This study used a multilevel analysis to examine how neighbourhood factors modify the effect of smoking on birth weight in British Columbia, Canada. The study found:
1) Maternal smoking had a significant negative and non-linear association with birth weight that varied substantially between neighbourhoods.
2) Neighbourhood socioeconomic status, education levels, air pollution, and immigrant density interacted with smoking levels and were associated with birth weight. Higher neighbourhood education and immigrant density helped offset the negative impact of smoking on birth weight.
3) Including neighbourhood variables and their interactions with individual factors explained a large portion of the variability in birth weight between neighbourhoods. This suggests neighbourhood context influences how risk factors like smoking affect birth outcomes
The document discusses Ayurvedashram's preconception care program. It aims to improve health outcomes for mothers and babies through biomedical, behavioral and social interventions before conception. The program addresses prevalent risk factors like obesity, smoking, stress and nutrition which can negatively impact fertility and pregnancy. It seeks to fill a gap in evidence-based resources for managing lifestyle factors known to influence conception and child health.
This study examined the relationship between three types of parent-reported child maltreatment (neglect, psychological aggression, and corporal punishment) and obesity in preschool children. The study found an association between neglect in the prior year and obesity at age 3, but no association between the other two types of maltreatment and obesity. The results add to evidence that neglect and obesity may share some developmental origins related to mental health conditions. However, the study had limitations such as using parent self-reports and not examining more severe forms of abuse.
Childhood obesity treatment literature reviewAmber Breidel
This document provides summaries of several studies related to childhood obesity treatment:
- One study found no significant differences in anthropometric measures between intervention and control groups for adolescent obesity treatment in Kuwait over 6 months.
- A Swedish study is evaluating the effectiveness of different approaches to treat preschool obesity and expects the treatment will improve both primary and secondary outcomes.
- A study evaluated a group medical visit program for treating obesity in an underserved community and found reductions in BMI z-score and improvements in lifestyle factors and empowerment measures.
- A study found that participants in a two-year multidisciplinary weight management program maintained treatment effects and did not significantly change BMI z-scores between post-treatment and 24
Childhood obesity prevention literature reviewAmber Breidel
This document provides a literature review on childhood obesity prevention and treatment. It summarizes 18 research studies related to prevention and treatment approaches. Key findings from the prevention studies include the role of television in childhood obesity, the relationship between fussy eating and body composition, and the impact of parental support programs. Key findings from the treatment studies include the effectiveness of appetite awareness training and factors influencing healthy lifestyle changes in low-income families engaged in obesity treatment programs. The review covers a range of interventions, outcomes, populations and methodologies.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
This study assessed behavioral problems among overweight school children in Tarrant County, Texas. Survey data on over 3,500 Caucasian and Hispanic children aged 0-14 was analyzed. Results showed that among Caucasian children, being overweight or obese was linked to behavioral issues like bullying others, exhibiting problematic social behaviors, and experiencing bullying. However, weight status did not significantly predict suspensions for Hispanic children. The study concludes that childhood obesity can negatively impact physical and mental health into adulthood, and suggests further research on academic and social development impacts.
The document summarizes research on the effectiveness of prevention programs in addressing childhood obesity. It reviews studies that evaluated after-school programs focused on nutrition education, physical activity, or both. The review found some programs resulted in reductions in BMI and improved healthy eating, but longer-term interventions are still needed to drive meaningful changes. The review analyzed six studies varying in sample size, location, intervention duration and focus (physical activity only vs. both physical activity and nutrition). Overall the evidence does not clearly support or refute after-school programs' ability to prevent obesity, but some positive outcomes were seen.
The document discusses Ayurvedashram's preconception care program. It aims to improve health outcomes for mothers and babies through biomedical, behavioral and social interventions before conception. The program addresses prevalent risk factors like obesity, smoking, stress and nutrition which can negatively impact fertility and pregnancy. It seeks to fill a gap in evidence-based resources for managing lifestyle factors known to influence conception and child health.
This study examined the relationship between three types of parent-reported child maltreatment (neglect, psychological aggression, and corporal punishment) and obesity in preschool children. The study found an association between neglect in the prior year and obesity at age 3, but no association between the other two types of maltreatment and obesity. The results add to evidence that neglect and obesity may share some developmental origins related to mental health conditions. However, the study had limitations such as using parent self-reports and not examining more severe forms of abuse.
Childhood obesity treatment literature reviewAmber Breidel
This document provides summaries of several studies related to childhood obesity treatment:
- One study found no significant differences in anthropometric measures between intervention and control groups for adolescent obesity treatment in Kuwait over 6 months.
- A Swedish study is evaluating the effectiveness of different approaches to treat preschool obesity and expects the treatment will improve both primary and secondary outcomes.
- A study evaluated a group medical visit program for treating obesity in an underserved community and found reductions in BMI z-score and improvements in lifestyle factors and empowerment measures.
- A study found that participants in a two-year multidisciplinary weight management program maintained treatment effects and did not significantly change BMI z-scores between post-treatment and 24
Childhood obesity prevention literature reviewAmber Breidel
This document provides a literature review on childhood obesity prevention and treatment. It summarizes 18 research studies related to prevention and treatment approaches. Key findings from the prevention studies include the role of television in childhood obesity, the relationship between fussy eating and body composition, and the impact of parental support programs. Key findings from the treatment studies include the effectiveness of appetite awareness training and factors influencing healthy lifestyle changes in low-income families engaged in obesity treatment programs. The review covers a range of interventions, outcomes, populations and methodologies.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
This study assessed behavioral problems among overweight school children in Tarrant County, Texas. Survey data on over 3,500 Caucasian and Hispanic children aged 0-14 was analyzed. Results showed that among Caucasian children, being overweight or obese was linked to behavioral issues like bullying others, exhibiting problematic social behaviors, and experiencing bullying. However, weight status did not significantly predict suspensions for Hispanic children. The study concludes that childhood obesity can negatively impact physical and mental health into adulthood, and suggests further research on academic and social development impacts.
The document summarizes research on the effectiveness of prevention programs in addressing childhood obesity. It reviews studies that evaluated after-school programs focused on nutrition education, physical activity, or both. The review found some programs resulted in reductions in BMI and improved healthy eating, but longer-term interventions are still needed to drive meaningful changes. The review analyzed six studies varying in sample size, location, intervention duration and focus (physical activity only vs. both physical activity and nutrition). Overall the evidence does not clearly support or refute after-school programs' ability to prevent obesity, but some positive outcomes were seen.
Son preference and fertility behavior evidence from Viet Nam - Project statementHanh To
This project seeks to contribute to the current literature of son preference and sex imbalance in Vietnam and other developing countries by extending the measure of “son preference” to birth interval, number of children and probability of using contraceptive methods.
