The longitudinal association between asthma severity and physical fitness by neighborhood factors among New York City public school youth.

PURPOSE: This paper aims to examine the association between asthma severity and one-year lagged fitness in New York City Public school youth by neighborhood opportunity. METHODS: Using the Child Opportunity Index 2.0 and individual-level repeated measures NYC Office of School Health (OSH) fitness surveillance data (2010-2018), we ran multilevel mixed models stratified by neighborhood opportunity, adjusting for sex, race/ethnicity, grade level, poverty status, and time. Asthma severity was based on a physician-completed Asthma Medication Administration Form (MAF) from each school year and drawn from the Automated Student Health Record (ASHR). RESULTS: Across all youth in grades 4-12 (n = 939,598; 51.7 % male; 29.9 % non-Hispanic Black, 39.3 % Hispanic; 70.0 % high poverty), lower neighborhood opportunity was associated with lower subsequent fitness. Youth with severe asthma and very low and low neighborhood opportunity had the lowest 1-year lagged fitness z-scores - 0.24 (95 % CI, -0.34 to -0.14) and - 0.26 (95 % CI, -0.32 to -0.20), respectively, relative to youth with no asthma and very high opportunity. CONCLUSIONS: An inverse longitudinal relationship between asthma severity and subsequent fitness was observed. Study findings have implications for public health practitioners to promote physical activity and improved health equity for youth with asthma, taking neighborhood factors into account.

Associations Between Neighborhood Opportunity and Indicators of Physical Fitness for New York City Public School Youth.

Background: Fewer than 1/4th of US children and adolescents meet physical activity (PA) guidelines, leading to health disparities that track into adulthood. Neighborhood opportunity may serve as a critical modifiable factor to improve fitness attainment and reduce these disparities. We drew data from the Child Opportunity Index to examine associations between neighborhood indicators of opportunity for PA and multiple fitness indicators among New York City public school youth. Methods: Multilevel generalized linear mixed models were used to estimate the overall and sex-stratified associations between neighborhood indicators (green space, healthy food, walkability, commute time) and indicators for physical fitness [curl-ups, push-ups, Progressive Aerobic Cardiovascular Endurance Run (PACER), sit-and-reach] using the New York City FITNESSGRAM data set. Results: The analytic sample [n = 299,839; median (interquartile range) age = 16 (12-17)] was 50.1% female, 37.5% Hispanic, 26.2% non-Hispanic Black, and most (69.5%) qualified for free/reduced price school meals. Neighborhood indicators were positively associated with higher values of indicators for physical fitness. The strongest associations were observed between walkability and both BMI and PACER, and commute time with BMI, push-ups, and PACER. For example, walkability had the greatest magnitude of effects for BMI and muscular strength and endurance (BMI: ß: -0.75, 95% confidence interval, CI: -1.01 to -0.49; PACER: ß: 1.98, 95% CI: 1.59 to 2.37), and particularly for girls compared with boys (BMI, girls: ß: -0.91, 95% CI: -1.22 to -0.66); BMI, boys: ß: -0.56, 95% CI: -0.86 to -0.25); PACER, girls: ß: 2.11, 95% CI: 1.68 to 2.54; push-ups, boys: ß: 1.71, 95% CI: 1.31 to 2.12). Conclusion: Neighborhood indicators were associated with multiple measures of youth fitness. Continued research on neighborhood opportunity and youth fitness may better inform place-based public health interventions to reduce disparities.

COVID-19 vaccines for children: Racial and ethnic disparities in New York City.

