Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations.

OBJECTIVES: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. METHODS: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. RESULTS: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

The Prevalence of Cardiovascular Disease and Other Comorbidities Among American Indian and Alaska Native Adults with Diabetes.

AIMS: American Indians and Alaska Native (AI/ANs) peoples experience significant health disparities compared to the U.S. general population. We report comorbidities among AI/ANs with diabetes to guide efforts to improve their health status. METHODS: Drawing upon data for over 640,000 AI/ANs who used services funded by the Indian Health Service, we identified 43,518 adults with diabetes in fiscal year 2010. We reported the prevalence of comorbidities by age and cardiovascular disease (CVD) status. Generalized linear models were estimated to describe associations between CVD and other comorbidities. RESULTS: Nearly 15% of AI/AN adults had diabetes. Hypertension, CVD and kidney disease were comorbid in 77.9%, 31.6%, and 13.3%, respectively. Nearly 25% exhibited a mental health disorder; 5.7%, an alcohol or drug use disorder. Among AI/ANs with diabetes absent CVD, 46.9% had 2 or more other chronic conditions; the percentage among adults with diabetes and CVD was 75.5%. Hypertension and tobacco use disorders were associated with a 71% (95% CI for prevalence ratio: 1.63 - 1.80) and 33% (1.28 - 1.37) higher prevalence of CVD, respectively, compared to adults without these conditions. CONCLUSION: Detailed information on the morbidity burden of AI/ANs with diabetes may inform enhancements to strategies implemented to prevent and treat CVD and other comorbidities.

Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes.

BACKGROUND: The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes. OBJECTIVE: The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes. RESEARCH DESIGN: This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics. SUBJECTS: AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578). MEASURES: We compared health status and hospital utilization outcomes for ECP users and nonusers. RESULTS: Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001). CONCLUSIONS: Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.

Sex Differences in Diabetes Prevalence, Comorbidities, and Health Care Utilization among American Indians Living in the Northern Plains.

BACKGROUND: The American Indian (AI) population experiences significant diet-related health disparities including diabetes and cardiovascular disease (CVD). Owing to the relatively small sample size of AIs, the population is rarely included in large national surveys such as the NHANES. This exclusion hinders efforts to characterize potentially important differences between AI men and women, track the costs of these disparities, and effectively treat and prevent these conditions. OBJECTIVE: We examined the sex differences in diabetes prevalence, comorbidity experience, health care utilization, and treatment costs among AIs within a Northern Plains Indian Health Service (IHS) service unit. METHODS: We assessed data from a sample of 11,144 persons using an IHS service unit in the Northern Plains region of the United States. Detailed analyses were conducted for adults (n = 7299) on prevalence of diabetes by age and sex. We described sex differences in comorbidities, health care utilization, and treatment costs among the adults with diabetes. RESULTS: In our sample, adult men and women had a similar prevalence of diabetes (10.0% and 11.0%, respectively). The prevalence of CVD among men and women with diabetes was 45.7% and 34.0%, respectively. Among adults with diabetes, men had a statistically higher prevalence of hypertension and substance use disorders than women. The men were statistically less likely to have a non-substance use mental health disorder. Although men had higher utilization and costs for hospital inpatient services than women, the differences were not statistically significant. CONCLUSIONS: In this AI population, there were differences in comorbidity profiles between adult men and women with diabetes, which have differential mortality and cost consequences. Appropriate diabetes management addressing gender-specific comorbidities, such as substance use disorders for men and non-substance use mental health disorders for women, may help reduce additional comorbidities or complications to diabetes.

Food choices and distress in reservation-based American Indians and Alaska Natives with type 2 diabetes.

