Identifying Ontarians with Type 2 Diabetes Mellitus in Administrative Data: A Comparison of Two Case Definitions.

INTRODUCTION: This study compared two previously validated sensitive and specific diabetes case definitions to explore the impact of different classification methods in Ontario ICES administrative data. METHODS: This study included patients captured by the Ontario Diabetes Database with type 2 diabetes using either the sensitive cohort definition (≥ 2 physician visits for diabetes within 1 year or ≥ 1 drug claim for diabetes or ≥ 1 hospitalization with diabetes), or the specific cohort definition (≥ 3 physician visits for diabetes within 1 year), between October 1, 2013 to September 30, 2015. Each cohort's demographic and clinical features were described using descriptive analysis. RESULTS: Using sensitive and specific definitions, 1,093,812 and 783,228 patients with type 2 diabetes were identified, respectively. Overall, the demographic and clinical characteristics were similar between cohorts. Patients in the sensitive cohort had mean age of 64.1 years and were 52.4% male, compared to 64.8 years and 53.6% male in the specific cohort. In the sensitive and specific cohorts respectively, 64.4% and 55.7% of patients reported one-year mean HbA1c of < 7% (53 mmol/mol) and 25.3% and 31.5% reported levels between 7.0-8.5% (53-69 mmol/mol). CONCLUSIONS: Although sample sizes were different between sensitive and specific cohorts, demographic and clinical characteristics were similar.

Perianal Fistulas Are Associated with Persistently Higher Direct Health Care Costs in Crohn's Disease: A Population-Based Study.

BACKGROUND: The economic impact of perianal fistulas in Crohn's disease (CD) has not been formally assessed in population-based studies in the biologic era. AIM: To compare direct health care costs in persons with and without perianal fistulas. METHODS: We performed a longitudinal population-based study using administrative data from Ontario, Canada. Adults (> 17 years) with CD were identified between 2007 and 2013 using validated algorithms. Perianal fistula positive "cases" were matched to up to 4 "controls" with CD without perianal fistulas based on age, sex, geographic region, year of CD diagnosis and duration of follow-up. Direct health care costs, excluding drug costs from private payers, were estimated annually beginning 5 years before (lookback) and up to 9 years after perianal fistula diagnosis (study completion) for cases and a standardized date for matched controls. RESULTS: A total of 581 cases were matched to 1902 controls. The annual per capita direct cost for cases was similar at lookback compared to controls ($2458 ± 6770 vs $2502 ± 10,752; p = 0.952), maximally greater in the first year after perianal fistulas diagnosis ($16,032 ± 21,101 vs $6646 ± 13,021; p < 0.001) and remained greater at study completion ($11,358 ± 17,151 vs $5178 ± 9792; p < 0.001). At perianal fistula diagnosis, the cost difference was driven primarily by home care cost (tenfold greater), publicly-covered prescription drugs (threefold greater) and hospitalizations (twofold greater), whereas at study completion, prescription drugs were the dominant driver (threefold greater). CONCLUSION: In our population-based cohort, perianal fistulas were associated with significantly higher direct healthcare costs at the time of perianal fistulas diagnosis and sustained long-term.

Estimating the Associated Burden of Illness and Healthcare Utilization of Newly Diagnosed Patients Aged ≥65 with Mantle Cell Lymphoma (MCL) in Ontario, Canada.

