Associations between pediatric asthma and age at menarche: evidence from the Indonesian Family Life Survey.

OBJECTIVE: To examine the association between pediatric asthma and age at menarche, and to assess whether early life factors modify the association. METHODS: This is a retrospective cross-sectional study using the Indonesian Family Life Survey Fifth Wave which had a total of 11 822 females aged 15-57 years to evaluate whether those with pediatric asthma were associated with earlier menarche, compared to females without asthma. We performed a weighted linear regression model adjusting for age, urbanicity, parental smoking, infectious disease history during childhood, childhood socioeconomic status, and health status during childhood. We also performed analyses by age at asthma diagnosis, interval length between asthma diagnosis and menarche, urbanicity, parental smoking, and infectious disease history during childhood. RESULTS: In the adjusted model, females with pediatric asthma had an earlier average age at menarche by 5.2 months and those diagnosed with asthma at 5-8 years of age had the fastest acceleration by 14.9 months. The significant association persisted among those with 0-5 years interval between asthma diagnosis and menarche, who resided in urban areas, and those without infectious disease history during childhood. CONCLUSIONS: Our findings showed that females with pediatric asthma were associated with an earlier age at menarche, and some early life factors modified the association. Better asthma management with more targeted strategies at those at risk of earlier menarche may improve the reproductive and future health of children with asthma. Future studies to elucidate the mechanisms between pediatric asthma and age at menarche are warranted.

A multilevel analysis of the triple burden of malnutrition in Indonesia: trends and determinants from repeated cross-sectional surveys.

BACKGROUND: Although child malnutrition has been reducing, the coexistence in mothers and children of various forms of malnutrition has continued to rise around the world. In the Indonesian context, a knowledge gap exists on the coexistence of multiple malnutrition burdens. This study examines trends in the coexistence of the triple burden of malnutrition (TBM) among mother-child pairs living in the same house and explores multilevel (individual, household, and community) factors associated with TBM in Indonesia. METHODS: We used data from the 2013 and 2018 Indonesia Basic Health Research, the nationally representative survey of the Indonesian population, as repeated cross-sectional surveys. Study samples were mothers and children (0-59 months old), who resided in the same household and indicated by the same identifier number. The anthropometric measurements of the mothers and children, and the hemoglobin levels of the children were collected. We employed a multilevel mixed-effects model to consider the hierarchical data structure. The model captured the role of cluster, district, provincial differences, and the individual, household, community-level, and TBM status characteristics. RESULTS: Of 3,891 mother-child pairs analyzed, 24.9% experienced TBM. Girls had 63% higher odds than boys of TBM (aOR: 1.63; 95% CI: 1.30 to 2.03). Significantly lower odds were found in children of mothers who had a gestational age lower than 37 weeks (aOR: 0.72; 95% CI: 0.55 to 0.94). At the household level, children with a father who had a high-school, primary-school, or no school education had significantly higher odds of TBM than children of fathers who had graduated from academy. Children of mothers who visited Antenatal Care (ANC) no more than 6 times had significantly lower odds (aOR: 0.65; 95% CI: 0.47 to 0.88). Children of mothers who consumed Iron and Folic Acid (IFA) supplements had significantly lower odds. CONCLUSION: TBM is related to characteristics at not just the individual level but also the family and community levels. To achieve significant outcomes, integrated nutrition interventions in Indonesia should also consider family and community factors.

Transforming stress program on medical students' stress mindset and coping strategies: a quasi-experimental study.

OBJECTIVE: Stress is a significant concern in medical education, and identifying effective ways to deal with stress may help with students' mental health and professional development. This study aimed to examine the effects of the Transforming Stress Program (TSP) amongst first-year medical students on their stress mindset and coping strategies when confronted with stressors. METHODS: We conducted a quasi-experimental study at the University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam. A total of 409 first-year students at the Faculty of Medicine were divided into intervention group (205 students) and control group (204 students). The 10-week TSP was delivered as an extra-curricular course. The training adopts psychoeducation based on Dialectical Behavioral Therapy with mindfulness as a fundamental practice incorporated into each component of the program. The intervention group received the training in the first semester; the control group received identical program in the second semester. Stress Mindset Measurement and Brief Coping Orientation to Problems Experienced were measured before the intervention (T0), immediately after intervention on Intervention group (T1), and six months after intervention on Intervention group (T2). RESULTS: At T1, the intervention group showed 65% improvements in stress mindset scores and increases in coping strategies scores in six domains (Problem solving, Social support, Humor, Religion, Venting, and Self-distraction) and decreases in three (Avoidance, Substance use, and Self-blame). The effect sizes were significant in all outcomes (Cohen's d > 0.2). Measurements of the control group did not change significantly in the same period. At T2, effects of the TSP were found decreased in some domains (Avoidance, Substance use, and Self-blame) compared to T1, but largely remained significantly better than T0. CONCLUSIONS: The TSP is a feasible and effective approach that significantly enhanced medical students' stress mindset and coping strategies. Some effects were still observable 6 months after the intervention. The relatively intensive intervention requires support of the school administration and staff.