Vaccination is an indispensable tool to reduce negative outcomes due to COVID-19. Although COVID-19 disproportionately affected lower income and Black and Hispanic communities, these groups have had lower population-level uptake of vaccines. Using detailed cross-sectional data, we examined racial and ethnic group differences in New York City schoolchildren becoming fully vaccinated (two doses) within 6 months of vaccine eligibility. We matched school enrollment data to vaccination data in the Citywide Immunization Registry, a census of all vaccinations delivered in New York City. We used ordinary least squares regression models to predict fully vaccinated status, with key predictors of race and ethnicity using a variety of different control variables, including residential neighborhood or school fixed effects. We also stratified by borough and by age. The sample included all New York City public school students enrolled during the 2021-2022 school year. Asian students were most likely to be vaccinated and Black and White students least likely. Controlling for student characteristics, particularly residential neighborhood or school attended, diminished some of the race and ethnicity differences. Key differences were also present by borough, both overall and by racial and ethnic groups. In sum, racial and ethnic disparities in children's COVID-19 vaccination were present. Vaccination rates varied by the geographic unit of borough; controlling for neighborhood characteristics diminished some disparities by race and ethnicity. Neighborhood demographics and resources, and the attributes, culture and preferences of those who live there may affect vaccination decisions and could be targets of future efforts to increase vaccination rates.

Longitudinal Associations Between Neighborhood Child Opportunity and Physical Fitness for New York City Public School Youth.

Neighborhood environments can support fitness-promoting behavior, yet little is known about their influence on youth physical fitness outcomes over time. We examined longitudinal associations between neighborhood opportunity and youth physical fitness among New York City (NYC) public school youth. The Child Opportunity Index (COI), a composite index of 29 indicators measuring neighborhood opportunity at the census-tract level, along with scores on 4 selected COI indicators were linked to NYC FITNESSGRAM youth data at baseline. Fitness outcomes (measured annually, 2011-2018) included body mass index, curl-ups, push-ups, and Progressive Aerobic Cardiovascular Endurance Run (PACER) laps. Unstratified and age-stratified, adjusted, 3-level generalized linear mixed models, nested by census tract and time, estimated the association between COI and fitness outcomes. The analytical sample (n = 204,939) lived in very low (41%) or low (30%) opportunity neighborhoods. Unstratified models indicated that overall COI is modestly associated with improved youth physical fitness outcomes. The strongest opportunity-fitness associations were observed for PACER. Stratified models show differences in associations across younger vs. older youth. We find that neighborhood factors are associated with youth fitness outcomes over time, with the strength of the associations dependent on age. Future implications include better informed place-based interventions tailored to specific life stages to promote youth health.

The longitudinal association between asthma severity and physical fitness among new York City public school youth.

Severe persistent childhood asthma is associated with low physical activity and may be associated with poor physical fitness. Research on the asthma severity-fitness association longitudinally and across sociodemographic subgroups is needed to inform fitness interventions targeting youth with asthma. We evaluated the relationship between asthma severity (categorized as severe, mild, or no asthma) and subsequent fitness in New York City (NYC) public school youth enrolled in grades 4-12 using the NYC Fitnessgram dataset (2010-2018). Longitudinal mixed models with random intercepts were fit to test the association between asthma severity and one-year lagged fitness z-scores by clustering repeated annual observations at the student level. Models were adjusted for sex, race/ethnicity, grade level, poverty status, time, and stratified by sociodemographic factors. The analytic sample included 663,137 students (51% male; 31% non-Hispanic Black, 40% Hispanic; 55% in grades 4-8, 70% high poverty; 87%, 11% and 1% with no, mild, and severe asthma, respectively). Students with severe asthma and mild asthma demonstrated -0.19 (95% CI, -0.20 to -0.17) and - 0.10 (95% CI, -0.11 to -0.10), respectively, lower fitness z-scores in the subsequent year relative to students without asthma. After stratifying by demographics, the magnitude of the asthma severity-fitness relationship was highest for non-Hispanic white vs. all other racial/ethnic subgroups, and was similar across sex, grade level, and household poverty status. Overall, we observed an inverse longitudinal relationship between asthma severity and subsequent fitness among urban youth, particularly non-Hispanic Whites. Future research should examine how neighborhood-level factors impact the asthma severity-fitness relationship across racial/ethnic subgroups.

Severe obesity and fitness in New York City public school youth, 2010-2018.

