Ursodeoxycholic acid for prevention of gallstone disease after laparoscopic sleeve gastrectomy: an Atlantic Canada perspective.

BACKGROUND: Prophylactic ursodeoxycholic acid (UDCA) may be beneficial in reducing gallstone disease after bariatric surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) 2019 guidelines recommend a 6-month course of UDCA for patients undergoing laparoscopic sleeve gastrectomy (LSG). This has not been adopted broadly. This study intends to assess the effect of routine UDCA administration following LSG on symptomatic gallstone disease. METHODS: We performed a retrospective chart review of patients who underwent LSG, between 2009 and 2019, at two tertiary care centers in Atlantic Canada. At one center, UDCA 250 mg oral twice daily was routinely prescribed following LSG for 6 months to patients with an intact gallbladder. At the other center, UDCA was not prescribed. Primary and secondary outcomes were cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) rates. Compliance with and side effects of UDCA therapy were analyzed. RESULTS: A total of 751 patients were included in the study. Patients who had prior cholecystectomy or were lost to follow up were excluded. After exclusion criteria were applied, 461 patients were included for analysis: 303 in the UDCA group and 158 in the group who did not receive UDCA. Cholecystectomy rate was not significantly associated with UDCA administration, however there was a trend towards less cholecystectomy in patients who received UDCA (8.3% vs. 13.9%, p = 0.056). ERCP rate was significantly lower in patients who received UDCA (0.3% vs 2.5%, p = 0.031). Rate of gallstone disease requiring intervention, either cholecystectomy or ERCP, was significantly decreased in patients who received UDCA (8.9% vs 15.8%, p = 0.022). The most common barriers to compliance with UDCA were cost (45.4%) and nausea (18.1%). CONCLUSION: This is the first study to demonstrate lower rates of ERCP in patients receiving routine UDCA following LSG. Our findings support the ASMBS 2019 guidelines for administering UDCA after LSG for preventing gallstone disease.

The prototype of a preference-based index of weight-related quality of life: demonstrating the possibilities.

PURPOSE: Evidence for comparative and cost-effectiveness of weight-loss interventions is lacking as there are no obesity-specific measures fit for this purpose. This study aimed to estimate the extent to which a prototype of a brief, multi-dimensional obesity-specific Preference-Based Index of Weight-Related Quality of Life (PBI-WRQL) could fill this gap. METHODS: Longitudinal data from a Canadian bariatric cohort was used. Forty-eight items from the IWQoL-Lite, EQ-5D-3L, and SF-12V2 were mapped onto the WHO ICF domains, and one item was chosen for the dimension based on fit to the Rasch model. Individuals' health ratings (0-100) were regressed on each dimension, and the regression coefficients for the response options were used as weights to generate a total score. Generalized estimation equations were used to compare measure parameters across groups and levels of converging constructs. RESULTS: Pre-surgery data were available on 201 people (Women: 82%; BMI: 48.8 ± 6.7 kg/m2; age: 43 ± 9.0 years) and on 125 (62%) at 6 months post-bariatric surgery. Seven dimensions with three response options formed the PB-WRQL prototype: Mobility/Physical Function, Pain, Depression, Participation, Energy, Peripheral Edema, and Dyspnea. The prototype showed substantial change (mean + 40) with bariatric surgery, higher than the EQ-5D (mean + 11.5). The prototype showed the strongest relationship with BMI at baseline (t = - 3.68) and was the most sensitive to change in BMI (t = - 3.42). CONCLUSION: This study demonstrates that a brief, 7-dimension index weighted by health impact performed as well as the 31-item IWQoL-Lite and better than the EQ-5D-3L. These findings demonstrate the potential value of the brief PB-WRQL prototype index and support its further development using preference weights to reflect the current generation's needs and concerns.

Maternal history of asthma modifies the risk of childhood persistent asthma associated with maternal age at birth: Results from a large prospective cohort in Canada.