BACKGROUND: With the emergence of therapies for mantle cell lymphoma (MCL), understanding the treatment patterns and burden of illness among older patients with MCL in Canada is essential to inform decision making. METHODS: A retrospective study using administrative data matched individuals aged ≥65 who were newly diagnosed with MCL between 1 January 2013 and 31 December 2016 with general population controls. Cases were followed for up to 3 years in order to assess healthcare resource utilization (HCRU), healthcare costs, time to next treatment or death (TTNTD), and overall survival (OS); all were stratified according to first-line treatment. RESULTS: This study matched 159 MCL patients to 636 controls. Direct healthcare costs were highest among MCL patients in the first year following diagnosis (Y1: CAD 77,555 ± 40,789), decreased subsequently (Y2: CAD 40,093 ± 28,720; Y3: CAD 36,059 ± 36,303), and were consistently higher than the costs for controls. The 3-year OS after MCL diagnosis was 68.6%, with patients receiving bendamustine + rituximab (BR) experiencing a significantly higher OS compared to patients treated with other regimens (72.4% vs. 55.6%, p = 0.041). Approximately 40.9% of MCL patients initiated a second-line therapy or died within 3 years. CONCLUSION: Newly diagnosed MCL presents a substantial burden to the healthcare system, with almost half of all patients progressing to a second-line therapy or death within 3 years.

Estimating the Burden of Illness of Relapsed Follicular Lymphoma and Marginal Zone Lymphoma in Ontario, Canada.

BACKGROUND: Many patients with advanced follicular lymphoma (FL) and marginal zone lymphoma (MZL) relapse after first-line chemotherapy. OBJECTIVE: To examine healthcare resource utilization (HCRU) and cost, treatment patterns, progression, and survival of patients with FL and MZL who relapse after first-line treatment, in Ontario, Canada. METHODS: A retrospective, administrative data study identified patients with relapsed FL and MZL (1 January 2005-31 December 2018). Patients were followed for up to three years post relapse to assess HCRU, healthcare costs, time to next treatment (TTNT), and overall survival (OS), stratified by first- and second-line treatment. RESULTS: The study identified 285 FL and 68 MZL cases who relapsed after first-line treatment. Average duration of first-line treatment was 12.4 and 13.4 months for FL and MZL patients, respectively. Drug (35.9%) and cancer clinic costs (28.1%) were major contributors to higher costs in year 1. Three-year OS was 83.9% after FL and 74.2% after MZL relapse. No statistically significant differences were observed in TTNT and OS between patients with FL who received R-CHOP/R-CVP/BR in the first line only versus both the first- and second- line. A total of 31% of FL and 34% of MZL patients progressed to third-line treatment within three years of initial relapse. CONCLUSION: Relapsing and remitting nature of FL and MZL in a subset of patients results in substantial burden to patients and the healthcare system.

Understanding strategies to improve medication adherence among persons with type 2 diabetes: A scoping review.

AIMS: The objectives of this scoping review were to: (1) identify the target audience and contexts in which strategies to improve type 2 diabetes mellitus (T2DM) medication adherence have been used, (2) provide an overview of behaviour change techniques (BCTs) used, (3) describe the determinants of behaviour targeted by strategies and (4) to identify current gaps in strategies. METHODS: A systemic search for articles related to T2DM, medication adherence and strategies was conducted in EMBASE, Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily using the OvidSP platform on 11 March 2021. All publications involving strategies to overcome medication non-adherence among adults with T2DM were included. Strategies were categorized according to the BCT taxonomy and the determinants of behaviour targeted by each strategy were classified by using the Theoretical Domains Framework (TDF). RESULTS: The search identified 58 articles and 61 strategies. The BCT categories Antecedents and Natural consequences and BCTs Feedback on outcome(s) of behaviour, Adding objects to the environment and Information about health consequences were identified most frequently as components of strategies resulting in statistically significant improvement in medication adherence. Strategies targeting the TDF domains Reinforcement and Beliefs about Consequences most often resulted in statistically significant improvements in adherence measures. CONCLUSIONS: The findings from this review identify BCTs and targeted behaviours with demonstrated success. Further exploration of the myriad of BCTs and the corresponding determinants of behaviour which were not accessed may be warranted for the development of future strategies to improve medication adherence in type 2 diabetes.

A Cross-sectional Survey to Assess Reasons for Therapeutic Inertia in People With Type 2 Diabetes Mellitus and Preferred Strategies to Overcome It From the Perspectives of Persons With Diabetes and General/Family Practitioners: Results From the MOTION Study.