BACKGROUND: Obesity is associated with poorer youth fitness. However, little research has examined the magnitude of this relationship in youth with severe obesity. Therefore, we sought to determine the relationship between increasing weight status and fitness within a sample of children and adolescents from New York City public schools. METHODS: This study utilized longitudinal data from the NYC Fitnessgram dataset years 2010-2018. Height and weight along with fitness were measured annually during physical education classes. Severity of obesity was defined using body mass index relative to the 95th percentile and then categorized into classes. A composite measure of fitness was calculated based on scores for three fitness tests: aerobic capacity, muscular strength, and muscular endurance. To examine the weight status-fitness relationship, repeated measures mixed models with random-intercepts were constructed. Stratified models examined differences by demographic factors. RESULTS: The sample included 917,554 youth (51.8% male, 39.3% Hispanic, 29.9% non-Hispanic Black, 14.0%, 4.6%, and 1.6% class I, II and III obesity, respectively). Compared to youth with healthy weight, increasing severity of obesity was associated with decreased fitness: overweight (ß = - 0.28, 95% CI:-0.29;-0.28), class I obesity (ß = - 0.60, 95% CI:-0.60; - 0.60), class II obesity (ß = - 0.94, 95% CI:-0.94; - 0.93), and class III obesity (ß = - 1.28; 95% CI:-1.28; - 1.27). Stratified models showed the association was stronger among male and non-Hispanic White youth. CONCLUSION: Findings revealed that more severe obesity was associated with lower fitness. Future research is needed to develop targeted interventions to improve fitness in youth with obesity.

NYC FITNESSGRAM: Population-Level Physical Fitness Surveillance for New York City Youth.

NYC FITNESSGRAM, monitored by the New York City (NYC) Department of Education and the NYC Department of Health and Mental Hygiene, functions as the NYC Department of Education's citywide youth fitness surveillance program. Here we present the methods, characteristics, and data used in this surveillance system to monitor physical fitness in public school students (grades kindergarten through 12; initiated in 2006; n = 6,748,265 observations; mean sample of 519,097 observations per year to date) in New York, New York. Youth physical fitness prevalence estimates, longitudinal trends, and spatial analyses may be investigated using continuous fitness composite percentile scores and Cooper Institute for Aerobic Research-defined sex- and age-specific Healthy Fitness Zones. Healthy Fitness Zones are based on individual-child fitness test performance, with standard errors clustered at the school and student levels and adjusted for sociodemographic characteristics. Results may be used to show trends in youth fitness attainment over time and highlight disparities in the fitness prevalence of NYC students. In sum, continuous fitness composite percentile scores offer the opportunity for prospective tracking of shifts in youth physical fitness on a population scale and across subpopulations. NYC FITNESSGRAM can accompany a growing body of surveillance tools demonstrating the potential for population-level surveillance tools to promote global public health.

Longitudinal Association between Weight Status, Aerobic Capacity, Muscular Strength, and Endurance among New York City Youth, 2010-2017.

Background: Child weight status is inversely associated with fitness, but less is known about this relationship across fitness domains. This study examined the longitudinal association between weight status and fitness domains in a large, diverse sample of children. Methods: Data were drawn from the New York City Fitnessgram (2010-2011 to 2017-2018). Height and weight were collected annually and converted to weight status using Centers for Disease Control and Prevention growth charts. Aerobic capacity, muscular strength, and endurance were measured as age and sex standardized z-scores based on the fitness performance tests. Repeated-measures multilevel models were run testing the association between weight status and 1-year lagged fitness domains. Results: The sample included 917,554 children (51.8% male, 39.3% Hispanic, 29.9% non-Hispanic Black, 13.9%, 4.7%, and 1.7% class I, II, and III obesity, respectively). For each fitness domain, fitness scores decreased with increasing weight status across all demographic categories, with the lowest fitness scores observed in children with the most severe obesity, and highest magnitude of effects for aerobic capacity, and particularly among boys, non-Hispanic Whites, and older youth. For example, compared with youth with healthy weight, youth with overweight had 0.28 standard deviation lower aerobic capacity performance [confidence interval (95% CI): -0.29 to -0.28], followed by class 1 obesity (ß = -0.57, 95% CI: -0.58 to -0.57), class 2 obesity (ß = -0.88, 95% CI: -0.88 to -0.88), and class 3 obesity (ß = -1.19, 95% CI: -1.20 to -1.18). Conclusions: Compared with youth with healthy weight, youth at every other weight status had lower subsequent fitness, with the magnitude of the relationship increasing as weight status increased. Future research should examine interventions targeting aerobic capacity to reduce fitness disparities.