A presentation by Linda Adair as part of the Childhood Risk and Resilience panel discussion at the International Symposium on Cohort and Longitudinal Studies in Developing Contexts, UNICEF Office of Research - Innocenti, Florence, Italy 13-15 October 2014
The document analyzes research on the nature vs nurture debate around obesity. It summarizes studies finding both genetic/biological and environmental factors influence obesity. The authors treated a client using diet/exercise modifications based on evidence that lifestyle changes can decrease weight. Their client achieved a 30% weight loss in 3 months, supporting the influence of external factors. Overall, the authors found evidence that environmental/behavioral interventions have greater impact on obesity than medical approaches.
The document provides key findings from Vietnam's 2014 Multiple Indicator Cluster Survey (MICS). It includes summaries of 10 topics: child mortality, nutrition, child health, water and sanitation, reproductive health, child development, literacy and education, child protection, HIV/AIDS, and access to media/ICT. For each topic, it highlights 2-6 relevant indicators and provides data on national averages as well as breakdowns by region, wealth, and ethnicity. The objective is to disseminate timely findings on Millennium Development Goal and MICS indicators to evaluate Vietnam's progress.
This study examined the association between parental education level, accuracy in perceiving a child's weight status, and willingness to accept obesity counseling from non-physician providers. The study found that parental education level was not associated with accurately perceiving a child's weight, having an overweight or obese child, or willingness to receive counseling from sources other than a physician. Parents of all education levels were most willing to receive counseling from a medical doctor and least willing from a schoolteacher. The study was limited by using a convenience sample and only assessing two non-physician counseling sources.
Planned Parenthood audited textbooks and curricula used in California school districts' health education classes and found that more than half were not complying with state Education Code requirements to provide comprehensive sexual health education. The report showed some improvement in districts but also areas still needing improvement. Comprehensive sexual health education is important to reduce unintended teen pregnancy and STDs by providing youth with information to make responsible decisions. It gives them tools to be productive members of society while a lack of education increases costs due to issues like unintended pregnancy.
This document discusses strategies to combat the obesity epidemic from a public health perspective. It summarizes data showing increasing obesity rates among children and links childhood obesity to adult obesity. It then outlines priority targets to reduce obesity including behaviors during pregnancy, reducing energy intake, increasing fruit/vegetable consumption, limiting sugar-sweetened beverages and TV time, and increasing breastfeeding and physical activity. Finally, it recommends multi-level strategies including changing the food environment, increasing access to healthy options, limiting marketing of unhealthy foods to kids, and creating supportive policies across communities, schools, and worksites to promote these behavioral changes.
This document discusses the relationships between reproductive health, population change, and economic development. It examines evidence that improvements in reproductive health, such as lower fertility and better maternal and child health, can contribute to human capital development and economic returns in three key ways: 1) Healthier women with fewer children invest more in education; 2) Women participate more in labor markets; 3) Better reproductive health increases women's ability to earn and save, helping families escape poverty. The document reviews studies showing pathways and evidence for these connections.
598 fourth grade students from 12 schools in the Greater Philadelphia area were measured to assess anthropometric data and compare to national and regional standards. Height, weight, BMI, and waist circumference were measured from January to May 2014. Results found the average BMI for boys and girls was higher than US standards, with 18.3% of students overweight and 18.2% obese. The frequency of overweight and obesity was greater than US standards but similar to Philadelphia regional standards. Girls had a higher frequency of overweight while boys had a higher frequency of obesity compared to US standards.
Latent Class Analysis of Adolescent Health Behaviorsasclepiuspdfs
This document discusses a study that uses latent class analysis to identify patterns of health behaviors among adolescents ages 10-19 using data from the National Longitudinal Study of Adolescent Health. The study examines eight health behaviors - sleep, alcohol consumption, cigarette smoking, physician visits, meal autonomy, wearing braces, general health assessment, and tattoos. Latent class analysis identified three distinct classes of adolescents - healthy, moderately healthy, and unhealthy - based on their responses to questions about these behaviors. The classes differed for males and females. The study aims to characterize adolescent health behaviors without including parental attributes.
This document summarizes the Coordinated Approach To Child Health (CATCH) program, which aims to prevent childhood obesity through environmental and behavioral changes in schools. CATCH targets physical education, classroom health education, cafeteria nutrition, and family involvement. Studies show CATCH is effective at increasing physical activity and healthy eating, and has reduced obesity rates. CATCH has now been implemented in over 2,000 Texas schools and other states, demonstrating the potential for effective programs to have public health impact at scale.
This document discusses obesity trends in Texas and prevention efforts. It finds that obesity rates have doubled in Texas over the past few decades for both adults and children. For adults, over 60% are now overweight or obese, with higher rates among low-income and minority groups. Around 30% of school-aged children are overweight or obese as well. The document then outlines Texas' strategic plan to address obesity through awareness, mobilizing communities, promoting healthy policies, and monitoring rates. It provides examples of prevention initiatives across the state.
1) The document explores the relationship between energy balance and weight status in adolescents using data from the CDC's Youth Risk Behavior Survey.
2) An energy balance composite score was created from survey items related to energy intake (food and drink) and energy expenditure (physical activity and sedentary behavior).
3) Results found the energy balance composite and energy expenditure scores varied significantly based on weight category, with healthier weight adolescents having lower energy intake, higher energy expenditure, and lower composite scores.
4) Racial/ethnic differences were also observed in energy balance scores, with weight category more strongly associated with scores across ethnic groups.
A presentation by Maureen Samms-Vaughn as part of the Childhood Risk and Resilience panel discussion at the International Symposium on Cohort and Longitudinal Studies in Developing Contexts, UNICEF Office of Research - Innocenti, Florence, Italy 13-15 October 2014
Maternal Alcohol Use Disorder and Risk of Child Contact with the Justice Syst...BARRY STANLEY 2 fasd
These finding were actually first described in - Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects [FAE] - Final Report, August 1996: Ann P Streissguth et.al. Often ignored, but never refuted.
Perhaps the most important point of this 20 year old report was that early diagnosis was a major contributing factor in reducing subsequent involvement with the justice system.
I was disappointed, but not surprised, that this paper did not mention the importance of an early diagnosis.
Barry Stanley
1) Childhood obesity has more than doubled in the past few decades and poses significant health risks.
2) Early identification of excessive weight gain is important through tracking BMI percentiles over time.
3) Pediatricians should discuss healthy eating and physical activity with families during routine visits to promote prevention and early recognition of obesity issues.
Childhood obesity has been described as the main health-related problem in developed countries, due to its link with physical, social and psychological consequences with an increased risk for developing metabolic and cardiovascular diseases in adulthood.
All the pupils of both sexes attending the second year of all the primary schools in Pavia, Northern Italy, were recruited (n=470) for this study. Measurements of weight, height and waist circumference (WC) were taken under standard conditions. Body Mass Index (BMI) and waist-to-height-ratio (W/HtR) were computed and sex specific percentile values for BMI, WC and W/HtR were calculated and compared with the same percentiles available for different countries.