OBJECTIVES: Although multiple causes of therapeutic inertia in type 2 diabetes mellitus (T2DM) have been identified, few studies have addressed the behavioural aspects of treatment-intensification decisions among persons with type 2 diabetes (PwT2DM) and general practitioners/family practitioners (GPFPs). METHODS: A quantitative online survey was developed to capture from 300 PwT2DM and 100 GPFPs the following information: 1) perspectives on shared decision-making (SDM) related to treatment intensification, using the 9-item Shared Decision Making Questionnaire and the Shared Decision Making Questionnaire---physician version; 2) intentions to intensify treatments, using the Theory of Planned Behaviour (TPB); and 3) preferred strategies to overcome causes of therapeutic inertia in T2DM. Regression methods were applied post hoc to examine correlations with SDM scores, behavioural intentions and behaviours. RESULTS: SDM scores showed a significantly lower level of perceived involvement in decision-making related to treatment intensification among PwT2DM compared with GPFPs. The TPB identified that, for PwT2DM, attitudes, perceived behavioural control and age were associated with variation in intention to intensify treatment and, for GPFPs, perceived behavioural control and not being in a shared/group practice were associated with intentions to intensify treatment. PwT2DM behaviour, measured as hesitancy to intensify treatment, was associated with age. PwT2DM want more information to become more comfortable with the treatment decision-making process, whereas GPFPs desired support from other health professionals, and more time to address issues among PwT2DM. CONCLUSIONS: Strategies directed at providing GPFPs with tools/approaches to increase PwT2DM involvement in the decision-making process, such as behavioural coaching, decision aids and goal setting, may increase acceptance of treatment intensification, leading to a reduction in therapeutic inertia in T2DM.

Persons With Diabetes and General/Family Practitioner Perspectives Related to Therapeutic Inertia in Type 2 Diabetes Mellitus Using Qualitative Focus Groups and the Theoretical Domains Framework: Results From the MOTION Study.

OBJECTIVES: Therapeutic inertia in type 2 diabetes (T2DM) is the failure to receive timely treatment intensification as indicated according to T2DM treatment guidelines. Multifactorial causes of therapeutic inertia in T2DM have been documented at the level of persons with diabetes (PwD), health-care providers and health-care systems. METHODS: We developed a 3-part mixed-methods research program, called the Moving to Overcome Therapeutic Inertia Obstacles Now in T2DM (MOTION) study, to inform the development of strategies to address therapeutic inertia in T2DM. We present the results from focus groups with the following objectives: 1) understanding PwD and general practitioner/family practitioner (GPFP) determinants of behaviour related to treatment intensification using the Theoretical Domains Framework (TDF); and 2) identifying the sources of behaviours contributing to therapeutic inertia in T2DM, as proposed by the Behaviour Change Wheel (BCW). Two focus groups with PwD and 4 with GPFPs were conducted. Transcripts from the focus groups were coded independently by 2 investigators to identify themes, then mapped to TDF domains and linked using the BCW. RESULTS: For PwD, the most commonly coded TDF domains were intentions, goals, knowledge, beliefs about consequences and social influences. For GPFPs, the most common domains were intentions, environmental context and resources and social/professional role and identity. The BCW identified that PwD interventions should include reflective motivation, psychological capability and social opportunity; GPFP interventions should include physical opportunity, social opportunity and reflective motivation. CONCLUSIONS: Comprehensive strategies that target both PwD and GPFP barriers would encourage a more collaborative approach toward treatment intensification decisions and reducing therapeutic inertia.

Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review.

The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.

Real-World Observational Study on the Characteristics and Treatment Patterns of Allergic Asthma Patients Receiving Omalizumab in Canada.