Prevalence of iron and folic acid supplements consumption and associated factors among pregnant women in Eswatini: a multicenter cross-sectional study.

BACKGROUND: During pregnancy, nutritional requirements increase and if not met, pregnancy-related complications may manifest. To prevent these undesirable outcomes, the World Health Organization recommends daily oral iron and folic acid (IFA) supplementation as part of antenatal care. Despite this recommendation, the use of IFA supplements is still very low in several developing countries. Additionally, no prior information exists regarding the level of consumption of IFA in Eswatini. Thus, this study aimed to determine the prevalence of consumption of IFA supplements and to identify factors associated with the consumption of IFA supplements among pregnant women in Eswatini. METHODS: A cross-sectional questionnaire survey was conducted among 330 pregnant women aged ≥ 18 years in their third trimester in Eswatini. Participants were recruited from eight purposively selected healthcare facilities from July 2019 to October 2019. Good consumption was defined as consuming all or almost all IFA supplements throughout pregnancy. RESULTS: During the first trimester, 10.3 % of the participants consumed all or almost all IFA supplements. In the second and third trimesters, those who consumed all or almost all supplements were 37 and 39.7 %, respectively, for iron and 37.6 and 40.9 %, respectively, for folic acid. Barriers, including side effects, forgetfulness, safe previous pregnancies without IFA, others' advice against consumption, IFA stock-outs, inability to meet transport costs, and inadequate supply of IFA tablets, contribute to low consumption of IFA. Multivariate logistic regression models showed that the barriers were inversely associated with good consumption of IFA supplements. Better knowledge and attitude toward IFA and older maternal age were positively associated with good consumption of IFA supplements. CONCLUSIONS: Low consumption of IFA supplements in overall pregnancy is mainly owing to the late antenatal care attendance. Strategies such as establishing a preconception care unit and school-based provision of IFA may be helpful. It is evident that most women still lack knowledge, and some have negative attitudes about IFA supplements. Health education to raise awareness and emphasize the importance of starting antenatal care early as well as consuming supplements on time should be revisited and intensified. Multiple strategies such as including community health care workers for distributing IFA supplements, discussing with clients about the measures to reduce forgetfulness, advising ways to prevent and manage the side effects, providing subsidies to cover transport costs, and ensuring adequate supply of IFA supplements in facilities may need to be employed to reduce the identified barriers.

Comparison between American Institute of Medicine Guidelines and Local Recommendation for Gestational Weight Gain in Taiwanese Primiparous Women.

OBJECTIVES: American Institute of Medicine (IOM) recommends different ranges of gestational weight gain (GWG) based on pre-pregnancy body mass index (BMI). In Taiwan, IOM guidelines are implemented concurrently with the local recommendation for GWG (10-14 kg). This study compared between the two sets of guidelines in relation to adverse perinatal outcomes. METHODS: We analyzed 31,653 primiparas with singletons from 2011 to 2016 annual National Breastfeeding Surveys. Logistic regressions for preterm birth, small for gestational age (SGA), large for gestational age (LGA), cesarean section and excessive postpartum weight retention (EPWR) were fitted separately for GWG categorized according to IOM and Taiwan ranges. Areas under the receiver-operator curves (AUC) and the predicted probabilities for each outcome were compared in each BMI group. RESULTS: AUC for both guidelines ranged within 0.51-0.73. Compared to Taiwan recommendation, IOM ranges showed lower probabilities of SGA for underweight (0.11-0.15 versus 0.14-0.18), of LGA for obese (0.12-0.15 versus 0.15-0.18), of EPWR for overweight (0.19-0.30 versus 0.27-0.39), and obese (0.15-0.22 versus 0.25-0.36); and higher probabilities of EPWR for underweight (0.17-0.33 versus 0.14-0.22). CONCLUSIONS FOR PRACTICE: Discriminative performance of IOM and Taiwan recommendations was poor for the five adverse birth outcomes, and no preference for either set of recommendations could be inferred from our results. In the absence of specific GWG guidelines, health care workers may provide inconsistent information to their patients. Future research is needed to explore optimal GWG ranges that can reliably predict locally relevant perinatal outcomes for mother and child.

