expect to realize cost savings by reimbursing preconception care in this high-risk population.

Financial implications of implementing standards of care for diabetes and pregnancy.

This article examines the financial implications of implementing standards of care for pregnancy among women with diabetes, including both the costs of enhanced treatment and the savings of avoided adverse outcomes. Numerous studies have demonstrated the harmful effects of poor blood glucose control for both mother and fetus. Standards set forth by the American Diabetes Association aim to reduce maternal complications and fetal adverse outcomes, such as congenital malformations. Because the precise configuration of resources required to meet these standards was not outlined in the American Diabetes Association statement, a panel of physicians (all specialists in pregnancy care for women with diabetes) was convened to develop a model program. Implementing such a program during the preconception and prenatal periods will represent an intensification of resource use in the outpatient setting. However, through these preventive measures, medical care costs for maternal and fetal complications can be avoided.

Seasonal differences in breast-feeding in rural Egypt.

Two surveys in Upper and Lower rural Egypt allowed an analysis of the seasonality of infant feeding. The first, including 937 children, was conducted during the relatively cool season of low diarrhea incidence in January-April 1978; the second, including 976 children, took place during the hot season of high diarrhea incidence in August-September 1980. Of infants 6-11 mo old, the proportion exclusively breast-feeding was greater in the hot-season survey (40% vs 16% in Lower Egypt, p less than 0.01; 36% vs 22% in Upper Egypt, p less than 0.01). Of children 12-17 mo old, a higher proportion were completely weaned during the hot season in Lower Egypt only (28% vs 14%, p less than 0.01). This difference was explained by an increase in pregnancy rates during the hot season resulting in less breast-feeding. Seasonal variation must be considered in the interpretation of infant-feeding surveys.

PIP: 2 surveys in Upper and Lower rural Egypt allowed an analysis of the seasonality of infant feeding. The 1st, including 937 children, was conducted during the relatively cool season of low diarrhea incidence in January-April 1978; the 2nd, including 976 children, took place during the hot season of high diarrhea in August-September 1980. On infants 6-11 mo old, the proportion exclusively breastfeeding was greater in the hot-season survey (40% vs. 16% in Lower Egypt, p0.01; 36% vs 22% in Upper Egypt, p0.01). Of children 12-17 months old, a higher proportion were completely weaned during the hot season in Lower Egypt only (28% vs 14%, p0.01). This difference was explained by an increase in pregnancy rates during the hot season resulting in less breastfeeding. Seasonal variation must be considered in the interpretation of infant-feeding surveys.

Overweight adults in the United States: the behavioral risk factor surveys.

Using data on 19,405 adults from telephone interviews across the US, 1981-1983, we examined the sociodemographic characteristics, health-risk behaviors, body image, and dieting of overweight adults classified by the 1959 Metropolitan Life Insurance tables for weight and height. By self-report, 23% were overweight vs 29% in 1960-62. This modest decline in overweight remained after age-adjusting the 1981-1983 rate to the 1960 population. In 1981-1983, more blacks and Hispanics than whites were overweight [rate ratio (RR) = 1.43]. After adjustment for age and education, more over- than average-weight adults had uncontrolled hypertension, were binge drinking, and had a sedentary lifestyle. Among overweight men and women, 72% and 52%, respectively, were not dieting. Overweight adults acknowledging they were overweight were dieting more often than those without this perception (RR = 1.53). Results are discussed in light of research documenting weight gain and overweight as independent risk factors for cardiovascular disease incidence and mortality.

Body composition of Peruvian children with short stature and high weight-for-height. II. Implications for the interpretation for weight-for-height as an indicator of nutritional status.

In some child populations, low height-for-age, suggesting chronic undernutrition, may paradoxically be accompanied by relatively high weight-for-height, suggesting obesity. This growth pattern was investigated with anthropometric assessment and body composition studies using H2(18)O stable isotope dilution in 139 preschool-age Peruvian children. Results suggested low height-for-age (15th percentile National Center for Health Statistics [NCHS]) and high weight-for-height (60th percentile NCHS). Skinfold thicknesses were lower whereas arm muscle areas were more similar to NCHS reference values. Total body water (as percent body weight) was greater than reference values, consistent with lower body fat. Differences in body proportions did not account adequately for the high weight-for-height. The data suggest that the high weight-for-height in these children is not obesity but is associated with lower body fat and greater lean tissue or lean tissue hydration that may reflect dietary, environmental, or genetic influences. Weight-for-height cutoffs for wasting or obesity may require different interpretations for different populations.