BACKGROUND: Omalizumab is a treatment option for pediatric and adult patients with moderate to severe allergic asthma poorly controlled with standard inhaled therapies. Clinical trials and observational studies have demonstrated the efficacy of omalizumab. There is limited real-world evidence on the characteristics and treatment patterns of Canadian asthma patients receiving omalizumab. OBJECTIVE: We profiled Canadian omalizumab users to estimate time to omalizumab discontinuation and to assess changes in concurrent medication usage before, during, and after therapy. METHODS: This was a retrospective, observational, cohort study that analyzed data from Canadian prescription claims databases. An algorithm was used to select naïve users of omalizumab with an inferred diagnosis of GINA 5-asthma who made a claim for omalizumab from February 1, 2007, to June 2, 2015. Demographic and baseline characteristics were assessed at index. Outcomes examined over the analysis period included (i) daily omalizumab dose per patient and per claim; (ii) omalizumab discontinuation (defined as ≥100-day gap in making omalizumab claims) and its potential predictors (ie, age, sex, province of residence, drug insurer; assessed by Cox Proportional Hazards Model); and (iii) for patients who discontinued omalizumab, changes in concurrent medication usage before, during, and 6 months after omalizumab usage. RESULTS: The final study cohort consisted of 1160 patients (mean age: 45.8 ± 15.2 years; 64.7% female). During the first year of omalizumab therapy, 29.5% of patients discontinued treatment. The singular characteristic that predicted omalizumab discontinuation with statistical significance was age group (20‒34 years vs 12‒19 years; hazard ratio 1.75, 95% confidence interval 1.11-2.76; P<0.05). There were significant reductions in the use of some concurrent inhaled and oral asthma medications during and/or after omalizumab use (P<0.05). CONCLUSION: Nearly one-third of patients who initiated omalizumab in Canada for refractory, moderate to severe allergic asthma discontinued treatment during the first year.

Development and Validation of the Bicultural Youth Acculturation Questionnaire.

OBJECTIVES: Acculturation is a multidimensional process involving changes in behaviour and beliefs. Questionnaires developed to measure acculturation are typically designed for specific ethnic populations and adult experiences. This study developed a questionnaire that measures acculturation among ethnically diverse populations of youth that can be included as a module in population surveys. METHODS: Questionnaires measuring acculturation in youth were identified in the literature. The importance of items from the existing questionnaires was determined using a Delphi process and this informed the development of our questionnaire. The questionnaire was then pilot tested using a sample of 248 Canadians aged 18-25 via an online system. Participants identified as East and South East Asian (27.8%), South Asian (17.7%) and Black (13.7%). The majority were 1st (33.5%) or 2nd generation immigrants (52.0%). After redundant items were eliminated, exploratory factor analysis grouped items into domains, and, for each domain, internal consistency, and convergent validity with immigrant generation then age at immigration estimated. A subset of participants re-completed the questionnaire for reliability estimation. RESULTS: The literature review yielded 117 articles that used 13 questionnaires with a total of 440 questions. The Delphi process reduced these to 32 questions. Pilot testing occurred in 248 Canadians aged 18-25. Following item reduction, 16 questions in three domains remained: dominant culture, heritage language, and heritage culture. All had good internal consistency (Cronbach's alphas > .75). The mean dominant domain score increased with immigrant generation (1st generation: 3.69 (95% CI: 3.49-3.89), 2nd: 4.13 (4.00-4.26), 3rd: 4.40 (4.19-4.61)), and mean heritage language score was higher among those who immigrated after age 12 than before (p = .0001), indicative of convergent validity. CONCLUSIONS: This Bicultural Youth Acculturation Questionnaire has demonstrated validity. It can be incorporated into population health surveys to elucidate the impact of acculturation on health outcomes among bicultural youth.

Active transportation and bullying in Canadian schoolchildren: a cross-sectional study.