BACKGROUND: Asthma is a prevalent disease that affects many Canadians. Persistent asthma can affect quality of life, and has multiple health implications. Maternal age at birth has been associated with many adverse health outcomes in children. Conflicting study results exist regarding maternal age at birth and childhood asthma. The association between maternal age at birth and persistent asthma in children is still unknown. OBJECTIVE: To investigate the relationship between maternal age at birth and persistent asthma in children at ten years of age. METHODS: This is a prospective cohort study including all children aged 0-2 years who took part in the first cycle of the National Longitudinal Survey of Children and Youths (NLSCY) and were followed every two years until eight to ten years of age in Cycle 5. An interaction term between maternal age at birth and maternal asthma history was introduced in a multivariate model to examine modification effects of maternal asthma history on the association. RESULTS: Multivariate logistic regression demonstrated that older maternal age at birth was significantly associated with an increased risk of childhood persistent asthma in mothers with a history of asthma (OR = 1.20, 95% CI: 1.04-1.40, p = .016). No relationship was found in mothers without a history of asthma. CONCLUSION: Maternal history of asthma has an impact on the association between maternal age at birth and childhood persistent asthma in children by age ten. The finding may help explain the inconsistent results in the literature regarding the risk of asthma associated with maternal age at birth.

Mothers' experiences of breastfeeding a child with tongue-tie.

Tongue-tie is characterized by an abnormally tight, short and thick lingual frenulum restricting the tongue's movement. This functional impairment can hinder a child's ability to maintain an effective latch and suckle and may lead to complex breastfeeding difficulties. The primary aim of this study was to explore the experiences of mothers who have breastfed a child with tongue-tie, including their experiences with the health care system. A qualitative description study design was used. Two semistructured focus groups were conducted in February 2016 with a total of nine participants in the largest metropolitan area of Newfoundland and Labrador, Canada. Content analysis using constant comparison revealed a common incongruity between participants' breastfeeding expectations and their actual experiences of feeding a child with tongue-tie. Three major themes are discussed: mothers' well-being, strained interpersonal relationships and frustration with the health care system.

Diabetes and the occurrence of infection in primary care: a matched cohort study.

BACKGROUND: People with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care. METHODS: Using the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections. RESULTS: We identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07-1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections. CONCLUSION: Patients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.

The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks.

BACKGROUND: Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS: We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS: Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION: The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.

CONTEXTE: Même si la gastrectomie longitudinale par laparoscopie (GLL) s'est révélée sûre et efficace pour le traitement de l'obésité sévère (indice de masse corporelle ≥ 35), les fuites survenant à la ligne d'agrafes demeurent une complication majeure et sont responsables d'une bonne partie des complications et des décès associés à cette chirurgie. Plusieurs des centres effectuant des GLL procèdent au dépistage systématique des fuites à la ligne d'agrafes en réalisant des tests avec des agents de contraste le jour suivant la chirurgie. Nous avons évalué l'utilité du test à la gastrografine comme méthode de dépistage précoce des fuites à la ligne d'agrafes au jour 1, ainsi que les coûts qui y sont associés. MÉTHODES: Nous avons mené une étude rétrospective à partir d'une base de données créée de façon prospective qui portait sur 200 patients ayant subi une GLL entre 2011 et 2014 en raison d'une obésité sévère. Les principaux indicateurs de résultats étaient l'incidence de fuites à la ligne d'agrafes et les résultats obtenus aux tests à la gastrografine. Les renseignements sur le coût des tests d'imagerie nous ont été fournis par les départements appropriés des hôpitaux. RÉSULTATS: Selon les résultats des tests à la gastrografine au jour 1 obtenus pour les 200 patients ayant subi une GLL, 3 patients (1,5 %) présentaient des fuites à la ligne d'agrafes. Il s'agissait en réalité d'un vrai positif et 2 faux négatifs. Le diagnostic des faux négatifs a ensuite été effectué par tomographie par ordinateur. La sensibilité du test à la gastrografine était donc de 33 % au cours de cette étude. Le coût total de ce test, pour les 200 patients, était de 35 000 $. CONCLUSION: Le recours à des examens systématiques du tractus gastro-intestinal supérieur au moyen d'agents de contraste pour le dépistage précoce des fuites à la ligne d'agrafes a une faible sensibilité et est associé à des coûts élevés. Nous recommandons plutôt l'utilisation sélective de la tomographie par ordinateur.

Safety and Efficacy of Incretin-Based Therapies in Patients With Type 2 Diabetes Mellitus and CKD: A Systematic Review and Meta-analysis.