Context, importance, and process for creating a body mass index surveillance system to monitor childhood obesity within the New York City public school setting.

The Office of School Health, a joint program of the Departments of Health and Education, administers New York City's (NYC) body mass index (BMI) surveillance system to monitor childhood obesity. We describe the context, importance, and process for creating a multi-agency, school-based BMI surveillance system using BMI collected from annual FITNESSGRAM® physical fitness assessments conducted as part of a larger physical activity and wellness curriculum in NYC public schools. We also summarize our current system and methodology, highlighting the types of data and data sources that comprise the system and partnership between the Departments of Health and Education that enable data sharing. Strategies for addressing threats to data quality, including missing data, biologically implausible values, and imprecise/subjective weight or height equipment are discussed. We also review current and future surveillance data products, and provide recommendations for collecting, analyzing, interpreting, and reporting BMI data for childhood obesity surveillance. Collaboration between Departments of Health and Education as well as attention to safeguards of BMI reporting and data quality threats have enabled NYC to collect high quality BMI data to accurately monitor childhood obesity trends. These findings have implications for youth BMI surveillance systems in the United States and globally.

Latino Children's Obesity Risk Varies by Place of Birth: Findings from New York City Public School Youth, 2006-2017.

Introduction: Research showing that place of birth (POB) predicts excess weight gain and obesity risk among Latino adults has not prompted similar research in Latino children, although childhood is a critical period for preventing obesity. Objective: To identify differences in obesity risk among Latino children by POB. Methods: Longitudinal cohort observational study on public school children self-identified by parent/guardian as Latino in grades K-12 for school years 2006-07 through 2016-17 with measured weight and height (n = 570,172students; 3,103,642observations). POB reported by parent/guardian was categorized as continental United States [not New York City (NYC)] (n = 295,693), NYC (n = 166,361), South America (n = 19,452), Central America (n = 10,241), Dominican Republic (n = 57,0880), Puerto Rico (n = 9687), and Mexico (n = 9647). Age- and sex-specific BMI percentiles were estimated based on established growth charts. Data were analyzed in 2020. Results: Prevalence of obesity was highest among US (non-NYC)-born girls (21%) and boys (27%), followed by NYC-born girls (19%) and boys (25%). Among girls, South Americans (9%) had the lowest prevalence of all levels of obesity, while Puerto Ricans (19%) and Dominicans (15%) had the highest prevalence. Among boys, South Americans also had the lowest prevalence of all levels of obesity (15%), while Puerto Ricans (22%) and Mexicans (21%) had the highest. In adjusted models, obesity risk was highest in US (non-NYC)-born children, followed by children born in NYC (p < 0.001). Immigrant Latino children exhibited an advantage even after controlling for individual and neighborhood sociodemographic features, particularly Dominicans, South Americans, and Puerto Ricans. Conclusions: The heterogeneity of obesity risk among Latino children highlights the importance of POB.

Physical fitness disparities among New York City public school youth using standardized methods, 2006-2017.

Standardized physical fitness monitoring provides a more accurate proxy for youth health when compared with physical activity. Little is known about the utilization of broad-scale individual-level youth physical fitness testing to explore health disparities. We examined longitudinal trends in population-level fitness for 4th-12th grade New York City youth during 2006/7-2016/17 (average n = 510,293 per year). Analyses were performed in 2019. The primary outcome was whether or not youth achieved sex-/age-specific performance levels (called the Healthy Fitness Zone) on the aerobic capacity, muscular strength and muscular endurance tests using the NYC FITNESSGRAM. The Cooper Institute's most recent Healthy Fitness Zone criteria were applied to all tests and years. Prevalence estimates were weighted, accounted for school clustering, adjusted for student-level sociodemographics, and run by sociodemographic subgroups and year. The overall prevalence for meeting 3 Healthy Fitness Zones increased from 15.5% (95%CI: 13.9%-17.0%) in 2006/7 to 23.3% (95%CI: 22.2%-24.4%) in 2016/17 for students in grades 4-12. Fitness for all student groups increased over time, although Hispanic and non-Hispanic black girls consistently had the lowest prevalence of meeting 3 Healthy Fitness Zones as compared to all other race/sex subgroups. Also, 9th-12th graders had a lower prevalence of meeting 3 Healthy Fitness Zones as compared to 4th-8th graders. Given forecasted sharp increases in cardiovascular disease prevalence, routine youth fitness surveillance using standardized, criterion referenced methods can identify important fitness disparities and inform interventions.