The results show that according to Cole’s cut-off point reference standards, 12.5% and 9.0% of boys and girls respectively are overweight, 4.7% and 5.2% respectively are obese. The WC mean value is equal to 60.0 ± 6.0 cm in boys and 59.0 ± 6.7 cm in girls. Using different 90th reference worldwide standard percentiles for WC as a comparison, the prevalence of our children with WC > 90th percentile is very different. The W/HtR mean value of the total sample is 0.46 ± 0.03. Assuming a cutoff of 0.5, 87.6% of the pupils have a W/HtR value ≤ 0.5, while 12.4% of the subjects have a value > 0.5, showing abdominal obesity among 55 children at an early age.
Our results point out the need for specific preventive and treatment interventions by identifying and implementing effective strategies, policies, and nutritional education programs in order to decrease the prevalence rate of obesity as well as the risk of metabolic disorders.
This document summarizes a systematic review of factors associated with childhood overweight and obesity in South Asian countries. The review included 11 studies from India, Pakistan, Bangladesh, and Sri Lanka that used BMI to measure overweight and obesity in children and adolescents. The studies found wide variation in overweight prevalence from 3.1-19.7% and obesity prevalence from 1.2-14.5%. Lack of physical activity was associated with overweight/obesity in most studies, while higher socioeconomic status, urban residence, and consumption of junk food/fast food were also identified as risk factors.
1. The study analyzed weight gain data from ages 18 to 22 for young adults in the National Longitudinal Survey of Youth 1997.
2. College graduates gained an average of 1.6 kg/m2 (11 lbs) while non-college graduates gained 1.9 kg/m2 (13 lbs) on average.
3. College graduation was associated with 0.34 kg/m2 less weight gain (2 lbs less) compared to non-college graduates.
This document summarizes research on parental influence on childhood obesity. It reviews studies that examine three areas of parental influence: control, attitudes, and behaviors. Regarding control, some studies found that less parental control over food intake was associated with higher child BMI, while others found the opposite. For attitudes, studies found that parental beliefs that heavier children are healthier and using food to control behavior were linked to higher child BMI. Parental concern over child weight and perception of child eating behaviors were also linked to higher BMI. The document concludes by addressing gaps in research on this topic.
El documento describe las tendencias artísticas y estilos arquitectónicos que surgieron en Europa y América del Norte durante el siglo XIX. El eclecticismo, que combina elementos de diferentes estilos, se hizo popular a finales del siglo. Nuevos estilos como el neogótico y el modernismo reflejaban la nostalgia por el pasado. La revolución industrial también dio lugar a nuevos materiales como el hierro y el vidrio, lo que condujo al desarrollo de la arquitectura de hierro y cristal. El arte también evolucionó
El Día de la Canción Criolla se celebra el 31 de octubre para resaltar las raíces de la música criolla peruana y sembrar orgullo nacional. La fecha fue establecida en 1944 por el presidente Manuel Prado a sugerencia de Juan Manuel Carrera del Corral para conmemorar la música criolla. La música criolla es una mezcla de culturas que incluye ritmos africanos y representa la identidad nacional peruana. En esta fecha, se realizan diversas actividades musicales en todo el país para promover la cultura
Son preference and fertility behavior evidence from Viet Nam - Project statementHanh To
This project seeks to contribute to the current literature of son preference and sex imbalance in Vietnam and other developing countries by extending the measure of “son preference” to birth interval, number of children and probability of using contraceptive methods.
A presentation by Linda Adair as part of the Childhood Risk and Resilience panel discussion at the International Symposium on Cohort and Longitudinal Studies in Developing Contexts, UNICEF Office of Research - Innocenti, Florence, Italy 13-15 October 2014
The document analyzes research on the nature vs nurture debate around obesity. It summarizes studies finding both genetic/biological and environmental factors influence obesity. The authors treated a client using diet/exercise modifications based on evidence that lifestyle changes can decrease weight. Their client achieved a 30% weight loss in 3 months, supporting the influence of external factors. Overall, the authors found evidence that environmental/behavioral interventions have greater impact on obesity than medical approaches.
The document provides key findings from Vietnam's 2014 Multiple Indicator Cluster Survey (MICS). It includes summaries of 10 topics: child mortality, nutrition, child health, water and sanitation, reproductive health, child development, literacy and education, child protection, HIV/AIDS, and access to media/ICT. For each topic, it highlights 2-6 relevant indicators and provides data on national averages as well as breakdowns by region, wealth, and ethnicity. The objective is to disseminate timely findings on Millennium Development Goal and MICS indicators to evaluate Vietnam's progress.
This study examined the association between parental education level, accuracy in perceiving a child's weight status, and willingness to accept obesity counseling from non-physician providers. The study found that parental education level was not associated with accurately perceiving a child's weight, having an overweight or obese child, or willingness to receive counseling from sources other than a physician. Parents of all education levels were most willing to receive counseling from a medical doctor and least willing from a schoolteacher. The study was limited by using a convenience sample and only assessing two non-physician counseling sources.
Planned Parenthood audited textbooks and curricula used in California school districts' health education classes and found that more than half were not complying with state Education Code requirements to provide comprehensive sexual health education. The report showed some improvement in districts but also areas still needing improvement. Comprehensive sexual health education is important to reduce unintended teen pregnancy and STDs by providing youth with information to make responsible decisions. It gives them tools to be productive members of society while a lack of education increases costs due to issues like unintended pregnancy.
This document discusses strategies to combat the obesity epidemic from a public health perspective. It summarizes data showing increasing obesity rates among children and links childhood obesity to adult obesity. It then outlines priority targets to reduce obesity including behaviors during pregnancy, reducing energy intake, increasing fruit/vegetable consumption, limiting sugar-sweetened beverages and TV time, and increasing breastfeeding and physical activity. Finally, it recommends multi-level strategies including changing the food environment, increasing access to healthy options, limiting marketing of unhealthy foods to kids, and creating supportive policies across communities, schools, and worksites to promote these behavioral changes.
This document discusses the relationships between reproductive health, population change, and economic development. It examines evidence that improvements in reproductive health, such as lower fertility and better maternal and child health, can contribute to human capital development and economic returns in three key ways: 1) Healthier women with fewer children invest more in education; 2) Women participate more in labor markets; 3) Better reproductive health increases women's ability to earn and save, helping families escape poverty. The document reviews studies showing pathways and evidence for these connections.
598 fourth grade students from 12 schools in the Greater Philadelphia area were measured to assess anthropometric data and compare to national and regional standards. Height, weight, BMI, and waist circumference were measured from January to May 2014. Results found the average BMI for boys and girls was higher than US standards, with 18.3% of students overweight and 18.2% obese. The frequency of overweight and obesity was greater than US standards but similar to Philadelphia regional standards. Girls had a higher frequency of overweight while boys had a higher frequency of obesity compared to US standards.