BACKGROUND: The pharmacokinetics and pharmacodynamics of antidiabetic therapies for patients with type 2 diabetes are often altered in the context of chronic kidney disease (CKD). STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Patients with type 2 diabetes and CKD. SELECTION CRITERIA FOR STUDIES: 2 reviewers independently screened studies identified through bibliographic databases (Cochrane Library, PubMed, Embase, International Pharmaceutical Abstracts), clinical trial registries, and references from pertinent articles and clinical practice guidelines. Eligible studies included randomized controlled trials evaluating incretin-based therapy in adults with type 2 diabetes and estimated glomerular filtration rates < 60mL/min/1.73m2. INTERVENTIONS: Incretin-based therapies (dipeptidyl peptidase 4 inhibitors and glucagon-like peptide 1 receptor agonists) compared to placebo or active antidiabetic therapies. OUTCOMES: Changes in glycated hemoglobin (HbA1c), hypoglycemia, mortality, change in fasting plasma glucose, cardiovascular events, and end-stage renal disease. RESULTS: Of 1,619 nonduplicate records screened, 13 studies were included. Compared to placebo, incretin-based therapies significantly reduced HbA1c levels (n = 9; weighted mean difference, -0.64; 95% CI, -0.79 to -0.48; I2 = 43%); however, compared with active comparators, they did not (n = 4; weighted mean difference, -0.07; 95% CI, -0.25 to 0.12; I2 = 38%). Incretin-based therapies significantly increased the risk for hypoglycemia compared to placebo (n = 7; relative risk [RR], 1.38; 95% CI, 1.01-1.89; I2 = 0%) but no effect was observed versus active comparators (n = 4; RR, 0.24; 95% CI, 0.03-1.94; I2 = 52%). Limited evidence exists for all-cause mortality (placebo: n = 7 [RR, 1.21; 95% CI, 0.64-2.29; I2 = 0%]; active comparators: n = 3 [RR, 0.70; 95% CI, 0.32-1.54; I2 = 0%]). LIMITATIONS: Variation among interventions, small number of studies, heterogeneity between studies, and high risk for attrition bias in 7 of the selected studies. CONCLUSIONS: In patients with moderate or severe CKD, incretin-based therapies are effective in reducing HbA1c levels. Hypoglycemic events are rare, and wide CIs for the association preclude any definitive conclusions. Likewise, wide CIs were observed for mortality, cardiovascular events, and end-stage renal disease.

The Newfoundland and Labrador Bariatric Surgery Cohort Study: Rational and Study Protocol.

BACKGROUND: In Canada, there has been a disproportionate increase in adults with Class II (BMI 35.0-39.9 kg/m2) or Class III obesity (BMI ≥ 40 kg/m2) affecting 9 % of Canadians with increases projected. Individuals affected by severe obesity (BMI ≥ 35) are at increased risk of high blood pressure, cardiovascular disease, diabetes, cancer, impaired quality of life, and premature mortality. Bariatric surgery is the most effective treatment for severe obesity. Laparoscopic sleeve gastrectomy (LSG), a relatively new type of bariatric surgery, is growing in popularity as a treatment. The global prevalence of LSG increased from 0 to 37.0 % between 2003 and 2013. In Canada and the US, between 2011 and 2013, the number of LSG surgeries increased by 244 % and LSG now comprises 43 % of all bariatric surgeries. Since 2011, Eastern Health, the largest regional health authority in Newfoundland and Labrador (NL), Canada has performed approximately 100 LSG surgeries annually. METHODS: A population-based prospective cohort study with pre and post surgical assessments at 1, 3, 6, 12, 18, 24 months and annually thereafter of patients undergoing LSG. This study will report on short - to mid-term (2-4 years) outcomes. Patients (n = 200) followed by the Provincial Bariatric Surgery Program between 19 and 70 years of age, with a BMI between 35.0 and 39.9 kg/m2 and an obesity-related comorbidity or with a BMI ≥ 40 kg/m2 are enrolled. The study is assessing the following outcomes: 1) complications of surgery including impact on nutritional status 2) weight loss/regain 3) improvement/resolution of comorbid conditions and a reduction in prescribed medications 4) patient reported outcomes using validated quality of life tools, and 5) impact of surgery on health services use and costs. We hypothesize a low complication rate, a marked reduction in weight, improvement/resolution of comorbid conditions, a reduction in related medications, improvement in quality of life, and a decrease in direct healthcare use and costs and indirect costs compared to pre-surgery. DISCUSSION: Limited data on the impact of LSG as a stand-alone procedure on a number of outcomes exist. The findings from this study will help to inform evidence-based practice, clinical decision-making, and the development of health policy.

Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification.

BACKGROUND: Newfoundland and Labrador (NL) has the highest rate of obesity in Canada, prompting the establishment of a bariatric surgery program at the Health Sciences Centre in NL. This retrospective study examined 30-day complication rates in more than 200 consecutive patients who underwent laparoscopic sleeve gastrectomy (LSG) between May 2011 and February 2014. METHODS: We performed a chart review and collected data on 30-day postoperative complications. Complications were graded and reported using the Clavien-Dindo classification. Grades I and II were defined as minor and grades III and higher were defined as major complications. RESULTS: We reviewed the charts of the first 209 patients to undergo LSG. The mean body mass index was 49.2, 81% were women and the average age was 43 years. Comorbidities included hypertension (55.0%), obstructive sleep apnea (46.4%), dyslipidemia (42.1%), diabetes (37.3%), osteoarthritis (36.4%) and cardiovascular disease with previous cardiac stents (5.3%). Furthermore, 38.3% of patients reported psychiatric diagnoses, such as depression and anxiety. The overall 30-day complication rate was 15.3%. The complication rate for minor complications was 13.4% and for major complications was 1.9% (2 leaks, 1 stricture and 1 fistula). CONCLUSION: Our results support the feasibility of safely performing LSG surgery at bariatric centres completing fewer than 125 procedures annually.

CONTEXTE: Comme la province de Terre-Neuve-et-Labrador (T.-N.-L.) a le taux d'obésité le plus élevé au Canada, un programme de chirurgie bariatrique a été mis en place au Centre des sciences de la santé de T.-N.-L. La présente étude rétrospective a étudié les taux de complications dans les 30 premiers jours chez plus de 200 patients consécutifs ayant subi une gastrectomie longitudinale laparoscopique (GLL) entre mai 2011 et février 2014. MÉTHODES: Après avoir effectué une analyse des dossiers et recueilli des données sur les complications postopératoires survenues dans les 30 jours, nous avons évalué et consigné les complications à l'aide de la classification de Clavien­Dindo. Les grades I et II étaient des complications mineures et les grades III et plus, des complications majeures. RÉSULTANTS: Nous avons analysé les dossiers des 209 premiers patients à avoir subi une GLL. L'indice de masse corporelle moyen était de 49,2, 81 % des patients étaient des femmes et l'âge moyen était de 43 ans. Les comorbidités comprenaient l'hypertension (55,0 %), l'apnée obstructive du sommeil (46,4 %), la dyslipidémie (42,1 %), le diabète (37,3 %), l'arthrose (36,4 %) et les maladies cardiovasculaires avec des antécédents d'endoprothèses cardiaques (5,3 %). De plus, 38,3 % des patients ont mentionné un diagnostic psychiatrique, comme la dépression ou l'anxiété. Le taux global de complications dans les 30 jours était de 15,3 %. Le taux de complications mineures était de 13,4 % et celui de complications majeures, de 1,9 % (2 fuites, 1 striction et 1 fistule). CONCLUSION: Nos résultats viennent confirmer qu'il est possible d'effectuer des GLL de façon sécuritaire dans les centres bariatriques qui pratiquent moins de 125 interventions par année.

'Fat girls' and 'big guys': gendered meanings of weight loss surgery.

Over 80% of weight loss surgery (WLS) patients are women, yet gender is overwhelmingly absent in WLS research. This article discusses the findings of 54 interviews with twenty-one women and six men waiting for WLS in Newfoundland and Labrador, Canada. We critically examine the ways that gender shapes the meaning of WLS in these narratives. We explore gendered meanings in participants' perspectives on their embodied experiences before surgery, social support as they decided to undergo the procedure, and their expectations for their lives after WLS. We draw on feminist theory to explain how these findings counter the dominant gender-neutral medical model of obesity.

High rates of International Code violations: a cross-sectional study in a region of Canada with low breastfeeding rates.