Urinary phthalate metabolites are associated with biomarkers of DNA damage and lipid peroxidation in pregnant women - Tainan Birth Cohort Study (TBCS).

Phthalate exposure and oxidative stress have been linked to adverse reproductive outcomes in experimental studies, whereas no clear line has been drawn for human, especially in pregnant women. This study explored relationships between urinary phthalate metabolites and biomarkers of lipid peroxidation and oxidative and nitrosative DNA damage. Measurements from 97 Taiwanese pregnant women were taken at three different times during second and third trimesters. Five oxidative/nitrosative stress biomarkers - 8-hydroxy-2'-deoxyguanosine (8-OHdG), 8-nitroguanine (8-NO2Gua), 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA), 8-isoprostaglandin F2α (8-isoPF2α), and malondialdehyde (MDA), and 11 phthalate metabolites were measured in urine samples. Linear regressions in each visit and linear mixed-model regressions were fitted to estimate percent changes in oxidative/nitrosative stress biomarkers resulting from inter-tertile increase of phthalate metabolite level and the cumulative concentrations of di (2-ethylhexyl) phthalate (DEHP) and dibutyl phthalate. The highest urine concentrations of phthalate metabolites and the greatest number of significant positive associations between phthalate metabolites and oxidative/nitrosative stress biomarkers were observed in the third visit and in repeated measurements analysis, respectively. Of the biomarkers related to DNA damage, 8-OHdG (25.4% inter-tertile increase for mono-iso-butyl phthalate) was more sensitive to phthalate exposure than 8-NO2Gua. Among the biomarkers of lipid peroxidation, HNE-MA (61.2% inter-tertile increase for sum of DEHP metabolites) was more sensitive than 8-isoPF2α and MDA. Our findings support the hypothesis that pregnant phthalate exposure increases the oxidative stress biomarkers of DNA damage and lipid peroxidation. Future research may elucidate the mediating roles of oxidative/nitrosative stress biomarkers in the link between phthalate exposure and adverse reproductive outcomes.

Evaluation of factors contributing to the decline in exclusive breastfeeding at 6 months postpartum: The 2011-2016 National Surveys in Taiwan.

BACKGROUND: Since 1992, breastfeeding promotion in Taiwan considerably raised the breastfeeding rates; however, more recent surveillance showed that breastfeeding indicators stagnated or even decreased. METHODS: We analyzed 6 cross-sectional national surveys of 69 159 postpartum women to examine the breastfeeding trends at 6 months postpartum during 2011-2016 in Taiwan and the contributing role of maternal and environmental factors. Data were collected through telephone interviews, using structured questionnaires with randomly selected mothers, who gave birth in those years. A multinomial logistic regression was used to analyze the data. RESULTS: Partial breastfeeding rates at 6 months postpartum increased from 2011 to 2016 (25.4%-45.1%, crude odds ratio [OR] = 1.14 per year of study); however, the rates of exclusive breastfeeding at 6 months postpartum declined (24.5%-14.8%, crude OR = 0.91 per year of study). During this period, increases in maternal age and educational level, employment outside the house, and prepregnancy obesity were observed. Despite a growing number of births at certified baby-friendly hospitals, fewer mothers experienced early skin-to-skin contact and rooming-in in 2016 than in 2011. Adjustment for breastfeeding-related factors did not appreciably change the odds ratio for year of birth. Prenatal intention to breastfeed was most strongly associated with breastfeeding at 6 months postpartum (OR > 5). CONCLUSIONS: Maternal and environmental factors in the study could not explain the decline in exclusive breastfeeding. The decline in exclusive breastfeeding, accompanying the increase in partial breastfeeding, suggests that more support is needed for mothers who intend to breastfeed exclusively.

Factors Associated with Vaccination Coverage among 0-59-Month-Old Children: A Multilevel Analysis of the 2020 Somaliland Demographic and Health Survey.

Globally, there has been little growth in vaccination coverage, with countries in the Horn of Africa having the lowest vaccination rates. This study investigated factors associated with vaccination status among children under five years old in Somaliland. The 2020 Somaliland Demographic and Health Survey surveyed women aged 15-49 years from randomly selected households. This multilevel analysis included 2673 primary caregivers of children under five. Only 34% of children were ever vaccinated. Childhood vaccination coverage was positively associated with high-budget regions, high healthcare facility density, and children older than 23 months. Vaccination coverage was greater for urban and rural residents than for nomadic people. Children whose mothers could read part of one sentence or one complete sentence were more likely to be vaccinated than illiterate mothers. Children whose mothers received antenatal care (ANC) once, two to three times, or four times or more were more likely to be vaccinated than those whose mothers received no ANC. Childhood vaccination coverage in Somaliland is low. Promoting maternal ANC visits and increasing women's literacy may enhance vaccination coverage. Funds should be allocated to areas with low resources, particularly for nomadic people, to boost vaccination uptake.