Latent Class Analysis of Adolescent Health Behaviorsasclepiuspdfs
This document discusses a study that uses latent class analysis to identify patterns of health behaviors among adolescents ages 10-19 using data from the National Longitudinal Study of Adolescent Health. The study examines eight health behaviors - sleep, alcohol consumption, cigarette smoking, physician visits, meal autonomy, wearing braces, general health assessment, and tattoos. Latent class analysis identified three distinct classes of adolescents - healthy, moderately healthy, and unhealthy - based on their responses to questions about these behaviors. The classes differed for males and females. The study aims to characterize adolescent health behaviors without including parental attributes.
This document summarizes the Coordinated Approach To Child Health (CATCH) program, which aims to prevent childhood obesity through environmental and behavioral changes in schools. CATCH targets physical education, classroom health education, cafeteria nutrition, and family involvement. Studies show CATCH is effective at increasing physical activity and healthy eating, and has reduced obesity rates. CATCH has now been implemented in over 2,000 Texas schools and other states, demonstrating the potential for effective programs to have public health impact at scale.
This document discusses obesity trends in Texas and prevention efforts. It finds that obesity rates have doubled in Texas over the past few decades for both adults and children. For adults, over 60% are now overweight or obese, with higher rates among low-income and minority groups. Around 30% of school-aged children are overweight or obese as well. The document then outlines Texas' strategic plan to address obesity through awareness, mobilizing communities, promoting healthy policies, and monitoring rates. It provides examples of prevention initiatives across the state.
1) The document explores the relationship between energy balance and weight status in adolescents using data from the CDC's Youth Risk Behavior Survey.
2) An energy balance composite score was created from survey items related to energy intake (food and drink) and energy expenditure (physical activity and sedentary behavior).
3) Results found the energy balance composite and energy expenditure scores varied significantly based on weight category, with healthier weight adolescents having lower energy intake, higher energy expenditure, and lower composite scores.
4) Racial/ethnic differences were also observed in energy balance scores, with weight category more strongly associated with scores across ethnic groups.
A presentation by Maureen Samms-Vaughn as part of the Childhood Risk and Resilience panel discussion at the International Symposium on Cohort and Longitudinal Studies in Developing Contexts, UNICEF Office of Research - Innocenti, Florence, Italy 13-15 October 2014
Maternal Alcohol Use Disorder and Risk of Child Contact with the Justice Syst...BARRY STANLEY 2 fasd
These finding were actually first described in - Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects [FAE] - Final Report, August 1996: Ann P Streissguth et.al. Often ignored, but never refuted.
Perhaps the most important point of this 20 year old report was that early diagnosis was a major contributing factor in reducing subsequent involvement with the justice system.
I was disappointed, but not surprised, that this paper did not mention the importance of an early diagnosis.
Barry Stanley
1) Childhood obesity has more than doubled in the past few decades and poses significant health risks.
2) Early identification of excessive weight gain is important through tracking BMI percentiles over time.
3) Pediatricians should discuss healthy eating and physical activity with families during routine visits to promote prevention and early recognition of obesity issues.
Childhood obesity has been described as the main health-related problem in developed countries, due to its link with physical, social and psychological consequences with an increased risk for developing metabolic and cardiovascular diseases in adulthood.
All the pupils of both sexes attending the second year of all the primary schools in Pavia, Northern Italy, were recruited (n=470) for this study. Measurements of weight, height and waist circumference (WC) were taken under standard conditions. Body Mass Index (BMI) and waist-to-height-ratio (W/HtR) were computed and sex specific percentile values for BMI, WC and W/HtR were calculated and compared with the same percentiles available for different countries.
The results show that according to Cole’s cut-off point reference standards, 12.5% and 9.0% of boys and girls respectively are overweight, 4.7% and 5.2% respectively are obese. The WC mean value is equal to 60.0 ± 6.0 cm in boys and 59.0 ± 6.7 cm in girls. Using different 90th reference worldwide standard percentiles for WC as a comparison, the prevalence of our children with WC > 90th percentile is very different. The W/HtR mean value of the total sample is 0.46 ± 0.03. Assuming a cutoff of 0.5, 87.6% of the pupils have a W/HtR value ≤ 0.5, while 12.4% of the subjects have a value > 0.5, showing abdominal obesity among 55 children at an early age.
Our results point out the need for specific preventive and treatment interventions by identifying and implementing effective strategies, policies, and nutritional education programs in order to decrease the prevalence rate of obesity as well as the risk of metabolic disorders.
This document summarizes a systematic review of factors associated with childhood overweight and obesity in South Asian countries. The review included 11 studies from India, Pakistan, Bangladesh, and Sri Lanka that used BMI to measure overweight and obesity in children and adolescents. The studies found wide variation in overweight prevalence from 3.1-19.7% and obesity prevalence from 1.2-14.5%. Lack of physical activity was associated with overweight/obesity in most studies, while higher socioeconomic status, urban residence, and consumption of junk food/fast food were also identified as risk factors.
1. The study analyzed weight gain data from ages 18 to 22 for young adults in the National Longitudinal Survey of Youth 1997.
2. College graduates gained an average of 1.6 kg/m2 (11 lbs) while non-college graduates gained 1.9 kg/m2 (13 lbs) on average.
3. College graduation was associated with 0.34 kg/m2 less weight gain (2 lbs less) compared to non-college graduates.
This document summarizes research on parental influence on childhood obesity. It reviews studies that examine three areas of parental influence: control, attitudes, and behaviors. Regarding control, some studies found that less parental control over food intake was associated with higher child BMI, while others found the opposite. For attitudes, studies found that parental beliefs that heavier children are healthier and using food to control behavior were linked to higher child BMI. Parental concern over child weight and perception of child eating behaviors were also linked to higher BMI. The document concludes by addressing gaps in research on this topic.
El documento describe las tendencias artísticas y estilos arquitectónicos que surgieron en Europa y América del Norte durante el siglo XIX. El eclecticismo, que combina elementos de diferentes estilos, se hizo popular a finales del siglo. Nuevos estilos como el neogótico y el modernismo reflejaban la nostalgia por el pasado. La revolución industrial también dio lugar a nuevos materiales como el hierro y el vidrio, lo que condujo al desarrollo de la arquitectura de hierro y cristal. El arte también evolucionó
El Día de la Canción Criolla se celebra el 31 de octubre para resaltar las raíces de la música criolla peruana y sembrar orgullo nacional. La fecha fue establecida en 1944 por el presidente Manuel Prado a sugerencia de Juan Manuel Carrera del Corral para conmemorar la música criolla. La música criolla es una mezcla de culturas que incluye ritmos africanos y representa la identidad nacional peruana. En esta fecha, se realizan diversas actividades musicales en todo el país para promover la cultura
The document provides an overview and analysis of the 1998 film Enemy of the State. The summary is as follows:
[1] Enemy of the State tells the story of a man whose life is turned upside down when he unknowingly receives evidence of a politician's crime. This causes the corrupt politician to send agents after the man to retrieve the evidence.