BACKGROUND: Exposure to marketing and promotion of commercial milk formula is associated with an increased likelihood of formula-feeding. In 1981, the International Code (IC) of Marketing of Breastmilk Substitutes was adopted by the 34th World Health Assembly to restrict the promotion, marketing and advertising of commercial milk formula and protect breastfeeding. RESEARCH AIM: The current study examines mothers' exposure to violations of the IC in Newfoundland and Labrador, a province of Canada with low breastfeeding rates. METHODS: A cross-sectional online survey measured exposure to IC violations (e.g., marketing, advertising and promotion of commercial milk formula) by mothers of infants less than two years old (n = 119). Data were collected on type, frequency, and location of violation. RESULTS: Most participants (87%, n = 104/119) reported exposure to at least one IC violation. Of this group (n = 104): 94% received coupons or discount codes for the purchase of commercial milk formula; 88% received free samples of commercial milk formula from manufacturers, and 79% were contacted directly by commercial milk formula companies via email, text message, mail or phone for advertising purposes. One-third (n = 28/104, 27%) observed commercial milk formula promotional materials in health care facilities. The most frequent locations were violations occurred were doctors' offices (79%), supermarkets(75%), and pharmacies (71%). CONCLUSION: The majority of mothers of young infants were exposed to violations of the IC involving the marketing, advertising and promotion of commercial milk formula. Companies producing commercial milk formula reached out directly to new mothers to offer unsolicited promotions and free samples of commercial milk formula.

A cross-sectional study of breastfed infants referred for tongue tie assessment and frenotomy in one Canadian health region.

Importance: Tongue tie (TT) is a condition that can cause infant feeding difficulties due to restricted tongue movement. When TT presents as a significant barrier to breastfeeding, a frenotomy may be recommended. Universally accepted diagnostic criteria for TT are lacking and wide prevalence estimates are reported. New referral processes and a Frenotomy Assessment Tool were implemented in one Canadian health region to connect breastfeeding dyads with a provider for TT evaluation and frenotomy. Objective: To determine the proportion of babies with TT as well as the frequency of frenotomy. Methods: This cross-sectional study included infants who initiated breastfeeding at birth and were referred for TT evaluation over a 14-month period. Data were collected retrospectively by chart review and analyzed using SPSS. Factors associated with frenotomy were examined using logistic regression. Results: Two hundred and forty-one babies were referred. Ninety-two percent (n = 222) were diagnosed with TT and 66.0% (n = 159) underwent frenotomy. In the multivariate model, nipple pain/trauma, inability to latch, inability to elevate tongue, and dimpling of tongue on extension were associated with frenotomy (P < 0.05). Most referrals in our region resulted in a diagnosis of TT; however, the number of referrals was lower than expected, and of these two-thirds underwent frenotomy. Interpretation: TT is a relatively common finding among breastfed infants. Future research should examine whether a simplified assessment tool containing the four items associated with frenotomy in our multivariate model can identify breastfed infants with TT who require frenotomy.

Patients' perceptions of waiting for bariatric surgery: a qualitative study.

BACKGROUND: In Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients' perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients' perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience. METHODS: Twenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery. RESULTS: Thematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants' accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon's office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others. CONCLUSION: Patients' perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

A qualitative study exploring factors associated with mothers' decisions to formula-feed their infants in Newfoundland and Labrador, Canada.

BACKGROUND: Breastfeeding has numerous health benefits. In 2010, the province of Newfoundland and Labrador had the lowest breastfeeding initiation rate (64.0%) in Canada. Formula feeding is associated with well-known health risks. Exclusive formula feeding is the "cultural norm" in some regions of the province. Women appear resistant to changing their infant feeding behaviors and remain committed to their decision to formula-feed. The primary aim of this qualitative study was to examine individual factors that shaped mothers' decisions to formula-feed their infants. Nineteen mothers who were currently formula feeding their children participated in the study. METHODS: Qualitative research in the form of focus groups was conducted in three communities in the province in 2010. A thematic content analysis identified the main themes that influenced mothers' decisions to formula-feed their infants. RESULTS: The main themes included issues concerning the support needed to breastfeed, the convenience associated with formula feeding, and the embarrassment surrounding breastfeeding in public. CONCLUSIONS: These findings help to better understand why mothers choose formula feeding over breastfeeding and may help to inform the development of public health interventions targeted at this population of mothers.