Body mass index as a dominant risk factor for metabolic syndrome among indonesian adults: a 6-year prospective cohort study of non-communicable diseases.

BACKGROUND: Non-communicable diseases (NCDs), notably cardiovascular disease and type 2 diabetes mellitus, are largely driven by metabolic syndrome (MetS), a cluster of critical risk factors. Despite extensive research, the progression of MetS, especially in Indonesia, has received limited attention. This research tracks adult MetS risk dynamics in a populous Bogor District cohort, providing crucial insights into its evolving nature. METHODS: This prospective open cohort study analysed secondary data from the Special Research - Cohort Study of Non-Communicable Diseases by the Ministry of Health, Republic of Indonesia from 2011 to 2018. The final sample was 1,376 Indonesian adult participants, all residents of Bogor District. MetS outcome, dietary assessment, physical activity, and biomarkers were analysed every two consecutive years. RESULTS: The risk of overweight and obese participants developing MetS was 2.4 and 4.4 times higher, respectively (95% CI: 1.176-3.320 and 3.345-5.740) than those with body mass index (BMI) in the normal range. Participants who reported less intentional physical exercise had a MetS risk 1.5 times higher (95% CI: 1.034-2.109) than those with more intentional physical exercise. The role of diet is also significant, evidenced by a 30% reduction in MetS risk for people with fat intakes in the 2nd quartile compared to the 1st quartile (95% CI: 0.505-0.972). Meanwhile, a carbohydrate intake in the 2nd quartile increased the risk of MetS 1.5 times (95% CI: 1.063-2.241) in comparison with the 1st quartile. CONCLUSIONS: Notably, participants with underweight BMI exhibited the highest cumulative survival of MetS, while those with obese BMI recorded the lowest cumulative survival. There is an urgent need for strategic interventions to enhance the existing early detection and NCD monitoring program. This involves a targeted focus on promoting a community-based healthy lifestyle in the Bogor District. The study emphasizes the importance of tailored public health measures to address specific risk factors identified in the local context, aiming to mitigate the prevalence and impact of MetS in the population.

Sources of stress, coping strategies and associated factors among Vietnamese first-year medical students.

OBJECTIVES: This study aims to examine the sources of stress among first-year medical students; the frequency of their coping strategies; the factors associated with specific stressors and specific coping strategies adopted by the participants. METHODS: We conducted a cross-sectional study with 409 first-year students at the University of Medicine and Pharmacy, Vietnam. The Vietnamese versions of the Higher Education Stress Inventory (V_HESI) and Brief Coping Orientation to Problems Experienced (V_Brief COPE) were validated and were used as measurement instruments for participants' sources of stress and coping strategies frequencies. The survey comprised questions of socioeconomic status, stress-related issues, the six sources of stress (using the V_HESI), and the nine coping strategies (using the V_Brief COPE). RESULTS: Among the six sources of stress, "Worries about future competence/endurance" had the highest mean score (3.02±0.64), while "Mismatch in professional role expectations" had the lowest score (1.60±0.53). "Financial concerns" and "Academic workloads" were also significant sources of stress. Regarding coping strategies, Self-distraction was most frequently adopted by the participants (2.80 ± 0.68). Problem-solving (2.72±0.53) and seeking Social support (2.62±0.70) were also common adaptive strategies. Avoidance (1.87±0.55) and substance-use (1.27±0.55) were the least frequent strategies. Students who experienced acute stress event were more likely to have financial concerns compared to others. Substance use was positively associated with stressors from "Mismatch in professional role expectations", "Non-supportive educational environment", "Having physical issues" and "Having part-time job". Self-blame was more frequent among students with "Worries about future competence/endurance", "Financial concerns", and "Academic workload". Male student tended to adopt humor strategy (ß = 0.19, p = 0.02), while less likely to utilize religious practices (ß = -0.21, p = 0.01). CONCLUSIONS: Two-thirds of the participants reported moderate to high levels of stress. "Worries about future competence/endurance" was the most concerned stressor, followed by "Academic workload", and "Financial concerns". The first-year medical students reported high frequency of utilization "Self-distraction", "Problem-solving" and "Social support" when confronting stress. The findings may help inform the school management to better support students' well-being.

Burnout, mental health, physical symptoms, and coping behaviors in healthcare workers in Belize amidst COVID-19 pandemic: A nationwide cross-sectional study.