OBJECTIVE: To examine the association between food choice and distress in a large national sample of American Indians/Alaska Natives (AI/AN) with type 2 diabetes. DESIGN: Participants completed a sociodemographic survey, an FFQ and the Kessler-6 Distress Scale. Foods were identified as 'healthy' or 'unhealthy' using a classification grounded in the health education provided by the programme case managers; healthy and unhealthy food scores were calculated using reported intake frequencies. Pearson's correlation coefficients for distress and food scores were calculated for all participants and by gender. Multiple linear regression models stratified by gender assessed the association between distress and food scores, controlling for sociodemographics and duration of type 2 diabetes. SETTING: Rural AI reservations and AN villages. SUBJECTS: AI/AN (n 2484) with type 2 diabetes. RESULTS: Both males (34·9 %) and females (65·1 %) had higher healthy food scores than unhealthy scores. In bivariate analysis, distress level had a significant negative correlation with healthy food scores among female participants, but the association was not significant among males. Significant positive correlations between distress and unhealthy food scores were found in both genders. In the final multivariate models, healthy food scores were not significantly related to distress; however, unhealthy food scores showed significant positive relationships with distress for both genders (females: ß=0·078, P=0·0007; males: ß=0·139, P<0·0001). CONCLUSIONS: Health professionals working with AI/AN diagnosed with type 2 diabetes should offer food choice strategies during difficult times and recognize that males may be more likely than females to select unhealthy foods when distressed.

Disparities in Potentially Preventable Hospitalizations Between American Indian and Alaska Native and Non-Hispanic White Medicare Enrollees.

OBJECTIVE: A number of health care initiatives seek to improve health outcomes by increasing access to outpatient services while reducing preventable acute events. We evaluated disparities between American Indian and Alaska Native (AI/AN) and non-Hispanic white (white) Medicare enrollees in access to outpatient preventive, primary, and specialty services by comparing their potentially preventable hospitalizations (PPHs). RESEARCH DESIGN: The study population included 121,311 adult AI/AN Medicare enrollees registered to use services funded by the Indian Health Service and 5,915,011 adult white enrollees living in the same counties. Medicare 2010 data and a nationally recognized algorithm were used to identify PPHs. RESULTS: Among AI/AN Medicare enrollees, 58.6% had either diabetes, cardiovascular disease, or both conditions; the AI/AN age-adjusted prevalence of either or both conditions was 1.2 times that of the white enrollees (P<0.001). The age-adjusted PPH rate for all AI/ANs was 74 admissions per 1000 adults, 1.5 times that of white enrollees (P<0.001). Nearly 90% of AI/AN PPHs were among AI/ANs with diabetes, cardiovascular disease, or both conditions; their PPH rate was 114 admissions per 1000 adults, 1.2 times that of white enrollees (P<0.001) with those conditions. CONCLUSIONS: Differences in disease burden and access to outpatient services may partly explain the higher PPH rates for AI/AN Medicare enrollees. The health care quality measure used in this study (PPH) was developed for the US general population. It is important to consider AI/AN socioeconomic and other characteristics when interpreting findings for such measures and enhancing programs and policies to improve AI/AN health outcomes.

Costs And Savings Associated With Community Water Fluoridation In The United States.

The most comprehensive study of US community water fluoridation program benefits and costs was published in 2001. This study provides updated estimates using an economic model that includes recent data on program costs, dental caries increments, and dental treatments. In 2013 more than 211 million people had access to fluoridated water through community water systems serving 1,000 or more people. Savings associated with dental caries averted in 2013 as a result of fluoridation were estimated to be $32.19 per capita for this population. Based on 2013 estimated costs ($324 million), net savings (savings minus costs) from fluoridation systems were estimated to be $6,469 million and the estimated return on investment, 20.0. While communities should assess their specific costs for continuing or implementing a fluoridation program, these updated findings indicate that program savings are likely to exceed costs.

Human type 1 diabetes is associated with T cell autoimmunity to zinc transporter 8.