Infant-feeding among low-income women: the social context that shapes their perspectives and experiences.

This article explores the perspectives of low-income women in order to better understand the social context that shapes their infant-feeding perspectives and experiences. The authors used purposive sampling to conduct 3 focus groups with 19 women who were formula-feeding their infants in 1 urban and 2 rural communities in the eastern region of the island of Newfoundland in Canada. Elements of the social context for infant-feeding included the prevalence of myths and misinformation about breastfeeding; cultural expectations about infant behaviour; the postnatal experience, including the medicalization of birth and breastfeeding; partner support and child-care workload; cultural stigma of breastfeeding; and a moralizing ideology that equates breastfeeding with "good mothering. "The authors discuss the implications of the findings from a nursing and public health perspective, offering 7 recommendations for how nurses and health professionals might better support women and their families.

Patient perceptions about obesity management in the context of concomitant care for other chronic diseases.

Background: Approximately 15% of Canadian adults live with two or more chronic diseases, many of which are obesity related. The degree to which Canadian obesity treatment guidelines are integrated into chronic disease management is unknown. Methods: We conducted a 12-min online survey among a non-probability sample of 2506 adult Canadians who met at least one of the following criteria: 1) BMI ≥30 kg/m2; 2) medical diagnosis of obesity; 3) undergone medically supervised treatment for obesity; or 4) a belief that excess/abnormal adipose tissue impairs their health. Participants must have been diagnosed with at least one of 12 prevalent obesity-related chronic diseases. Data analysis consisted of descriptive statistics. Results: One in four (26.4%) reported a diagnosis of obesity, but only 9.2% said they had received medically supervised obesity treatment. The majority (55%) agreed obesity makes managing their other chronic diseases challenging; 39% agreed their chronic disease(s) have progressed or gotten worse because of their obesity. While over half (54%) reported being aware that obesity is classified as a chronic disease, 78% responded obesity was their responsibility to manage on their own. Only 33% of respondents responded they have had success with obesity treatment. Interpretation: While awareness of obesity as a chronic disease is increasing, obesity care within the context of a wider chronic disease management model is suboptimal. More work remains to be done to make Canadian obesity guidelines standard for obesity care.

Patient Preferences for Attributes of Health Canada Approved Weight Loss Medications Among Adults Living with Obesity in Canada: A Qualitative Study.

Purpose: Obesity is a complex disease with negative impacts on physical and mental health. The treatment of obesity is an area where shared decision making and patient preferences play an important role. Recommendations surrounding weight loss medications are evolving and only recently, with the publication of the 2020 Canadian Obesity Management Clinical Guidelines, pharmacotherapy has become a recommended alternative for obesity management. Guidelines recommend three medications: orlistat, liraglutide, and naltrexone/bupropion. This study sought to identify medication attributes relevant to patients starting pharmacotherapy for weight management. Patients and Methods: Semi-structured focus groups and interviews were conducted with Canadian residents who were ≥18 years of age and were living with obesity (body mass index [BMI] ≥30kg/m2 or ≥27kg/m2 with adiposity-related complications). Sessions were conducted virtually, audio recorded, and transcribed. Two team members used a combination of inductive and deductive coding to independently code the data. A final coding template was agreed upon through discussion. Results: A total of 21 individuals participated (85.7% female, 76.2% ≥40 years of age) with the average BMI being 44.3 kg/m2. Participants touched upon many attributes which were categorized into five categories: 1) cost, 2) regimen, 3) side effects, 4) benefits, and 5) non-medication attributes. Cost of medications, lack of coverage by insurance companies, and stigma were identified as major barriers to accessing medications. There was consensus in the desire for a simple regimen, however there was heterogeneity among opinions on tolerability of side effects, desired benefits, and route of administration. Conclusion: This study identified attributes that influenced patient's decisions when considering a new anti-obesity medication. Understanding these attributes can assist clinicians in shared decision-making. This study highlighted the stigma that is prevalent among providers and the need for education. Further research should be conducted to understand the tradeoffs patients in our study make between the identified attributes.

The Effectiveness of Virtual Lactation Support: A Systematic Review and Meta-Analysis.