Surveillance data confirm multiyear predictions of rotavirus dynamics in New York City.

Prediction skill is a key test of models for epidemic dynamics. However, future validation of models against out-of-sample data is rare, partly because of a lack of timely surveillance data. We address this gap by analyzing the response of rotavirus dynamics to infant vaccination. Syndromic surveillance of emergency department visits for diarrhea in New York City reveals a marked decline in diarrheal incidence among infants and young children, in line with data on rotavirus-coded hospitalizations and laboratory-confirmed cases, and a shift from annual to biennial epidemics increasingly affecting older children and adults. A published mechanistic model qualitatively predicted these patterns more than 2 years in advance. Future efforts to increase vaccination coverage may disrupt these patterns and lead to further declines in the incidence of rotavirus-attributable gastroenteritis.

Continued Decline in Obesity and Severe Obesity Prevalence Among New York City Public School Youth in Grades K-8: 2011-2017.

OBJECTIVE: This study aimed to estimate population-level prevalence of obesity and severe obesity for New York City youth and examine the most recent trends over time. METHODS: All public school youth in grades kindergarten through eighth (K-8) (2011-2012 through 2016-2017) with valid weight and height measures were included (N = 1,137,782 unique students; 3,720,297 observations). Age- and sex-specific BMI percentiles for obesity and severe obesity were estimated using Centers for Disease Control and Prevention growth charts. Repeated cross-sectional analyses were conducted using logistic regression, weighting for missing or invalid responses and accounting for clustering by students and schools to examine trends over time and by sociodemographics. RESULTS: Among youth in K-8 (aged 5-15 years, 48.8% girls), the prevalence of obesity and severe obesity in 2011-2012 was 21.5% and 6.4%, respectively, compared with 20.2% and 6.0%, respectively, in 2016-2017. Since 2011-2012, decreasing trends in obesity and severe obesity (relative declines: 6.0% and 6.3%, respectively, P < 0.001) have been observed. Significant decreases were observed for all subgroups (P < 0.001), although there remained disparities in relative declines over time by race/ethnicity and poverty. CONCLUSIONS: Decreasing trends in obesity and severe obesity among all New York City K-8 public school youth are promising; however, persistent disparities highlight the need to improve intervention design and implementation strategies for groups disproportionately burdened by obesity.

The effects of student, school and neighborhood poverty on the association between fitness and absenteeism in New York City middle school youth.

Recent research demonstrates that youth fitness improvements are associated with lower absenteeism. This study assessed whether the effects of poverty on the longitudinal fitness-absenteeism relationship are consistent across poverty measures at the student, school, and neighborhood levels and across sex in New York City (NYC) public school youth individually followed over 4 years. Negative binomial longitudinal mixed models with random-intercepts were developed stratified by five dichotomized student, school and neighborhood poverty measures and sex to test the change in fitness-lagged absenteeism relationship in six cohorts of NYC middle school students (2006/7-2012/13). Models were adjusted for individual-level race/ethnicity, place of birth, change in obesity status, grade, time, and school size. The sample included 360,743 students (51% male, 39% Hispanic, 28% non-Hispanic black, 69% qualifying for free/reduced price school meals). Adjusted estimates showed an inverse dose-response fitness-absenteeism relationship in high poverty youth across all poverty measures, including the student, school and neighborhood levels. For example, in girls exposed to high poverty based on school neighborhood, absenteeism decreased by 11.3% (IRR = -0.12, 95% CI: -0.20, -0.04), 10.4% (IRR = -0.11, 95% CI: -0.21, -0.02), 6.8% (IRR = -0.07, 95% CI: -0.14, 0.00) and 4.9% (IRR = -0.05, 95% CI: -0.15, 0.04) for students who had a >20% increase, 10-20% increase, <10% change, and 10-20% decrease in fitness from the prior year, respectively, relative to the reference group (>20% decrease in fitness). Future research should explore the impact of tailored interventions for youth that aim to promote youth physical activity at each of the individual, school and neighborhood levels, and particularly among high poverty subgroups.