Evaluation of reactions to food additives: the aspartame experience.

Despite the widespread use of chemical food additives, few criteria exist to evaluate consumer reports of adverse reactions. We analyzed 231 consumer complaints associated with the food additive aspartame. We developed a methodologic approach to evaluate all complaints by adapting general criteria used to investigate adverse reactions to medications. Complaints were ranked according to the effects of cessation and rechallenge. Using this method, we found no clear symptom complex that suggests a widespread public health hazard associated with aspartame use; however, we identified some case reports in which the symptoms may be attributable to aspartame in commonly-consumed amounts. The systematic application of pre-defined review criteria, such as those described here, to monitor consumer complaints related to food additives will help identify products that warrant more focused clinical studies.

Body composition of Peruvian children with short stature and high weight-for-height. I. Total body-water measurements and their prediction from anthropometric values.

Total body water (TBW) was measured by 18O dilution in 139 undernourished, preschool Peruvian children with high weight-for-height. Values for TBW as a percent of body weight were relatively high, averaging 67.4 +/- 6.4%. Depending upon the method of calculation, mean values for the sample population for percent fat ranged from 9.4-18.5%. Regression of TBW on lean body mass suggested that hydration of the fat-free body was higher than for normally nourished children of comparable age. Thus, the increased weight-for-height in these children did not result from increased fat tissue, but from increased hydration of the fat-free body. TBW was most highly correlated with height and weight, both with r = 0.95. Equations predicting TBW from either height or weight were significantly different from those developed by other investigators to predict TBW for normal, well-nourished American children.

Design, synthesis, and cocrystal structure of a nonpeptide Src SH2 domain ligand.

The specific association of an SH2 domain with a phosphotyrosine (pTyr)-containing sequence of another protein precipitates a cascade of intracellular molecular interactions (signals) which effect a wide range of intracellular processes. The nonreceptor tyrosine kinase Src, which has been associated with breast cancer and osteoporosis, contains an SH2 domain. Inhibition of Src SH2-phosphoprotein interactions by small molecules will aid biological proof-of-concept studies which may lead to the development of novel therapeutic agents. Structure-based design efforts have focused on reducing the size and charge of Src SH2 ligands while increasing their ability to penetrate cells and reach the intracellular Src SH2 domain target. In this report we describe the synthesis, binding affinity, and Src SH2 cocrystal structure of a small, novel, nonpeptide, urea-containing SH2 domain ligand.

Measles vaccine efficacy in children previously vaccinated at 12 months of age.

During a large outbreak of measles in Ohio in 1976 it was possible to measure measles vaccine efficacy by age at time of vaccination and number of years since vaccination. Using a summed incidence method to control for the confounding variable introduced by mass immunization clinics held during the outbreak, vaccine efficacy was greater than 95% for children vaccinated at 12, 13, and 14 or more months of age. Vaccine efficacy for those vaccinated at 12 months of age was notably better than for those vaccinated at younger ages but not different from those vaccinated at older ages. Although recently administered vaccine appeared more efficacious than vaccine administered in the past, this difference was not significant when controlled for age at vaccination. Evaluation of the mass clinics held during the outbreak demonstrated that 59.6% of the inadequately immunized children attended the clinics, but this was not substantially different from the proportion of adequately immunized who attended (52.4%). Recommendations for measles revaccination need not include children previously vaccinated at 12 months of age or greater.

Mumps disease and its health impact: an outbreak-based report.

An outbreak of mumps in a middle school (grades 6 to 8) in Ohio during 1981 was investigated to describe the clinical findings, health impact, and costs. Individuals with clinical mumps in the middle school and in family members were questioned concerning symptoms, complications, hospitalizations, school days absent, and parental work days missed. There were 62 cases of clinical mumps in the middle school and 13 cases among family members. Parotitis lasted an average of 7.4 days and fever (if present) lasted an average of 2.5 days with a mean temperature of 38.6 degrees C (101.4 degrees F). The duration of parotitis and fever increased with age. Complications included encephalitis, aseptic meningitis, orchitis, oophoritis, mastitis, and pancreatitis. Visits to physicians were made by 62.7% (47/75) of the individuals with mumps for a total of 63 visits, and two patients were hospitalized for a total of six days. Persons who attended middle school missed an average of 4.9 days of school. The estimated direct and indirect costs associated with this outbreak were $2,460 and $1,353, respectively, or $51 per case. States lacking mumps immunization requirements experienced a three-times greater incidence of mumps in 1982 than States that required all school pupils to be immunized. We recommend that all States institute compulsory mumps school immunization laws for all school children.