BACKGROUND: Bullying is a recognized social problem within child populations. Engagement in childhood bullying often occurs in settings that are away from adult supervision, such as en route to and from school. Bullying episodes may also have a negative impact on school childrens' decisions to engage in active transportation. METHODS: Using a cross-sectional design, we analyzed reports from the 2009/10 cycle of the Canadian Health Behaviour in School-Aged Children (HBSC) study. Records from this general health survey were obtained for 3,997 urban students in grades 6-10 who lived in close proximity of their school and were hence ineligible for school bussing. Students who indicated walking or bicycling to school were classified as engaged in active transportation. Victims and perpetrators of bullying were defined using standard measures and a frequency cut-off of at least 2-3 times per month. Analyses focused on relations between bullying and active transportation, as well as barriers to active transportation as perceived by young people. RESULTS: 27% of young people indicated being victimized, and 12% indicated that they engaged in bullying. Girls were more likely to be victimized than boys, and younger students were more likely to be victimized than older students. Engagement in active transportation was reported by 63% of respondents, of these, 68% indicated that worrying about bullying on the way to school was an impediment to such transportation methods. Victimization by bullying (adjusted OR = 1.26, 95% CI: 1.00 - 1.59) was reported more frequently by children who used active transportation. CONCLUSIONS: Health promotion efforts to promote engagement in active transportation of students to school have obvious value. The potential for modest increases in exposure to bullying should be considered in the planning of such initiatives.

Influence of country of birth and ethnicity on body mass index among Canadian youth: a national survey.

BACKGROUND: The body mass index (BMI) of youth often changes when they immigrate to a new country as a result of the adoption of new behaviours, a process called acculturation. We investigated whether BMI differs by country of birth (Canada v. other countries) and ethnicity, both individually and together. We also examined whether time since immigration and health-related behaviour explain any observed BMI differences. METHODS: Data sources were the Canadian Health Behaviour in School-Aged Children study and the Canada Census of Population. Participants were youth in grades 6-10 (weighted sample n = 19 272). A questionnaire was used to assess participants' sociodemographic characteristics, height, weight and health-related behaviour. We calculated BMIs from participants' self-reported heights and weights and used World Health Organization growth references to determine BMI percentiles. RESULTS: Based on self-reported heights and weights, BMI percentiles for foreign-born youth were lower than those of youth born in Canada (-4, 95% confidence interval [CI] -6 to -2). This difference did not decrease with time since immigration. Similarly, BMI percentiles were lower among East and Southeast Asian youth than their peers from the Canadian host culture (-4, 95% CI -6 to -2). Finally, BMI percentiles for foreign-born Arab and West Asian youth and East Indian and South Asian youth were lower than their Canadian-born peers of the same ethnicity (-14, 95% CI -22 to -7; -8, 95% CI -14 to -3). INTERPRETATION: Immigrant generation and ethnicity were related to BMI among Canadian youth, both independently and together. Some ethnic groups showed differences by country of birth, i.e., East Indian and South Asian, while others showed no such difference, i.e., East and Southeast Asian. There was no association with time since immigration. Our findings reinforce the need to investigate country of birth and ethnicity when considering the determinants of childhood BMI.

Time since immigration and ethnicity as predictors of physical activity among Canadian youth: a cross-sectional study.

BACKGROUND: Little is known about patterns of physical activity engaged in by youth after they immigrate to a new country. This study aims to investigate relationships between immigrant generation and ethnicity with physical activity, and to determine if the relationship between immigrant generation and physical activity was modified by ethnicity. METHODS: The data sources were Cycle 6 (2009-2010) of the Canadian Health Behaviour in School-Aged Children Study and the 2006 Canada Census of Population. Participants (weighted n = 23,124) were young people from grades 6-10 in 436 schools. Students were asked where they were born, how long ago they moved to Canada, their ethnicity, and how many days a week they accumulated at least 60 minutes of moderate-to-vigorous physical activity (MVPA). RESULTS: Youth born outside of Canada were less likely to be active than peers born in Canada; 11% vs 15% reported 7 days/week of at least 60 minutes of MVPA (p = .001). MVPA increased with time since immigration. Compared to Canadian-born youth, youth who immigrated within the last 1-2 years were less likely to get sufficient MVPA on 4-6 days/week (odds ratio: 0.66, 95% confidence interval: 0.53-0.82) and 7 days/week (0.62; 0.43-0.89). East and South-East Asian youth were less active, regardless of time since immigration: 4-6 days/week (0.67; 0.58-0.79) and 7 days/week (0.37; 0.29-0.48). CONCLUSION: Time since immigration and ethnicity were associated with MVPA among Canadian youth. Mechanisms by which these differences occur need to be uncovered in order to identify barriers to physical activity participation among youth.