Recently we demonstrated that zinc transporter 8 (ZnT8) is a major target of autoantibodies in human type 1 diabetes (T1D). Because the molecules recognized by T1D autoantibodies are typically also targets of autoreactive T cells, we reasoned that this would likely be the case for ZnT8. To test this hypothesis, IFN-γ-producing T cells specific for ZnT8 in the peripheral blood of 35 patients with T1D (<6 mo after onset at blood draw) and 41 age-matched controls were assayed by ELISPOT using a library of 23 overlapping dipeptide pools covering the entire 369 aa primary sequence. Consistent with our hypothesis, patients showed significantly higher T cell reactivity than the matched controls, manifest in terms of the breadth of the overall response and the magnitude of responses to individual pools. Therefore, the median number of pools giving positive responses (stimulation index ≥ 3) in the control group was 1.0 (range, 0-7) compared with 6.0 (range, 1-20; p < 0.0001) for the patients. Similarly, the median stimulation index of positive responses in controls was 3.1 versus 5.0 in the patients (p < 0.0001). Individually, 7 of 23 pools showed significant disease association (p < 0.001), with several of the component peptides binding the disease associated HLA-DR3 (0301) and -DR4 (0401) molecules in vitro. We conclude that ZnT8 is also a major target of disease-associated autoreactive T cells in human T1D, and we suggest that reagents that target ZnT8-specific T cells could have therapeutic potential in preventing or arresting the progression of this disease.

What children eat during afternoons and evenings: is it important?

OBJECTIVE: To complete a description of the dietary intakes of New Zealand schoolchildren by describing afternoon and evening foods and nutrients. DESIGN: Twenty-four hour dietary recall data from the 2002 Children's Nutrition Survey were analysed to describe food and nutrient intakes during the afternoon (14.00 to 16.59 hours) and evening (17.00 to 23.59 hours). SETTING: New Zealand homes and schools. SUBJECTS: Children (n 2875) aged 5-14 years. RESULTS: Most children consumed something during the afternoon (79 %) and evening (98 %). Children were less likely to consume something during non-school day afternoons; if 11-14 years of age; and when of Pacific ethnicity. Afternoon food consumers had higher daily intakes for most nutrients. Afternoon intake accounted for much of this difference. In the afternoon, children consumed fruit (26 %) and biscuits/crackers (21 %). Evening eating contributed to daily intakes of energy (40 %), fat (43 %), carbohydrate (35 %), sucrose (20 %), glucose (24 %), vitamin A (47 %), Ca (26 %) and Fe (40 %). Children aged 5-6 years consumed a lower proportion of their daily energy intake during the evening than older children. In the evening, just one-third of children consumed vegetables (45 % if including potato/kumara/taro), 19 % fruit and 17 % ate hot chips. Children were more likely to consume vegetables if they also consumed potato/kumara/taro. Twenty-three per cent of children had powdered drinks/cordials, 21 % had soft drinks and 19 % had milk. CONCLUSIONS: Consuming foods/drinks in the afternoon positively influenced macronutrient distribution, increasing the carbohydrate proportion. During the evening 40 % of energy intake was consumed but less than one-half of children consumed vegetables; thus inclusion of vegetables in the evening is important, particularly in meals without potato/kumara/taro.

Nutrients and foods consumed by New Zealand children on schooldays and non-schooldays.

OBJECTIVE: To describe and compare food and nutrient intakes in New Zealand (NZ) children on schooldays and non-schooldays. DESIGN: Secondary analysis of cross-sectional data from the NZ 2002 Children's Nutrition Survey. Dietary intake was assessed using computer-assisted multi-pass 24 h dietary recalls in the home. Data were adjusted for survey weightings to be representative of the NZ population. The effect of day category on nutrient intake, and likelihood of consumption of food categories were determined using linear and logistic regression. SETTING: NZ homes and schools. SUBJECTS: A total of 2572 children (538 non-schooldays and 2034 schooldays) at the age of 5-14 years. RESULTS: There were differences in the proportion consuming some food groups between schooldays and non-schooldays, although the majority of nutrient intakes including energy did not differ by day category. Mean cholesterol intake was higher on non-schooldays; dietary fibre and available carbohydrate, in particular sucrose and fructose, were higher on schooldays. Hot chips were twice as likely to be consumed on a non-schoolday. Soft drink consumption was higher on non-schooldays for Maori/New Zealand European and others and powdered drinks/cordial consumption did not vary by day category. More children consumed snack bars (normal weight, obese), fruit, sandwiches, biscuits/crackers and snack foods on schooldays. There was no difference in consumption of pies/sausage rolls by day category. CONCLUSIONS: The proportion of consumers of a variety of foods differed significantly between non-schooldays and schooldays; few nutrient intakes differed. The present study indicates that family food, wherever it is consumed, is the mainstay of nutrition for NZ schoolchildren.