Growth of vegetarian children: The Farm Study.

To examine the effects of a vegetarian diet on child growth, height and weight data of 404 vegetarian children aged 4 months to 10 years who lived in a collective community in Tennessee were studied. Height for age, weight for age, and weight for height were compared with the US growth reference. Birth weights, infant feeding patterns, and parental heights were also evaluated in relation to growth. Most of the height for age, weight for age, and weight for height (n = 833) were within the 25th and 75th percentiles of the US growth reference. The mean height for age and weight for age, however, were slightly less than the median of the reference population. For different age groups, the mean height ranged from 0.2 to 2.1 cm and the mean weight ranged from 0.1 to 1.1 kg less than the reference median. The largest height difference was observed at 1 to 3 years of age and may be partly the result of intrinsic irregularities in the US growth reference at those ages. By 10 years of age, children from The Farm averaged 0.7 cm and 1.1 kg less than the reference median, representing only 0.1 and 0.3 SD from the reference. Thus, these children have adequate attained growth, even though it was modestly less than that of the reference population.

Risk factors associated with failure to receive vaccinations.

A major purpose of a state-wide survey to document the vaccination status of 1,003 2-year-old children was to identify factors associated with failure to receive the recommended vaccinations. With a basic series of immunization defined as three doses of diphtheria-tetanus-pertussis (DTP), three oral polio vaccine (OPV), one measles, and one rubella, 72.5% of the children had completed the series. When the completed series was redefined to include a fourth DTP and mumps vaccine the rate of completion dropped to 40.8%. However, 59.1% of the children who had not completed this optimal series could be brought up-to-date with a single visit to their provider of medical care. Demographic variables independently associated with completion of the basic series were increased paternal education (P less than .001), increased maternal education (P less than .02), smaller family size (P less than .01) and higher socioeconomic status, as determined by census tract or rural town of residence (P less than .02). Race was not found to be a factor associated with vaccination rates when socioeconomic status was controlled. Patients who received their vaccinations from private physicians had a better vaccination rate than those who attended health department clinics. This difference persisted even when socioeconomic status was controlled by residence (P less than .02). The simultaneous comparison of parental education and family size demonstrated that a child having one parent with less than 12 years education or having at least three siblings has a fourfold greater risk of failure to complete his immunization than children whose parents are both college graduates. By using paternal and maternal education level and family size as screening variables, children at high risk for failure to complete their immunizations could be identified prospectively and made the target of intervention programs to improve compliance.

Distribution of beta-amyloid in the canine brain.

The distribution of amyloid-beta protein (A beta) in the canine brain was demonstrated by immunochemistry on serially sectioned tissues from 10 aged mixed breed dogs. Summation of quantitative data and relegation to anatomical sites for the 10 dogs showed A beta to be widely distributed in the cortex and hippocampus while completely absent in the brain stem and cerebellum. The highest density of A beta was in the dentate gyrus of the hippocampus. Cortical areas exhibiting the greatest A beta deposition were the posterior and medial suprasylvius gyrus and the proreus gyrus of the frontal lobe. Unlike humans the canine entorhinal cortex, amygdala, basal ganglia and olfactory bulbs were rarely affected. This suggested that the highly developed olfactory pathways of the canine are generally spared from A beta deposition.

Trends in the percentage of women who received no prenatal care in the United States, 1980-1992: contributions of the demographic and risk effects.

OBJECTIVE: To determine if the increase in the percentage of women who received no prenatal care in the United States relative to 1980 (from 1.3% in 1980 to 2.2% in 1989 and 1.7% in 1992) was due to increasing risks of no care in subgroups of women or increasing percentages of births to women at high demographic risk of no care. METHODS: We analyzed U.S. birth certificates for the period 1980-1992. The annual adjusted odds of no prenatal care relative to 1980 were computed by logistic regression models that included year, maternal characteristics, and interactions of these characteristics with year. We also examined changes in the annual distributions of births by maternal characteristics. RESULTS: The risk of no prenatal care in most subgroups increased during the early 1980s, peaked in the late 1980s, and declined thereafter. For example, among black women, the adjusted risk of no care more than doubled from 1980 to 1989. Throughout the 1980s and into the 1990s, the percentage of births to women at high demographic risk of no care increased. This increase in the percentage of births to women at high demographic risk shows no sign of abating. CONCLUSIONS: During the 1980s, increasing risks in subgroups of women drove the increase in the crude rate of no prenatal care. Despite decreases in the risks of no care in the early 1990s, increasing percentages of births to women with high demographic risk for no care prevented a decrease in the crude rate to the 1980 level.