Use of diagnostic imaging in the emergency department for cervical spine injuries in Kingston, Ontario.

OBJECTIVES: This study assessed the use and clinical yield of diagnostic imaging (radiography, computed tomography, and medical resonance imaging) ordered to assist in the diagnosis of acute neck injuries presenting to emergency departments (EDs) in Kingston, Ontario, from 2002-2003 to 2009-2010. METHODS: Acute neck injury cases were identified using records from the Kingston sites of the Canadian National Ambulatory Care Reporting System. Use of radiography was analyzed over time and related to proportions of cases diagnosed with clinically significant cervical spine injuries. RESULTS: A total of 4,712 neck injury cases were identified. Proportions of cases referred for diagnostic imaging to the neck varied significantly over time, from 30.4% in 2002-2003 to 37.6% in 2009-2010 (ptrend  =  0.02). The percentage of total cases that were positive for clinically significant cervical spine injury ("clinical yield") also varied from a low of 5.8% in 2005-2006 to 9.2% in 2008-2009 (ptrend  =  0.04), although the clinical yield of neck-imaged cases did not increase across the study years (ptrend  =  0.23). Increased clinical yield was not observed in association with higher neck imaging rates whether that yield was expressed as a percentage of total cases positive for clinically significant injury (p  =  0.29) or as a percentage of neck-imaged cases that were positive (p  =  0.77). CONCLUSIONS: We observed increases in the use of diagnostic images over time, reflecting a need to reinforce an existing clinical decision rule for cervical spine radiography. Temporal increases in the clinical yield for total cases may suggest a changing case mix or more judicious use of advanced types of diagnostic imaging.

Physical and emotional health problems experienced by youth engaged in physical fighting and weapon carrying.

Then aims of the current study were 1) to provide cross-national estimates of the prevalence of physical fighting and weapon carrying among adolescents aged 11-15 years; (2) To examine the possible effects of physical fighting and weapon carrying on the occurrence of physical (medically treated injuries) and emotional health outcomes (multiple health complaints) among adolescents within the theoretical framework of Problem Behaviour Theory. 20,125 adolescents aged 11-15 in five countries (Belgium, Israel, USA, Canada, FYR Macedonia) were surveyed via the 2006 Health Behaviour in School Aged Children survey. Prevalence was calculated for physical fighting and weapon carrying along with physical and emotional measures that potentially result from violence. Regression analyses were used to quantify associations between violence/weapon carrying and the potential health consequences within each country. Large variations in fighting and weapon carrying were observed across countries. Boys reported more frequent episodes of fighting/weapon carrying and medically attended injuries in every country, while girls reported more emotional symptoms. Although there were some notable variations in findings between different participating countries, increased weapon carrying and physical fighting were both independently and consistently associated with more frequent reports of the potential health outcomes. Adolescents engaging in fighting and weapon carrying are also at risk for physical and emotional health outcomes. Involvement in fighting and weapon carrying can be seen as part of a constellation of risk behaviours with obvious health implications. Our findings also highlight the importance of the cultural context when examining the nature of violent behaviour for adolescents.

Bullying as a mediator of relationships between adiposity status and weapon carrying.

OBJECTIVES: Although evidence links increased adiposity status with bullying involvement, it is unknown whether this leads to behaviors such as weapon carrying. The purpose of this study was to: (1) analyze relationships between adiposity status and risks for weapon carrying among Canadian school children, and (2) whether this relationship was mediated by reports of bullying. METHODS: We conducted a cross-sectional analysis of the health experiences of 7,877 Canadian children. Relationships between adiposity status and weapon carrying were evaluated. Evidence of mediation by bullying involvement was assessed. RESULTS: Overweight (OR: 1.45, 95% CI 1.04-2.02) and obese (OR: 2.19, 95% CI 1.43-3.35) males reported higher odds of weapon carrying relative to normal weight males. There was partial mediation of this relationship by physical and relational bullying, both as a perpetrator or a victim. No evidence of a relationship was identified for female students. CONCLUSIONS: Overweight and obese male students appear to be more likely to carry weapons for defensive and offensive purposes, a behavior mediated partially by bullying involvement. However, other factors may play a role as mediators in these etiological relationships.