BACKGROUND: The World Health Organization recommends lactation support to enhance the rates of exclusive breastfeeding. Access to in person lactation support may be limited due to scarcity of resources (e.g., healthcare professionals) and geography. Advances in technology have allowed lactation supports to be offered virtually through information and communication technologies (i.e., telephone, internet, and social media). RESEARCH AIMS: To (1) critically review and (2) statistically analyze the effectiveness of virtual lactation support for postpartum mothers' exclusive breastfeeding for up to 6 months. METHODS: A systematic review and meta-analysis were conducted using PRISMA guidelines. Studies were included if they were (a) randomized controlled trials, (b) with a virtual lactation support intervention during the postpartum period, (c) reported on exclusive breastfeeding outcomes. Two reviewers independently assessed the risk of bias and extracted data. The prevalence of exclusive breastfeeding in each group and the total number of participants randomized for each group were entered into random-effects meta-analyses to calculate a pooled relative risk (RR) at three different time points (1, 4, and 6 months). The sample size was 19 randomized control trials. RESULTS: Of the 19 studies, 16 (84.2%) were included in the meta-analysis (n = 5,254). Virtual lactation support was found to be effective at increasing exclusive breastfeeding at 1 month (RR, 1.21; 95% CI [1.09, 1.35]; p < .001) and 6 months (RR, 1.87; 95% CI [1.30, 2.68]; p < .001). CONCLUSION: In this meta-analysis of randomized controlled trials comparing virtual lactation support with other postnatal maternity care, virtual lactation support was associated with increasing exclusive breastfeeding rates at 1 month and 6 months postpartum.The study protocol was registered (CRD42021256433) with PROSPERO.

The Use of Patient Engagement to Gather Perceptions on the Cost of Infant Feeding.

Purpose: Patient-oriented research (POR) and patient engagement (PE) has highlighted the value of incorporating patients' ideas and priorities in health research. Using the guiding principles of POR and PE, the current study conducted PE sessions to gain insight on the perceptions of mothers regarding the costs of infant feeding. Methods: Four patient engagement sessions were held with mothers residing in Newfoundland and Labrador between November 2019 and January 2020. Mothers were targeted through the Brighter Futures Coalition of St. John's, a not-for-profit community organization. PE sessions were designed in a two-hour format, allowing the research team to engage mothers and identify costs of infant feeding from a mothers' perspective. Results: Through the guiding principles of patient-oriented research and patient engagement, our research team successful engaged with mothers in discussions surrounding the costs of infant feeding. The sessions allowed for an in-depth discussion surrounding monetary costs (eg, incidentals of breast or formula feeding), the associated costs of infant feeding and the workplace (eg, perceived productivity) and environment impacts (eg, single use plastics). During each session, evaluations were provided to solicit feedback on whether the goals and expectations of mothers had been met, and whether they felt their opinions were heard and understood. Conclusion: By conducting patient engagement sessions, informed by patient-oriented research guiding principles, we were able to successfully recruit and engage mothers in discussions that led to a better understanding of their perspectives on the costs of infant feeding.

Obesity prevalence estimates in a Canadian regional population of preschool children using variant growth references.

BACKGROUND: Childhood obesity is a public health problem in Canada. Accurate measurement of a health problem is crucial in defining its burden. The objective of this study is to compare the prevalence estimates of overweight and obesity in preschool children using three growth references. METHODS: Weights and heights were measured on 1026 preschool children born in Newfoundland and Labrador (NL), Canada, and body mass index calculated. The prevalence of overweight and obesity was determined and statistical comparisons conducted among the three growth references; the Centres for Disease Control (CDC), the International Obesity Task Force (IOTF) and the World Health Organization (WHO). RESULTS: CDC and IOTF produced similar estimates of the prevalence of overweight, 19.1% versus 18.2% while the WHO reported a higher prevalence 26.7% (p < .001). The CDC classified twice as many children as obese compared to the IOTF 16.6% versus 8.3% (p < .001) and a third more than the WHO 16.6% versus 11.3% (p < .01). There was variable level of agreement between methods. CONCLUSIONS: The CDC reported a much higher prevalence of obesity compared to the other references. The prevalence of childhood obesity is dependent on the growth reference used.