[2] The man, played by Will Smith, teams up with another character played by Gene Hackman to try to clear his name and expose the corrupt politician. They work to outwit the agents tracking the man and turn the tables on the politician behind the conspiracy.
[3] The film uses techniques like rapid editing during chase scenes to build tension
This document is a resume for Samina Kullab that outlines her qualifications and work history. She has over 20 years of experience in customer service roles, including as a bilingual contact associate and agent. She is proficient in several languages and excels at building rapport with customers to resolve issues and retain their business. Her education includes a BA in English and diplomas in phonetics and business administration.
Jojy John is an AML Surveillance Analyst with over 4 years of experience working at Tata Consultancy Services for HSBC and RBS Bank. He is responsible for investigating alerts for potential money laundering risks, monitoring suspicious activities and transactions, and ensuring compliance. John aims to utilize his skills and knowledge for organizational and self growth. He has a MBA in Finance and Bachelor's degree in Economics.
Este documento describe los diferentes tipos de periféricos de una computadora, incluyendo periféricos de entrada, salida, almacenamiento y comunicación. Los periféricos de entrada capturan datos del mundo exterior y los envían a la CPU para su procesamiento. Los periféricos de salida reciben datos procesados de la CPU y los presentan al usuario. Los periféricos de almacenamiento guardan datos para su uso futuro luego de ser eliminados de la memoria principal. Los periféricos de comunicación permiten la interacción entre CPUs y otros dispositivos.
El documento analiza la presencia en redes sociales de varias marcas. Sharpie se enfoca en generar contenido generado por usuarios para aumentar la lealtad de marca. Evian busca crear una experiencia nostálgica para hacer sentir a los consumidores más jóvenes. Bancolombia educa sobre finanzas personales de forma divertida.
La orientación profesional ayuda a las personas sin trabajo o que buscan uno mejor mediante la provisión de información para mejorar sus habilidades de búsqueda de empleo. Esto incluye crear currículos, prepararse para entrevistas y encontrar ofertas de trabajo, con el objetivo de reducir el desempleo formando a las personas y aumentando su autoestima. La orientación profesional suele proveerse en centros públicos de empleo por orientadores con formación en ciencias humanas o sociales especializados en temas laborales.
Una red funcional consiste en un cliente que realiza peticiones a un servidor, el cual responde. El cliente inicia solicitudes mientras que el servidor espera y acepta conexiones de múltiples clientes. Esta configuración ofrece ventajas como la centralización del control en el servidor y la escalabilidad al poder aumentar la capacidad de clientes y servidores por separado.
La orientación profesional ayuda a las personas sin trabajo o que buscan uno mejor mediante la provisión de información para facilitar la búsqueda de empleo. Los orientadores profesionales suelen tener títulos en ciencias humanas o sociales y trabajan para mejorar la autoestima de los clientes y prepararlos para conseguir trabajo a través de actividades como la creación de currículos y la preparación para entrevistas. La orientación profesional también busca reducir el desempleo formando a las personas para que se defiendan en la búsqueda de emple
John Von Neumann nació en 1903 en Budapest y fue un destacado matemático húngaro nacionalizado estadounidense. Mostró desde niño aptitudes extraordinarias para las matemáticas y estudió en varias universidades europeas como Berlín y Zurich. Realizó importantes contribuciones a la teoría de la demostración y los conjuntos. También desarrolló la primera teoría axiomática de los espacios de Hilbert y estudió los juegos de estrategia y la teoría económica del comportamiento. Propuso modelos de
Esta resolución establece los procedimientos para el registro, inscripción, citación y presentación de exámenes ante el Instituto Colombiano para el Fomento de la Educación Superior (ICFES). Define los cronogramas, tarifas y procesos de registro en línea. También regula la conducta de los examinandos, materiales permitidos, posibles faltas y sanciones aplicables como suspensión de resultados, anulación e inhabilidad para presentar exámenes. Finalmente, establece controles del ICFES para garantizar la transparencia y conf
La imagen analógica graba imágenes fijas en una superficie sensible a la luz usando película, mientras que la imagen digital está formada por una matriz de píxeles definidos por ceros y unos. Las imágenes digitales pueden ser en blanco y negro, escala de grises o a color dependiendo de la profundidad de bits, y requieren de una impresora.
La orientación profesional ayuda a las personas sin trabajo o que buscan uno mejor mediante la provisión de información para facilitar la búsqueda de empleo. Esto incluye crear currículos, prepararse para entrevistas y encontrar ofertas de trabajo, así como aumentar la autoestima. La orientación profesional suele ofrecerse en centros públicos de empleo por orientadores con formación en ciencias humanas o sociales especializados en temas laborales. La orientación es importante para el futuro profesional de los estudiantes y debe ser un proceso continuo,
La estructura de una base de datos incluye los tipos de datos, las relaciones entre datos y las restricciones sobre los datos. Una base de datos se diseña usando un modelo de datos y consiste en varios archivos lógicamente interrelacionados. Un sistema de gestión de base de datos permite definir, manipular y utilizar los datos en una base de datos, mientras que una hoja de cálculo solo permite manipular datos numéricos y alfanuméricos en tablas.
Este documento presenta un blog sobre música rock de la provincia de Misiones en Argentina. El blog da la bienvenida a bandas de rock, blues, punk y metal para que envíen información sobre su grupo, incluyendo detalles sobre los miembros, género musical, ciudad de origen e historia para ser presentados en el blog.
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This study analyzed data from a population-based perinatal registry in British Columbia from 2001-2006 to examine the relationship between smoking during pregnancy and adverse birth outcomes as well as other socioeconomic and behavioral risk factors. The results showed:
1) Heavier smoking (10 or more cigarettes per day) during pregnancy was associated with a greater risk of adverse birth outcomes like low birth weight and restricted fetal growth in a dose-dependent manner.
2) Heavier smokers were more likely to have risk factors like lower education, single parent status, drug/alcohol use, and fewer prenatal care visits compared to lighter or non-smokers.
3) The study suggests self-reported heavy smoking early in
This study examined the relationship between exposure to particulate matter (PM2.5) and birth weight in British Columbia, Canada from 2001-2006. The study used a multilevel analysis to account for individual and neighborhood factors. The results showed a significant negative association between PM2.5 exposure and lower birth weight, explaining over 8% of differences in birth weight between neighborhoods. Lower socioeconomic status neighborhoods had a more pronounced negative effect of PM2.5 on birth weight. Maternal smoking, age, gestational diabetes, and drug/alcohol use also modified the effect of PM2.5 exposure on birth weight. The study provides evidence that both neighborhood socioeconomic factors and PM2.5 exposure independently and interactively influence birth
Austin Journal of Drug Abuse and Addiction is an open access, peer reviewed, scholarly journal dedicated to publish articles in all areas of drug abuse and addiction treatment.
The renowned team of guest editors ensures a balanced, expert assessment of the articles published, with an aim to provide a forum for physicians, researchers and other healthcare professionals to find most recent advances in the areas of addiction treatment.