Using Indirect Measures to Identify Geographic Hot Spots of Poor Glycemic Control: Cross-sectional Comparisons With an A1C Registry.

OBJECTIVE: Focusing health interventions in places with suboptimal glycemic control can help direct resources to neighborhoods with poor diabetes-related outcomes, but finding these areas can be difficult. Our objective was to use indirect measures versus a gold standard, population-based A1C registry to identify areas of poor glycemic control. RESEARCH DESIGN AND METHODS: Census tracts in New York City (NYC) were characterized by race, ethnicity, income, poverty, education, diabetes-related emergency visits, inpatient hospitalizations, and proportion of adults with diabetes having poor glycemic control, based on A1C >9.0% (75 mmol/mol). Hot spot analyses were then performed, using the Getis-Ord Gi* statistic for all measures. We then calculated the sensitivity, specificity, positive and negative predictive values, and accuracy of using the indirect measures to identify hot spots of poor glycemic control found using the NYC A1C Registry data. RESULTS: Using A1C Registry data, we identified hot spots in 42.8% of 2,085 NYC census tracts analyzed. Hot spots of diabetes-specific inpatient hospitalizations, diabetes-specific emergency visits, and age-adjusted diabetes prevalence estimated from emergency department data, respectively, had 88.9%, 89.6%, and 89.5% accuracy for identifying the same hot spots of poor glycemic control found using A1C Registry data. No other indirect measure tested had accuracy >80% except for the proportion of minority residents, which had 86.2% accuracy. CONCLUSIONS: Compared with demographic and socioeconomic factors, health care utilization measures more accurately identified hot spots of poor glycemic control. In places without a population-based A1C registry, mapping diabetes-specific health care utilization may provide actionable evidence for targeting health interventions in areas with the highest burden of uncontrolled diabetes.

The Association of Health-Related Fitness and Chronic Absenteeism Status in New York City Middle School Youth.

BACKGROUND: Extensive research demonstrates the benefits of fitness on children's health and academic performance. Although decreases in health-related fitness may increase school absenteeism, multiple years of prospective, child-level data are needed to examine whether fitness changes predict subsequent chronic absenteeism status. METHODS: Six cohorts of New York City public school students were followed from grades 5-8 (2006/2007-2012/2013; N = 349,381). A longitudinal 3-level logistic generalized linear mixed model with random intercepts was used to test the association of individual children's changes in fitness and 1-year lagged chronic absenteeism. RESULTS: The odds of chronic absenteeism increased 27% [odds ratio (OR) 95% confidence interval (CI), 1.25-1.30], 15% (OR 95% CI, 1.13-1.18), 9% (OR 95% CI, 1.07-1.11), and 1% (OR 95% CI, 0.98-1.04), for students who had a >20% decrease, 10%-20% decrease, <10% increase or decrease, and 10%-20% increase in fitness, respectively, compared with >20% fitness increase. CONCLUSION: These findings contribute important longitudinal evidence to a cross-sectional literature, demonstrating reductions in youth fitness may increase absenteeism. Given only 25% of youth aged 12-15 years achieve the recommended daily 60 minutes or more of moderate to vigorous physical activity, future work should examine the potential for youth fitness interventions to reduce absenteeism and foster positive attitudes toward lifelong physical activity.

The association of fitness and school absenteeism across gender and poverty: a prospective multilevel analysis in New York City middle schools.