Milk fortified with the current adequate intake for vitamin D (5 microg) increases serum 25-hydroxyvitamin D compared to control milk but is not sufficient to prevent a seasonal decline in young women.

Low vitamin D status in women of childbearing age may have implications for health. Vitamin D status of New Zealanders (NZ), based on low serum 25-hydroxyvitamin D (25OHD) is suboptimal. Vitamin D status may be improved with supplements and/or fortified foods. Recently an Adequate Intake (AI) for Australia and NZ was set at 5 microg/d vitamin D. We aimed to determine the effect of daily consumption of milk powder fortified with 5 microg vitamin D3 on serum 25OHD concentration over 12 wks. 73 non-pregnant women (18 - 47 y) living in Dunedin, NZ (46 degrees S) were randomised to receive either unfortified (control) or fortified (5 microg vitamin D3) milk for 12 wks from January to April. Mean 25OHD was similar between groups at week 0 (control 74 vs 76 nmol/L) and fell significantly in both groups over the 12 weeks (control 53 nmol/L, fortified 65 nmol/L; p < 0.001). After 12 wks the fortified milk group had a serum 25OHD 19% (95% CI; 7, 32%) higher (10 nmol/L) than the control group after adjusting for baseline levels (p < 0.001). Daily consumption of fortified milk providing the current AI of 5 microg day vitamin D3 for 12 weeks resulted in higher 25OHD concentrations than control milk. This dose was not sufficient to prevent the seasonal decline in 25OHD. This study suggests an AI of 5 microg may be inadequate for New Zealanders to allow for seasonal changes in sunlight exposure, and is unlikely sufficient for other populations with low sunlight exposure.

Vitamin D insufficiency in New Zealanders during the winter is associated with higher parathyroid hormone concentrations: implications for bone health?

BACKGROUND: Parathyroid hormone concentration (PTH) is elevated in vitamin D insufficiency and when prolonged, this condition leads to reduced bone mass and possibly osteoporosis. The threshold of 25-hydroxyvitamin D above which PTH plateaus, is a criterion often used to define vitamin D adequacy. AIMS: To determine whether the higher rates of vitamin D inadequacy reported in the winter than summer months in New Zealand also result in higher PTH concentrations. Also to explore the relationship between 25-hydroxyvitamin D and PTH concentrations in a New Zealand population to determine if a threshold exists for plasma 25-hydroxyvitamin D concentration. METHODS: Plasma 25-hydroxyvitamin D and PTH concentrations were determined in 342 volunteers living in Invercargill and Dunedin (latitude 45-46 degrees S) in late summer (February) and early spring (October). RESULTS: Mean plasma 25-hydroxyvitamin D concentration was higher in the late summer versus early spring (79 vs 51 nmol/L; p<0.001). The lower plasma 25-hydroxyvitamin D in early spring versus summer was associated with a 0.2 pmol/L (p<0.001) higher PTH concentration. A threshold of 61 nmol/L was estimated for plasma 25-hydroxyvitamin D, above which there was no further decrease in PTH concentration. DISCUSSION: The higher PTH concentration in winter than summer suggests that the low 25-hydroxyvitamin D concentration in the winter months may be having an adverse effect on bone health. Many New Zealanders have 25-hydroxyvitamin D concentrations less than 62 nmol/L, especially in winter. Strategies to improve the vitamin D status of the population such as supplementation and food fortification may be needed.

Very high rates of vitamin D insufficiency in women of child-bearing age living in Beijing and Hong Kong.