Austin Journal of Drug Abuse and Addiction accepts original research articles, review articles and short communication on all the aspects of drug abuse and addiction treatment for review and possible publication.
Predictors of Smoking Cessation among Pregnant Women in San Bernardino County Temidayo Ogunrinu, MPH
This document summarizes a field practicum report evaluating the predictors of smoking cessation among pregnant women in San Bernardino County who participated in the Comprehensive Tobacco Treatment Program (CTTP). Quantitative analysis found that women in their first and third trimester were less likely to complete the program, as were Whites and Blacks. Qualitative focus groups revealed that incorporating family support and improving transportation assistance could help more women succeed. The program was effective for most, but some barriers prevented full participation.
International Journal of Humanities and Social Science Invention (IJHSSI) is an international journal intended for professionals and researchers in all fields of Humanities and Social Science. IJHSSI publishes research articles and reviews within the whole field Humanities and Social Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
Running Head The Study of Effects of Smoking in Pregnant Women1.docxtodd521
Running Head: The Study of Effects of Smoking in Pregnant Women 1
The Study of Effects of Smoking in Pregnant Women 21
The Study of Effects of Smoking in Pregnant Women
Smoking during pregnancy carries considerable dangers to both mother and the unborn baby. Prenatal exposure to maternal cigarette smoking (PEMCS) is linked, therefore, with many different obstetric complications such as an augmented danger of ectopic pregnancy, fetal development limitation, placental previa and abruption, preterm premature rip apart of the membranes, preterm delivery, unexpected newborn death syndrome, and oral facial clefts among others. Despite these risks, women still smoke during pregnancy. There is, therefore, a great need to develop policies and interventions such as discovering what can help the women to cease smoking, in order to reduce these risks. As such, alternatives such as the use of electronic cigarettes can be introduced to the pregnant smokers. Treatment for smoking can also be offered to women during pregnancy.
Background
The following section will discuss the background of the topic. Smoking during pregnancy exposes the mother and unborn child to great risks. Prenatal exposure to maternal cigarette smoking (PEMCS) is linked, therefore, with many different obstetric complications. According to Bauld (2017), the complications could range from an augmented danger of ectopic pregnancy, fetal development limitation, placental previa and abruption, preterm premature rip apart of the membranes, preterm delivery, unexpected newborn death syndrome, and oral facial clefts. Anblagan et al., (2013) includes more risks such as the development of respiratory diseases, gestational bleeding, obesity and obesity associated disorders like cardiovascular as well as diabetes results that start when the child reaches puberty. However, intrauterine growth restriction is the most common of them all. Considering all these risks and the fact that women who smoke carry on with this habit during pregnancy, there is a great need to develop policies and interventions that would address this matter. As such, there is need to discover what can be given to these women to help in cessation. General Problem Statement
The general problem is that there are limited researches that detail about smoking patterns in pregnant women. A research by Eiden et al., (2013) indicates a shifting trajectory in pregnant smokers and major changes in due course within each trajectory. This element is important as it has the prospective to notify timing of smoking cessation intervention. Specific Problem Statement
The specific problem is that there is little information about the stability of cessation efforts on the elements that distinguish women who effectively minimize smoking during their pregnancy in comparison to the persistent smokers who stop later in pregnancy. For example, little is known about low-income expectant smokers’ demographic factors such as monetary challenges, p.
The National Children's Study aims to understand environmental factors contributing to childhood obesity through a large prospective birth cohort study of 100,000 American children. It will address limitations of past studies by following children from before conception through age 21 and collecting extensive data on genetics, behaviors, social environment, chemical exposures, and health outcomes. This life-course approach will provide insights into early-life and community-level influences on obesity risk and their interactions. The study aims to guide evidence-based strategies for obesity prevention.
The National Children's Study aims to understand environmental factors contributing to childhood obesity through a large prospective birth cohort study of 100,000 American children. It will address limitations of past studies by following children from before conception through age 21 and collecting extensive data on genetic, behavioral, social, built environment, and chemical exposure factors. This life-course approach will provide insights into obesity origins and allow examination of interactions among multiple influences over time. The study aims to guide evidence-based strategies for obesity prevention.
The Effects of Smoking In Pregnant WomenA Capstone Present.docxtodd701
The Effects of Smoking In Pregnant Women
A Capstone Presented in Partial Fulfillment
of the Requirements for the Degree
Master of Healthcare Administration
PURDUE UNIVERSITY GLOBAL
September 4, 2018
The Effects of Smoking in Pregnant Women
Background
The following section highlights some historical and reviewed information or material on smoking during pregnancy, and some of the effects the practice has not only on the unborn children but also on the mothers. Most people associate smoking with heart disease, cancer and major health conditions that have been documented in different scholarly materials. Smoking during the period of pregnancy is attributed to additional health challenges most of which are connected with the well-being of the unborn child (Banderali et al., 2015). It has been documented that smoking cigarettes is the leading cause of preventable deaths in several parts of the country and the rest of the world. Estimated figures of smoking prevalence during pregnancy are most of the time derived from self-reported data and information.
Validation of these data and information using biochemical markers like cotinine has most of the time shown that women who are pregnant may hide their smoking especially when they understand the kind of reactions they could be exposed to. As a result, the self-reported smoking prevalence data and information during pregnancy is underestimated (Banderali et al., 2015). Since negative attitudes towards maternal smoking have been on the increasing trend over the recent past, the validity and credibility of self-reported smoking data and information may be of special attention (Banderali et al., 2015).
This literature perspective brings forth an understanding on the consequences of smoking during pregnancy from the perspective of brain functioning and how the developing fetus is likely to be affected by the common practice. Banderali et al. (2015) stress that mothers often want healthy babies full of life and with a high brain capacity. However, smoking has been illustrated to have an immediate impact on how the fetus is developed and how the capacity of the brain is affected. Environmental factors can massively modulate genetically programmed development of the brain during the fetal life, and maternal smoking is a harmful factor (Banderali et al., 2015). It is saddening that while pregnant mothers and other people in the society have widespread and detailed knowledge and information on the consequences of smoking on the development of the fetus, statistics still show that more than 20 percent of women in this category continue with the practice in several parts of the world, Europe and United States not left behind (Ekblad, Korkeila & Lehtonen, 2015).
Statistics speculate that women and first-time mothers especially those coming from low-income families are worst hit by the effects of smoking during pregnancy, as compared to the older women who have had mo.
lable at ScienceDirectAnnals of Epidemiology 26 (2016) 275.docxsmile790243
This study examines the association between alcohol consumption before and during pregnancy and the risk of preterm birth among over 46,000 first-time mothers in Norway. The study finds that 91% of participants consumed alcohol before pregnancy, while less than 20% reported drinking during pregnancy. Pre-pregnancy alcohol consumption was associated with a reduced risk of preterm birth, while drinking during pregnancy was not found to increase or decrease the risk. However, drinking 1-3 times per month during the first 15 weeks of pregnancy was associated with a higher risk of preterm birth. The study aims to provide a more solid basis for advising occasional drinkers during pregnancy but notes challenges from residual confounding factors.