The relationship between pregnancy intendedness and physical violence in mothers of newborns. The PRAMS Working Group.

OBJECTIVE: To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. METHODS: Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. RESULTS: The state-specific prevalences (+/- standard error) of physical violence ranged from 3.8 +/- 0.5 to 6.9 +/- 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9-46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7-6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. CONCLUSION: Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women.

Research has shown that pregnant women who smoke cigarettes increase their risk of having low birthweight (LBW) infants. Recent randomized trials indicate that women who quit smoking early in pregnancy reduce their risk of delivering a LBW infant. Using various sources, we estimated the cost-effectiveness of a smoking cessation program for preventing LBW and perinatal mortality. Assuming the program would cost $30 a participant and that 15% of the participants would quit smoking, we determined that a program offered to all pregnant smokers would shift 5,876 LBW infants to normal birthweight and would cost about $4,000 for each LBW infant prevented. Since infants born to smokers are at 20% greater risk for a perinatal death, a smoking cessation program could prevent 338 deaths at a cost of $69,542 for each perinatal death averted. Compared with the costs of caring for these LBW infants in a neonatal intensive care unit (NICU), smoking cessation programs would save $77,807,054, or $3.31 per $1 spent. The ratio of savings to costs increases to more than six to one when we include reducing long-term care for infants with disabilities secondary to LBW in the benefits from smoking cessation programs. These findings argue for routinely including smoking cessation programs in prenatal care for smokers.

Screening mammography for women 50 years of age and older: practices and trends, 1987.

Recently, public and private efforts have been mounted to promote screening mammography. To assess recent trends in the percentage of women 50 years of age and older who have had a screening mammogram, we analyzed data from interviews from women from 33 states who participated in the 1987 Behavioral Risk Factor Surveillance System. Our study group included 8,402 women 50 years of age and older who had visited a physician for a routine checkup in the last year; among these 8,402 women, only 29% reported having had a screening mammogram in the past year. However, of the women in the study group, the percentage who had a screening mammogram in the last year showed a relative increase of 38% during 1987, from 24% for women interviewed in the first quarter of 1987 to 33% for women interviewed in the fourth quarter. However, not all groups of patients benefited equally from the observed trend--the absolute and relative increases in the percentage of women screened were lowest for women who were older, less educated, in low-income groups, and who had poor personal health practices. Although the percentage of women 50 years of age and older who reported being screened increased dramatically during 1987, special efforts are needed to reach the patient groups that are being left behind in the trend toward increased use of screening mammograms.

The behavioral risk factor surveys: I. State-specific prevalence estimates of behavioral risk factors.

The prevalence of most behavioral risk factors varies substantially among states. The prevalence of current cigarette smoking ranges from 22 percent to 38 percent. Estimates of alcohol use show geographic clustering, with lower rates in the southeastern states. The prevalence of sedentary lifestyle, uncontrolled hypertension, overweight, and seatbelt use differs markedly among states. These findings represent an initial step toward the analysis of state-specific baseline risk-factor data for use in developing state programs aimed at reducing the leading causes of death in the United States.

The behavioral risk factor surveys: III. Chronic heavy alcohol use in the United States.

Results of adult telephone interview data from aggregated state surveys show significant chronic alcohol use (two or more drinks per day) by 8.7 percent of the U.S. population. Rates are higher in men than in women (13.8 percent versus 4.0 percent, and higher in whites than in blacks (9.1 percent versus 4.5 percent). Women 25-44 years of age have significantly lower rates (2.9 percent) than women 18-24 (5.7 percent) or women 45-64 (4.6 percent). Also, rates are higher in heavy smokers (over one pack per day) than nonsmokers (22.4 percent versus 5.9 percent), among nonusers of seatbelts than users of seatbelts (10.5 percent versus 6.2 percent), and in those who reported driving after having had "too much" to drink than in those who did not (32.3 percent versus 7.5 percent). Overweight women (2.7 percent) and those who eat in response to stress (3.1 percent) have lower rates of chronic heavy alcohol use than those without these risk factors. Alcohol-related morbidity contributes substantially to the loss of productive life. We conclude that examining alcohol consumption in the light of other lifestyle behaviors would help in the design of effective prevention programs based on multiple risk factor interventions.