Family meals and body mass index among adolescents: effects of gender.

Family meals have been identified as a protective factor against obesity among youth. However, gender specificities with respect to the relationship between the frequency of family meals and body mass index (BMI) have not been investigated. The purpose of this study was to examine the relationship between the frequency of family meals and BMI in male and female adolescents, while controlling for potential confounding factors associated with BMI, such as parental education, adolescent's age, and snack-food eating. Research participants were 734 male and 1030 female students (mean age, 14.12 years, SD = 1.62) recruited from middle schools and high schools in the capital region of Canada. Participants completed validated, self-report measures to assess the frequency of family meals and the risk factors associated with increased BMI, which was derived from objective measures of height and weight. After controlling for proposed confounding variables, a higher frequency of family meals was associated with lower BMI in females, but not in males. A Z-transformation test of the homogeneity of adjusted correlation coefficients showed a significant trend (p = 0.06), indicating that the relationship between family meals and BMI is stronger in females than males, consistent with our regression analyses. Our findings suggest that eating together as a family may be a protective factor against obesity in female adolescents, but not in male adolescents. Findings from this study have important implications for parents and health care practitioners advocating for more frequent family meals as part of a comprehensive obesity prevention and treatment program for female adolescents.

Obesity as a determinant of two forms of bullying in Ontario youth: a short report.

OBJECTIVE: Obesity can have negative effects in terms of stigma and discriminatory behavior. Past cross-sectional analyses have shown that overweight and obese youths are more likely to be involved in bullying. Here, we examine such relationships in a longitudinal analysis. Study outcomes were self-reports of: i) physical bullying victimization and perpetration and ii) relational bullying victimization and perpetration. METHODS: Participants were administered the Health Behaviour in School-Age Children Survey in 2006 and then again in 2007, and included 1,738 youths from 17 Ontario high schools. Relationships between adiposity and each of the four forms of bullying were evaluated using multi-level analyses. RESULTS: Excess adiposity was shown to precede bullying involvement in this study. Obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying. Among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls; p = 0.02). CONCLUSIONS: Findings are congruent with previous cross-sectional studies and confirm that obese youths are at increased risk of social consequences attributable to their appearance.

Effects of changing body-checking rules on rates of injury in minor hockey.

OBJECTIVE: In this study we explored the effects of the 2002 rule change in Ontario minor hockey, in which body-checking was introduced at the atom (ages 9-10) instead of the peewee (previously ages 12-13) age level. It was hypothesized that the introduction of body-checking at younger ages would result in higher overall rates of injury to minor hockey players, with concomitant increases in neurotraumatic injuries. PATIENTS AND METHODS: Participants included injured minor hockey players between the ages of 7 and 14 years in the Kingston area of Ontario, Canada. The Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program were used to identify injuries that presented to the only 2 emergency departments in this community. In our analyses, we compared rates and patterns of injury that required hospital-based emergency medicine care before (1997-1998 to 2001-2002 seasons) and after (2002-2003 to 2006-2007 seasons) implementation of the body-checking rule change. RESULTS: Overall rates of injury to minor hockey players declined in the years after the rule change. Rates of injury attributable to body-checking, as well as the natures and anatomic sites of injury caused by body-checking, remained consistent in the 2 study periods. CONCLUSIONS: In this historical study, we did not observe an increase in the overall rates of injury and concomitant neurotraumatic events. Increased enforcement of playing rules as well as temporal declines in emergency department use may have contributed to these findings.