Two-Generation Programs and HealthVO L . 2 4 N O. 1 .docxwillcoxjanay
Two-Generation Programs and Health
VO L . 2 4 / N O. 1 / S P R I N G 2 0 1 4 7 9
Summary
Parents’ health and children’s health are closely intertwined—healthier parents have healthier
children, and vice versa. Genetics accounts for some of this relationship, but much of it can
be traced to environment and behavior, and the environmental and behavioral risk factors for
poor health disproportionately affect families living in poverty. Unhealthy children are likely to
become unhealthy adults, and poor health drags down both their educational attainment and
their income.
Because of the close connection between parents’ and children’s health, write Sherry Glied
and Don Oellerich, we have every reason to believe that programs to improve parents’ health
will improve their children’s health as well. Yet few programs aim to work this way, except for a
narrow category of programs that target pregnant women, newborns, and very young children.
Glied and Oellerich assess these programs, discuss why there are so few of them, and suggest
ways to expand them. Their chief conclusion is that structural barriers in the U.S. health-
care system stand in the way of such programs. Some of these barriers have to do with health
insurance, access to care, and benefits, but the biggest one is the fact that physicians typically
specialize in treating either children or adults, rather than families as a whole. The Affordable
Care Act has begun to break down some of these barriers, the authors write, but much remains
to be done.
www.futureofchildren.org
Sherry
Glied
is
the
dean
and
a
professor
of
public
service
at
New
York
University’s
Robert
F.
Wagner
Graduate
School
of
Public
Service.
Don
Oellerich
is
the
deputy
chief
economist
in
the
Office
of
the
Assistant
Secretary
for
Planning
and
Evaluation
at
the
U.S.
Department
of
Health
and
Human
Services.
Two-‐Generation
Programs
and
Health
Sherry Glied and Don Oellerich
8 0 T H E F U T U R E O F C H I L D R E N
Sherry Glied and Don Oellerich
T
he health of children and
the health of their parents
are strongly linked. Health
depends on genes, environ-
ments, and behaviors; parents
and children share all of these. Specialized
providers—hospitals, doctors, and clinics—
provide services to children and parents that
contribute to their health. Well-established
and expanding government programs,
including Medicaid and the Children’s
Health Insurance Program (CHIP), as well
as employer-sponsored coverage and sub-
sidized coverage in health marketplaces,
help to finance this care. In short, we have
both the rationale and the financing basis
for two-generation approaches to health. Yet
relatively few two-generation interventions
aim to improve health, except for a narrow
category of programs that target pregnant
wom ...
1January 2020, Volume 8, Issue 1, Number 17Maryam Bahr.docxaulasnilda
1
January 2020, Volume 8, Issue 1, Number 17
Maryam Bahreynian1 , Marjan Mansourian2 , Nafiseh Mozaffarian3 , Parinaz Poursafa4 , Mehri Khoshhali3* , Roya Kelishadi3
Review Article:
The Association Between Exposure to Ambient Particulate
Matter and Childhood Obesity: A Systematic Review and
Meta-analysis
Context: Physical environment contamination and in particular, air pollution might cause long-term
adverse effects in child growth and a higher risk of catching non-communicable diseases later in life.
Objective: This study aimed to overview the human studies on the association of exposure to
ambient Particulate Matter (PM) with childhood obesity.
Data Sources: We systematically searched human studies published until March 2018 in PubMed,
Scopus, Ovid, ISI Web of Science, Cochrane library, and Google Scholar databases.
Study Selection: All studies that explored the association between PM exposure and childhood
obesity were assessed in the present study, and finally, 5 studies were used in the meta-analysis.
Data Extraction: Two independent researchers performed the data extraction procedure and
quality assessment of the studies. The papers were qualitatively assessed by STROBE (Strengthening
the Reporting of Observational studies in Epidemiology) statement checklist.
Results: The pooled analysis of PM exposure was significantly associated with increased Body Mass
Index (BMI) (Fisher’s z-distribution=0. 028; 95% CI=0. 017, 0. 038) using the fixed effects model. We
also used a random-effect model because we found a significant high heterogeneity of the included
studies concerning the PM (I2=94. 4%; P<0. 001). PM exposure was associated with increased BMI
(Fisher’s z-distribution=0. 022; 95% CI=-0. 057, 0. 102). However, the overall effect size was not
significant, and heterogeneity of the included studies was similar to the fixed effect model.
Discussion: Our findings on the significant association between PM10 exposure and the increased
BMI (r=0. 034; 95%CI=0. 007, 0. 061) without heterogeneity (I2=16. 6%, P=0. 274) (in the studies with
PM10) suggest that the PM type might account for the heterogeneity among the studies.
Conclusion: The findings indicate that exposure to ambient PM10 might have significant effects on
childhood obesity.
A B S T R A C T
Key Words:
Air pollution, Particulate
matter, Childhood
obesity, Meta-analysis
Article info:
Received: 10 Oct 2018
First Revision: 23 Feb 2019
Accepted: 09 Mar 2019
Published: 01 Jan 2020
1. Department of Nutrition Child Growth, and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Dis-
eases, Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran.
2. Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
3. Department of Pediatrics, Child Growth, and Development Research Center, Research Institute for Primordial Preve ...
1January 2020, Volume 8, Issue 1, Number 17Maryam Bahr.docxjesusamckone
1
January 2020, Volume 8, Issue 1, Number 17
Maryam Bahreynian1 , Marjan Mansourian2 , Nafiseh Mozaffarian3 , Parinaz Poursafa4 , Mehri Khoshhali3* , Roya Kelishadi3
Review Article:
The Association Between Exposure to Ambient Particulate
Matter and Childhood Obesity: A Systematic Review and
Meta-analysis
Context: Physical environment contamination and in particular, air pollution might cause long-term
adverse effects in child growth and a higher risk of catching non-communicable diseases later in life.
Objective: This study aimed to overview the human studies on the association of exposure to
ambient Particulate Matter (PM) with childhood obesity.
Data Sources: We systematically searched human studies published until March 2018 in PubMed,
Scopus, Ovid, ISI Web of Science, Cochrane library, and Google Scholar databases.
Study Selection: All studies that explored the association between PM exposure and childhood
obesity were assessed in the present study, and finally, 5 studies were used in the meta-analysis.
Data Extraction: Two independent researchers performed the data extraction procedure and
quality assessment of the studies. The papers were qualitatively assessed by STROBE (Strengthening
the Reporting of Observational studies in Epidemiology) statement checklist.