We aimed to describe the vitamin D status of young women living in two Chinese cities in the spring--Beijing in the north (latitude 39 degrees north) and Hong Kong (latitude 22 degrees north) in the south. We also examined the relationship between serum 25-hydroxyvitamin D and parathyroid hormone (PTH) concentrations to determine a threshold for serum 25-hydroxyvitamin D above which there is no further suppression of PTH. Finally, we examined whether dietary Ca intake influences this relationship. Non-pregnant women aged 18-40 years (n 441) were recruited between February and June. Fasting blood was collected and dietary intakes were assessed using 5 d food records. Mean serum 25-hydroxyvitamin D concentration was lower in Beijing than Hong Kong women (29 v. 34 nmol/l; P < 0.001). Vitamin D deficiency (< or = 25 nmol/l) was indicated in 40% of Beijing and 18% of Hong Kong women, and over 90% of women in both cities were insufficient (< or = 50 nmol/l). Mean Ca and vitamin D intakes were 478 mg/d and 2.0 microg/d, respectively. The relationship between 25-hydroxyvitamin D concentration and PTH was linear throughout the range with a slope of -0.36 (different from 0; P < 0.001; R 0.26), with no apparent threshold. There was no influence of Ca intake on the relationship between 25-hydroxyvitamin D and PTH concentration. Vitamin D deficiency is common and insufficiency is very common in non-pregnant women in Hong Kong and Beijing during spring. Serum 25-hydroxyvitamin D was inversely associated with PTH with no apparent threshold. Strategies such as vitamin D fortification or supplementation may be required.

Red cell folate and predicted neural tube defect rate in three Asian cities.

BACKGROUND: Periconceptional folic acid reduces neural tube defect (NTD) risk. Red blood cell folate concentration is inversely associated with NTD risk. In many countries there is a lack of information on NTD rates. Red cell folate status in women of childbearing age may be a surrogate for NTD rates and may be helpful in identifying countries or regions most likely to benefit from improved folate status. OBJECTIVE: To predict NTD rates using red cell folate concentrations in women of childbearing age living in three Asian cities Design: Cross-sectional convenience samples of non-pregnant women living in Beijing (n=220), Kuala Lumpur (n=389), and Jakarta (n=129). RESULTS: Red cell folate concentrations were highest (p<0.001) in women from Jakarta at 872 nmol/L (95% CI; 833, 910) followed by Kuala Lumpur at 674 nmol/L (95% CI: 644, 704) and lowest in Beijing at 563 nmol/L (95% CI: 524, 601). Accordingly, predicted NTD rates were highest in Beijing at 30/10000 (95% CI: 27, 33), followed by Kuala Lumpur at 24/10000 (95% CI: 22, 25), and lowest in Jakarta at 15/10000 (95% CI: 14,15). CONCLUSION: Our red blood cell folate data suggests that of the three cities improving the folate status of women in Beijing would have the greatest impact on NTD rates.

No alterations in the frequency of FOXP3+ regulatory T-cells in type 1 diabetes.

Regulatory T-cells (Tregs) play a critical role in maintaining dominant peripheral tolerance. Previous characterizations of Tregs in type 1 diabetes have used antibodies against CD4 and alpha-chain of the interleukin-2 receptor complex (CD25). This report extends those investigations by the addition of a more lineage-specific marker for Tregs, transcription factor forkhead box P3 (FOXP3), in subjects with type 1 diabetes, their first-degree relatives, and healthy control subjects. With inclusion of this marker, two predominant populations of CD4(+)CD25(+) T-cells were identified: CD4(+)CD25(+)FOXP3(+) as well as CD4(+)FOXP3(-) T-cells expressing low levels of CD25 (CD4(+)CD25(LOW)FOXP3(-)). In all study groups, the frequency of CD4(+)CD25(+)FOXP3(+) cells was age independent, whereas CD4(+)CD25(LOW)FOXP3(-) cell frequencies strongly associated with age. In terms of additional markers for delineating cells of Treg lineage, FOXP3(+) cells were CD127(-) to CD127(LOW) whereas CD25(+) cells were less restricted in their expression of this marker, with CD127 expressed across a continuum of levels. Importantly, no differences were observed in the frequency of CD4(+)CD25(+)FOXP3(+) T-cells in individuals with or at varying degrees of risk for type 1 diabetes. These investigations suggest that altered peripheral blood frequencies of Tregs, as defined by the expression of FOXP3, are not specifically associated with type 1 diabetes and continue to highlight age as an important variable in analysis of immune regulation.

Season and ethnicity are determinants of serum 25-hydroxyvitamin D concentrations in New Zealand children aged 5-14 y.