PURPOSE: One-fifth to one-third of students in high poverty, urban school districts do not attend school regularly (missing ≥6 days/year). Fitness is shown to be associated with absenteeism, although this relationship may differ across poverty and gender subgroups. METHODS: Six cohorts of New York City public school students were followed up from grades 5 to 8 during 2006/2007-2012/2013 (n = 349,381). Stratified three-level longitudinal generalized linear mixed models were used to test the association between changes in fitness and 1-year lagged child-specific days absent across gender and poverty. RESULTS: In girls attending schools in high/very high poverty areas, greater improvements in fitness the prior year were associated with greater reductions in absenteeism (P = .034). Relative to the reference group (>20% decrease in fitness composite percentile scores from the prior year), girls with a large increase in fitness (>20%) demonstrated 10.3% fewer days absent (incidence rate ratio [IRR] 95% confidence interval [CI]: 0.834, 0.964), followed by those who had a 10%-20% increase in fitness (9.2%; IRR 95% CI: 0.835, 0.987), no change (5.4%; IRR 95% CI: 0.887, 1.007), and a 10%-20% decrease in fitness (3.8%; IRR 95% CI: 0.885, 1.045). In girls attending schools in low/mid poverty areas, fitness and absenteeism also had an inverse relationship, but no clear trend emerged. In boys, fitness and absenteeism had an inverse relationship but was not significant in either poverty group. CONCLUSIONS: Fitness improvements may be more important to reducing absenteeism in high/very high poverty girls compared with low/mid poverty girls and both high/very high and low/mid poverty boys. Expanding school-based physical activity programs for youth particularly in high poverty neighborhoods may increase student attendance.

Individual-Level Fitness and Absenteeism in New York City Middle School Youths, 2006-2013.

INTRODUCTION: Youth health-related fitness positively affects academic outcomes, although limited research has focused on the relationship between fitness and school absenteeism. We examined the longitudinal association between individual children's fitness and lagged school absenteeism over 4 years in urban middle schools. METHODS: Six cohorts of New York City public school students were followed from grades 5 through 8 (school years 2006-2007 through 2012-2013; n = 349,381). A 3-level longitudinal generalized linear mixed model was used to test the association of change in fitness composite percentile scores and 1-year lagged child-specific days absent. RESULTS: Adjusted 3-level negative binomial models showed that students with a more than 20% increase, 10% to 20% increase, less than 10% increase or decrease, and 10% to 20% decrease in fitness from the year prior had 11.9% (95% confidence interval [CI], 7.2-16.8), 6.1% (95% CI, 1.0-11.4), 2.6% (95% CI, -1.1 to 6.5), and 0.4% (95% CI, -4.3 to 5.4) lower absenteeism compared with students with a more than 20% fitness decrease. CONCLUSION: Cumulative effects of fitness improvement could have a significant impact on child absenteeism over time, particularly in high-need subgroups. Future research should examine the potential for school-based fitness interventions to reduce absenteeism rates, particularly for youths who have fitness drop-offs in adolescence.

Evaluating and implementing temporal, spatial, and spatio-temporal methods for outbreak detection in a local syndromic surveillance system.

The New York City Department of Health and Mental Hygiene has operated an emergency department syndromic surveillance system since 2001, using temporal and spatial scan statistics run on a daily basis for cluster detection. Since the system was originally implemented, a number of new methods have been proposed for use in cluster detection. We evaluated six temporal and four spatial/spatio-temporal detection methods using syndromic surveillance data spiked with simulated injections. The algorithms were compared on several metrics, including sensitivity, specificity, positive predictive value, coherence, and timeliness. We also evaluated each method's implementation, programming time, run time, and the ease of use. Among the temporal methods, at a set specificity of 95%, a Holt-Winters exponential smoother performed the best, detecting 19% of the simulated injects across all shapes and sizes, followed by an autoregressive moving average model (16%), a generalized linear model (15%), a modified version of the Early Aberration Reporting System's C2 algorithm (13%), a temporal scan statistic (11%), and a cumulative sum control chart (<2%). Of the spatial/spatio-temporal methods we tested, a spatial scan statistic detected 3% of all injects, a Bayes regression found 2%, and a generalized linear mixed model and a space-time permutation scan statistic detected none at a specificity of 95%. Positive predictive value was low (<7%) for all methods. Overall, the detection methods we tested did not perform well in identifying the temporal and spatial clusters of cases in the inject dataset. The spatial scan statistic, our current method for spatial cluster detection, performed slightly better than the other tested methods across different inject magnitudes and types. Furthermore, we found the scan statistics, as applied in the SaTScan software package, to be the easiest to program and implement for daily data analysis.