BACKGROUND: Healthcare workers are vulnerable to burnout, especially during the COVID-19 pandemic in the low resource settings. Belize is a small Central American developing country known for its chronic healthcare worker shortage and this is the first study to assess burnout prevalence and its associated factors among healthcare workers in Belize. AIM: To evaluate the prevalence of burnout and its associated factors in HCWs in Belize covering multiple domains (mental health, physical symptoms, and coping behaviors) during the COVID-19 pandemic. METHODS: A cross-sectional survey that was developed and validated by a panel of experts was delivered online to all the healthcare workers in Belize from September to November 2021. Burnout was assessed using Copenhagen Burnout Inventory. Depression and anxiety screening was carried out using the Patient Health Questionnaire - 2 (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2). Burnout associated factors were estimated using logistic regression models. FINDINGS: Of the total of 263 participants, 27.76% had overall burnout: 56.65% had personal, 54.37% had work-related, and 19.39% had patient-related burnout. Burnout was positively associated with anxiety (OR: 3.14 [1.67, 5.92]), depression (OR: 4.45 [2.30, 8.61]), intentions of quitting their jobs (OR: 2.59 [1.49, 4.51]), health status worsening (OR: 2.21 [1.26, 3.87]), multiple physical symptom presentation (OR: 1.19, [1.10, 1.29]), and use of multiple maladaptive coping behaviors (OR: 1.66, [1.30, 2.12]). INTERPRETATION: Healthcare workers in Belize showed substantial levels of burnout which were significantly associated with using maladaptive coping behaviors, presenting multiple physical symptoms, quitting their jobs, health status worsening, and other mental health issues. These findings should be used to develop and implement programs such as regular health check-ups, health promotion awareness campaigns, and worker recruitment strategies which would improve the working conditions, quality of life, and psychological well-being of our healthcare workers.

Safety and immunogenicity of homologous versus heterologous booster dose with AZD1222, mRNA-1273, or MVC-COV1901 SARS-CoV-2 vaccines in adults: An observer-blinded, multi-center, phase 2 randomized trial.

OBJECTIVES: To report the safety and immunogenicity profile of a protein subunit vaccine (MVC-COV1901) compared to AZD1222 and mRNA-1273 when given as a third (booster) dose to individuals who have completed different primary vaccine regimens. METHODS: Individuals were classified according to their primary vaccine regimens, including two-dose MVC-COV1901, AZD1222, or mRNA-1273. A third dose of either half-dose MVC-COV1901, full-dose MVC-COV1901, standard-dose AZD1222, half-dose mRNA-1273 was administered in a 1:1:1:1 treatment ratio to individuals with an interval range of 84-365 days after the second dose. Endpoints included safety, humoral immunogenicity, and cell-mediated immune response on trial days 15 and 29. Exploratory endpoint included testing against variants of concern (Omicron). RESULTS: Overall, 803 participants were randomized and boosted - 201 received half-dose MVC-COV1901, 196 received full-dose MVC-COV1901, 203 received AZD1222, and 203 received half-dose mRNA-1273. Reactogenicity was mild to moderate, and less in the MVC-COV1901 booster group. Heterologous boosting provided the best immunogenic response. Boosting with mRNA-1273 in MVC-COV1901 primed individuals induced the highest antibody titers, even against Omicron, and cell-mediated immune response. CONCLUSIONS: Overall, MVC-COV1901 as a booster showed the best safety profiles. MVC-COV1901 as a primary series, with either homologous or heterologous booster, elicited the highest immunogenic response. CLINICALTRIALS: gov registration NCT05197153.

Safety and immunogenicity of MVC-COV1901 vaccine in older adults: Phase 2 randomized dose-comparison trial.

INTRODUCTION: Older adults are subject to higher COVID-19 infection and mortality rates. Safety and immunogenicity of MVC-COV1901, a protein subunit vaccine have been demonstrated in phase 2 clinical trial for the general population, and negative correlations have been observed between immune responses and age, however, older adults were under-represented. METHODS: A double-blind, randomized, multi-center study compared safety and immunogenicity of high-dose (25 mcg) to mid-dose (15 mcg) of MVC-COV1901 administered 2 times 28 days apart in 420 participants of 65 years and older. The results have been stratified by the comorbidity status. RESULTS: Both high and mid-dose regimens elicited mostly mild adverse events and robust immune responses when measured as neutralizing and binding antibodies titers. High doses elicited better immune responses in the group without comorbidities. CONCLUSION: Given the general population-associated safety and immunogenicity of MVC-COV1901, we recommend high dose for immunization of elder adults with MVC-COV1901. The clinical trial was registered at https://clinicaltrials.gov/ (NCT04822025).