New Zealand children, particularly those of Maori and Pacific ethnicity, may be at risk for low vitamin D status because of low vitamin D intakes, the country's latitude (35-46 degrees S), and skin color. The aim of this study was to determine 25-hydroxyvitamin D concentrations and their determinants in a national sample of New Zealand children aged 5-14 y. The 2002 National Children's Nutrition Survey was designed to survey New Zealand children, including oversampling of Maori and Pacific children to allow ethnic-specific analyses. A 2-stage recruitment process occurred using a random selection of schools, and children within each school. Serum 25-hydroxyvitamin D concentration [mean (99% CI) nmol/L] in Maori children (n = 456) was 43 (38,49), in Pacific (n = 646) 36 (31,42), and in New Zealand European and Others (NZEO) (n = 483) 53 (47,59). Among Maori, Pacific, and NZEO, the prevalence (%, 99% CI) of serum 25-hydroxyvitamin D deficiency (<17.5 nmol/L) was 5 (2,12), 8 (5,14), and 3 (1,7), respectively. The prevalence of insufficiency (<37.5 nmol/L) was 41 (29,53), 59 (42,75), and 25 (15,35), respectively. Multiple regression analysis found that 25-hydroxyvitamin D concentrations were lower in winter than summer [adjusted mean difference (99% CI) nmol/L; 15 (8,22)], lower in girls than boys [5 (1,10)], and lower in obese children than in those of "normal" weight [6 (1,11)]. Relative to NZEO, 25-hydroxyvitamin D concentrations were lower in Maori [9 (3,15)] and Pacific children [16 (10,22)]. Ethnicity and season are major determinants of serum 25-hydroxyvitamin D. There is a high prevalence of vitamin D insufficiency in New Zealand children, which may or may not contribute to increased risk of osteoporosis and other chronic disease. There is a pressing need for more convincing evidence concerning the health risks associated with the low vitamin D status in New Zealand children.

Folic acid fortified milk increases blood folate and lowers homocysteine concentration in women of childbearing age.

Daily consumption of 400 microg folic acid prior to conception and during early pregnancy is recommended for the prevention of neural tube defects (NTD). Strategies to increase folic acid consumption include supplements and fortified foods. Milk is consumed by women and can be fortified with folic acid but little is known about the effect of fortified milk on blood folate concentration in women of childbearing age. The objective of this study was to determine whether daily consumption of milk fortified with 375 microg folic acid increases blood folate and lowers homocysteine concentrations in women of childbearing age. Seventy-three non-pregnant women (aged 18-47 y) were randomized to receive either 75 g/d of a fortified or unfortified (control) milk powder for 12 weeks. Women who consumed the folic acid fortified milk had mean (95% CI) red blood cell and plasma folate concentrations that were 539 nmol/L (436, 641) and 35 nmol/L (30, 41) higher, respectively, than in the control group. Women drinking fortified milk had a 14% lower mean plasma homocysteine concentration at week 12 than women consuming the control milk. Daily consumption of fortified milk powder providing 375 microg folic acid increases blood folate and lowers homocysteine concentrations over 12 weeks in women of childbearing age. Daily consumption of fortified milk would be expected to reduce NTD risk.

Children who avoid drinking cow's milk are at increased risk for prepubertal bone fractures.

The full fracture histories of 50 children (30 girls and 20 boys, age range 3 to 13 years) who had avoided drinking cow's milk for prolonged periods were compared with those in a birth cohort of more than 1,000 children from the same city. Children who avoided milk did not use calcium-rich food substitutes appropriately and had low dietary calcium intakes and low bone mineral density values. Many were overweight (22 of 50). Significantly more of the children who avoided milk reported fractures (16 observed vs 6 expected, chi(2)=31.0, P<.001, df=5). They also experienced more total fractures than the birth cohort population (22 observed vs 8 expected, chi(2)=33.6, P<.001, df=5). All of the fractures occurred before puberty, the majority (18 of 22) being associated with only slight trauma. Forearm fractures were especially common (12 fractures). We conclude that young children avoiding milk are prone to fracture.