Exposome of attention deficit hyperactivity disorder in Taiwanese children: exploring risks of endocrine-disrupting chemicals.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is diagnosed in ~7% of school-aged children. The role of endocrine-disrupting chemicals (EDC) and oxidative stress in ADHD etiology are not clear. OBJECTIVE: Assessment of the associations between simultaneous exposure to multiple compounds and ADHD in children. METHODS: The case-control study included 76 clinically diagnosed ADHD cases and 98 controls, aged 4-15 years old. Concentrations quartiles of urinary metabolites of acrylamide, acrolein, nonylphenol, phthalates, and organophosphate pesticides and biomarkers of oxidative stress were used to fit logistic regressions for each compound and weighted quantiles sum (WQS) regression for the mixture. RESULTS: Positive dose-response relationships with ADHD were observed for 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA) (odds ratio(OR)Q4 = 3.73, 95%CI [1.32, 11.04], ptrend = 0.003), dimethyl phosphate (DMP) (ORQ4 = 4.04, 95%CI [1.34, 12.94], ptrend = 0.014) and diethyl phosphate (ORQ4 = 2.61, 95%CI = [0.93, 7.66], ptrend = 0.030), and for the mixture of compounds (ORWQS = 3.82, 95%CI = [1.78, 8.19]) with the main contributions from HNE-MA (28.9%) and DMP (18.4%). CONCLUSIONS: The dose-response relationship suggests enhanced susceptibility to EDC burden in children even at lower levels, whereas the main risk is likely from organophosphate pesticides. HNE-MA is recommended as a sensitive biomarker of lipid peroxidation in the further elucidation of the oxidative stress role in ADHD etiology.

Inadequate gestational weight gain contributes to increasing rates of low birth weight in Taiwan: 2011-2016 nationwide surveys.

OBJECTIVE: Low birth weight (LBW) is associated with adverse health outcomes. Incidence of LBW in Taiwan grew from 5% in 1997 to 8.4% in 2016. This study aims to identify the role of pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) in LBW rate changes during 2011-2016. MATERIALS AND METHODS: We analyzed 66 135 postpartum women from 6 cross-sectional national surveys. Data were collected through telephone interviews with randomly selected mothers. Logistic regression was applied to assess contribution of maternal characteristics to LBW time changes. RESULTS: LBW increased from 5.3% to 7.0% during 2011-2016 (crude odds ratio (OR) = 1.04/year, p-value for trend = 0.001). Inadequate GWG increased from 27.9% to 41.5% (p-value for trend <0.001). Along with the increase in overweight (9.7%-11.1%) and obese (4.8%-7.4%), prevalence of underweight fluctuated between 16.0% and 17.8%. LBW increased in underweight group from 6.3% to 9.5% (crude OR = 1.09/year, p-value for trend<0.001). Adjustment for GWG attenuated odds ratio per year in total sample (adjusted OR = 1.03, p-value for trend = 0.04) and in underweight (adjusted OR = 1.08, p-value for trend = 0.002). CONCLUSIONS: Increasing percentage of women with inadequate GWG could contribute to LBW increase in Taiwan during 2011-2016, especially for the underweight. Prenatal advice on GWG should be individualized according to pre-pregnancy BMI.

Human biomonitoring reference values and characteristics of Phthalate exposure in the general population of Taiwan: Taiwan Environmental Survey for Toxicants 2013-2016.

Since a 2011 incident involving phthalate-tainted food, Taiwanese people have become concerned with food quality, and they are still being exposed to certain levels of phthalates. However, no nationwide human biomonitoring survey had been conducted to gather information on levels or reference values (RVs) of phthalates in the Taiwanese population. We aimed to establish the urinary levels and RVs of phthalate metabolites and identify exposure characteristics among Taiwan's population. We enrolled 1857 participants 7 years of age and older from the Taiwan Environmental Survey for Toxicants (TESTs) conducted during 2013-2016. Levels of 11 phthalate metabolites in each participant's urine samples were determined using liquid chromatography-tandem mass spectrometry. For all phthalate metabolites except for mono-methyl phthalate (MMP), mono-ethyl phthalate (MEP), and mono-ethylhexyl phthalate (MEHP), urinary median levels were significantly higher in the 7-17-year old group than in the ≧18-year-old group. For most phthalate metabolites and in the general population, the geometric mean decreased with increasing age. Median levels of MEP (19.55 µg/L), mono-benzyl phthalate (MBzP) (2.11 µg/L), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) (22.82 µg/L), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEOHP) (16.08 µg/L), ΣDibutyl phthalate metabolites (ΣDBPm) (0.17 nmol/mL), Σdi-(2-ethylhexyl) phthalate metabolites (ΣDEHPm) (0.29 nmol/mL) were higher in participants from central Taiwan than those from other areas. The median level of DBP (ΣDBPm: 0.20 nmol/mL) was significantly higher in participants from harbor areas than those from other urbanization groups. The RV of the 95 percentile (P95) for phthalate metabolites in the 7-17/≧18-year-old groups were 185.95/208.19 µg/L for MMP, 198.46/265.81 µg/L for MEP, 119.85/69.99 µg/L for mono-isononyl phthalate (MiBP), 165.19/204.32 µg/L for Mono-n-butyl phthalate (MnBP), 15.61/11.73 µg/L for MBzP, 62.09/59.23 µg/L for MEHP, 149.70/69.66 µg/L for MEHHP, 112.06/35.07 µg/L for MEOHP, 195.20/93.83 µg/L for mono-(2-ethyl-5-carboxypentyl) phthalate (MECPP), 45.66/27.69 µg/L for mono-(2-carboxymethylhexyl) phthalate (MCMHP), and 9.09/12.13 µg/L for mono-iso-nonyl phthalate (MiNP). We concluded that phthalate exposure of the general population in Taiwan varies by sex, age, region, and urbanization level. Exposure by the 7-17-year-old group to DMP, DBP, and DEHP in Taiwan remains higher than that of youth from other countries. RV of phthalate metabolites in Taiwan were established in the current study.

Cumulative risk assessment of phthalates exposure for recurrent pregnancy loss in reproductive-aged women population using multiple hazard indices approaches.

Phthalates, which are commonly used in flexible plastics and consumer products, have been reported to be toxic to reproductive and developmental function in mammals. Past studies have focused on the toxic effects on male reproduction, with only a few studies conducted on the risks that cumulative exposure to phthalates have on the female reproductive system. We recruited 260 patients with recurrent pregnancy loss (RPL) of unknown etiology and 203 controls from the clinics of Obstetrics and Gynecology at a medical center in southern Taiwan from 2013 to 2020. The daily intake of phthalates was estimated from urine samples using the back-calculation method, after which the cumulative risk was determined using multiple hazard indices, including a dose-addition model, a receptor effect model, and a hazard index approach. The patients with RPL had a significantly higher cumulative exposure to phthalates (p < 0.05) than did the controls with a hazard index above one. After adjusted logistic regression analysis, we found that the risk of RPL was strongly related to the higher quartiles of DEHP, the DEHPTEQ for the antiandrogenic effect and adverse effects of the female reproductive system and the ERα binding effect (p < 0.05). Our work suggests that more attentions should be paid to the adverse effects induced by phthalates on female reproduction, especially the effects caused by the cumulative exposure to phthalates in women of reproductive age.

Dose-Response Relationships between Breastfeeding and Postpartum Weight Retention Differ by Pre-Pregnancy Body-Mass Index in Taiwanese Women.

Postpartum weight retention (PWR) is a risk factor for future obesity. The role of breastfeeding in reducing PWR is not fully understood. We examined the relationship between PWR and the duration of exclusive/partial breastfeeding in 52,367 postpartum women from 2012-2016 Taiwan national breastfeeding surveys. The women were interviewed at 7-14 months postpartum. Non-linear models were fit to examine the association between PWR and breastfeeding duration. PWR adjusted means and 95% confidence intervals were plotted and compared for the duration of exclusive/partial breastfeeding in the total sample and between pre-pregnancy body-mass index (BMI) groups (underweight, normal, overweight, and obese). Women who breastfed exclusively for >30 days showed significantly lower PWR than those who did not breastfeed and those who breastfed partially for the same duration, thereafter each additional duration of 30 days being associated with an average of 0.1-0.2 kg less PWR. Women who breastfed partially for 120 days showed lower PWR than those who did not or those who ceased to breastfeed, thereafter each additional duration of 30 days being associated with an average of 0.1 kg less PWR. Duration of breastfeeding needed to achieve significantly less PWR differed between pre-pregnancy BMI groups, but the effect of exclusive breastfeeding appeared earlier in the normal weight group. Women with obesity who breastfed exclusively for >30 or partially for >180 days, had lower PWR than non-obese groups. The observed dose-response relationship between breastfeeding duration and PWR supports the "every feeding matters" approach in breastfeeding promotion. The larger effect of exclusive and partial breastfeeding on PWR in women with obesity may draw special attention of breastfeeding promotion.

Mediating role of oxidative/nitrosative stress biomarkers in the associations between phthalate exposure and thyroid function in Taiwanese adults.

Phthalate exposure was shown to alter thyroid function, however it is unclear, whether oxidative and nitrosative stress explains the intermediate biological mechanism. This study aimed to investigate the associations between phthalate exposure, oxidative/nitrosative stress, and thyroid function in adults, and to examine the mediating role of oxidative/nitrosative stress in the associations between phthalate exposure and thyroid function. Levels of eleven urinary phthalate metabolites, three urinary biomarkers of oxidative/nitrosative stress (malondialdehyde [MDA], 8-OHdG, and 8-NO2Gua) and five serum thyroid hormones (thyroxine [T4], free T4, triiodothyronine, thyroid-stimulating hormone, and thyroxine-binding globulin) were measured in 266 Taiwanese adults. Cross-sectional associations between phthalate metabolites, biomarkers of oxidative/ nitrosative stress and thyroid hormones were analyzed using multivariate regression models. Mediation analysis was conducted to assess the role of oxidative/nitrosative stress in the associations between phthalate metabolites and thyroid hormone levels. Sum of di-(2-ethylhexyl) phthalate (DEHP) metabolites was positively associated with MDA (ßT1-T2 = 0.253, 95%CI [0.060, 0.447]; ß â‰§ T2 = 0.317, 95% CI [0.098, 0.536]; Ptrend = 0.005) and 8-NO2Gua (ßT1-T2 = -0.010, 95%CI [-0.138, 0.118]; ß â‰§ T2 = 0.144, 95% CI [-0.001, 0.289]; Ptrend = 0.045). Mono-n-butyl phthalate (MnBP) was positively associated with 8-NO2Gua (ßT1-T2 = 0.201, 95% CI [0.078, -0.324]; ß â‰§ T2 = 0.161, 95% CI [0.031, -0.292]; Ptrend = 0.018). T4 was negatively associated with MDA (ßT1-T2 =  -0.027, 95% CI [-0.088, 0.0034]; ß≧T2 = -0.094, 95% CI [-0.161, -0.028]; Ptrend = 0.005) and 8-NO2Gua (ßT1-T2 = -0.068, 95% CI [-0.127, -0.010]; ß≧T2 = -0.125, 95% CI [-0.184, -0.066]; Ptrend < 0.001). Free T4 was positively associated with MDA (Ptrend = 0.047) and with 8-NO2Gua (Ptrend < 0.001). 8-NO2Gua mediated 11% of the association between the sum of DEHP metabolites and T4, and 17% of the association between MnBP and free T4. These results suggest that phthalate exposure may influence thyroid hormone levels through induced oxidative/nitrosative stress.

Acupressure effect on sleep quality: A systematic review and meta-analysis.

Acupressure is a non-invasive treatment in which pressure is applied to specific body points. Following public health concerns about poor sleep quality and increasing interest in alternative treatments, a systematic review and a meta-analysis were designed to evaluate the effects of acupressure on the quality of sleep. Ten English (PubMed, CENTRAL, CINAHL etc.) and five Chinese (CNKI, WANFANG etc.) databases were searched and the validity of the eligible studies was critically appraised. Thirty-two eligible randomized controlled trials of moderate to high quality which employed polysomnography, actigraphy, or self-assessment sleep quality tools were included. We conducted a meta-analysis using a random effects model with the Pittsburgh sleep quality index (PSQI) as the primary outcome measure (968 adult patients, 13 trials) for trials investigating the effects of traditional Chinese medicine acupressure compared with standard and sham treatments. We performed subgroup analyses to detect sources of heterogeneity, identify the use of acupoints in different populations and explore the contributions of PSQI domains to the total score change. Comparison with the sham group (7 trials with 385 patients) yielded low heterogeneity and an overall effect of 13%-19% improvement in the PSQI score (MD = -3.41, 95% CI -4.08, -2.75; I2 = 12%). Based on data from four trials (n = 250), sleep latency and sleep duration were most affected. No adverse effects were reported in any of the reviewed trials. Within the limitations of clinical heterogeneity, the results showed that even fragile populations such as the elderly and dialysis patients can benefit from acupressure. Standardized treatment protocols involved 3-5 kg of pressure for one to five minutes per acupoint, delivered three to seven times a week for three to four weeks with the HT7 (Shenmen) acupoint used in most procedures. A high risk of bias due to absence of blinding of patients and personnel remains a serious methodological challenge for acupressure trials and poses a main limitation to presented results. This review has been registered in PROSPERO (registration number CRD42015025013).