Results: The pooled analysis of PM exposure was significantly associated with increased Body Mass
Index (BMI) (Fisher’s z-distribution=0. 028; 95% CI=0. 017, 0. 038) using the fixed effects model. We
also used a random-effect model because we found a significant high heterogeneity of the included
studies concerning the PM (I2=94. 4%; P<0. 001). PM exposure was associated with increased BMI
(Fisher’s z-distribution=0. 022; 95% CI=-0. 057, 0. 102). However, the overall effect size was not
significant, and heterogeneity of the included studies was similar to the fixed effect model.
Discussion: Our findings on the significant association between PM10 exposure and the increased
BMI (r=0. 034; 95%CI=0. 007, 0. 061) without heterogeneity (I2=16. 6%, P=0. 274) (in the studies with
PM10) suggest that the PM type might account for the heterogeneity among the studies.
Conclusion: The findings indicate that exposure to ambient PM10 might have significant effects on
childhood obesity.
A B S T R A C T
Key Words:
Air pollution, Particulate
matter, Childhood
obesity, Meta-analysis
Article info:
Received: 10 Oct 2018
First Revision: 23 Feb 2019
Accepted: 09 Mar 2019
Published: 01 Jan 2020
1. Department of Nutrition Child Growth, and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Dis-
eases, Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran.
2. Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
3. Department of Pediatrics, Child Growth, and Development Research Center, Research Institute for Primordial Preve.
Running head PICOT STATEMENT 1PICOT STATEMENT 5.docxtoltonkendal
Running head: PICOT STATEMENT 1
PICOT STATEMENT 5
PICOT Statement: Childhood Obesity
P-I-C-O-T Statement
P- Patients who suffer from obesity (BMI of more than 30)
I- Undertaking nutritional education, diet, and exercise
C- Comparison to nutritional education, endoscopic bariatric surgical intervention
O- Improved health outcomes in terms of overall weight
T - A year’s time limit
PICOT Statement: Childhood Obesity
Introduction
Childhood obesity poses serious health problems in the US as the number of overweight and obese population increases at a rapid pace every year. The effects of this problem have arrested the attention of policymakers, societal members, and government agencies. This has resulted in ranking childhood obesity as a national health concern. The adverse impacts of this disease go beyond the health realms to include economic burden on both personal and national budgets. While there are numerous risk factors and various evidence-based interventions to address this challenge, no single approach is consistently efficacious in curbing the disease. Consequently, it is imperative that efficacious initiatives and policies be developed to address the never-ending problem of childhood obesity. Multidisciplinary approaches are often broad and cut across all dimensions of personal health problems. Instead of placing emphasis solely on biomedical models, health care professionals should also seek to promote behavior change among obesity patients and their family members. A PICOT statement can be utilized as an effective tool to seek interventions of addressing childhood obesity.
PICOT Statement
Population
In the US, obesity prevalence is highest among children aged from 6 to 11 years (Cheung et al. 2016). The disease has tripled among this age group from 4.2 percent to 15.3 percent from 1963 to 2012. In the last three decades, increased cases of obesity prevalence have been noted among children of all ages, although the differences in obesity prevalence have been recorded in terms of age, race, ethnicity, and gender (Cheung et al. 2016). In this respect, children from socioeconomically disadvantaged families and some racial and ethnic minorities experience the higher median score on obesity than the dominant white population. Higher obesity rates are often recorded among blacks and Hispanics compared to whites. For instance, a survey on girls in the Southwest revealed that the yearly cases of obesity stood at 4.5 percent among Blacks, 2 percent among Hispanics, and 0.7 percent among white girls aged from 13 to 17 years (Cheung et al. 2016). For low-income earners, American Indians rank highest at 6.3 percent, followed closely by Hispanics at 5.5 percent.
Intervention
Evidence-based interventions that seek to reduce childhood obesity incidences in the country should target two major areas: prevention and treatment. High-quality RCT has been proven as one of the most effective preventative ...
Diet and Exercise Research Paper 2 PC correctedAustin Clark
This meta-analysis reviewed 7 randomized controlled trials examining the effects of diet, exercise, and mixed interventions on obesity measures in children. The studies included a total of 1,530 children who were approximately 55% overweight or obese at baseline. The analysis found no statistically significant effects of any intervention type on BMI, BMI z-score, or weight compared to controls. There was significant heterogeneity between the studies. While the results did not support the efficacy of these interventions, dietary interventions favored weight gain while exercise and mixed interventions favored weight loss, though insignificantly. Additional high-quality research is still needed to determine effective obesity interventions for children.
Running head The study of effects of smoking in pregnant women .docxtodd521
Running head: The study of effects of smoking in pregnant women 1
THE STUDY OF EFFECTS OF SMOKING IN PREGNANT WOMEN 6
Method
Introduction
Use of tobacco products which includes smoking cigarettes, smokeless tobacco and electronic cigarettes during pregnancy is considered to be the biggest cause of harm to young infants and their mothers. Smoking is considered to be a risk factor associated with adverse outcomes including pregnancy related effects, unhealthy and physical problems, cognitive deficits, behavioral and social problems. Statistics show that up to 13% of the women in the United Kingdom smoke during pregnancy although pregnancy motivates around 49% of the women to stop smoking. Ultimately, intervention and screening for smoking during pregnancy can be imperative in achieving smoking cessation, educating women’s partners and family members on the merits of smoking cessation during pregnancy. This section is an overview of the Methodologies used in my research assignment. The section focuses on the population used, sampling frame and the analyzed data and some of the recommended practices which result from the methodologies in regard to effects of smoking in pregnant women.Research Method and Design Appropriateness
Experts acknowledge that it is essential to know the difference between quantitative and qualitative research methods although there are misconceptions between the two. On the contrary both methods serve vastly diversified purposes. Quantitative research methods are used when it comes to quantifying the problem through generation of numerical data which is transformed into useable statistics. This method uses measureable data in formulation of facts and includes surveys, observations and reviews of records. Qualitative research method is used in gaining a clear understanding of underlying opinions, motivations and reasons. This method uses a small selected size sample and helps to develop ideas or hypotheses and gives insights into the problem. Qualitative research methods include focus groups, individual interviews, document reviews and in-depth interviews. This research study was designed to use qualitative approach in the form of in-depth interviews with women in the core group that was targeted. This method was more appropriate for my study because the fundamental goal of the research was to carry out face-to-face in-depth interviews at a well-known location. Due to the interests of including the views of a variety of women, an approach that was flexible to the actual location was adopted including local cafes, in-home, meeting rooms and in multiple special cases by telephone. This allowed the researching process many women in the client group.
Population
The study population on the effects of smoking in pregnant women involved an inclusion criterion of both white and black women pregnant smokers and pregnant non-smokers between 17 years and 36 years of age specifically in the state of Alabama Unit.
Running Head The Study of Effects of Smoking in Pregnant Women.docxtodd521
Running Head: The Study of Effects of Smoking in Pregnant Women
1
The Study of Effects of Smoking in Pregnant Women
4
The Study of Effects of Smoking in Pregnant Women
A Capstone Proposal Presented in Partial Fulfillment
of the Requirements for the Degree
Master of Healthcare Administration
Purdue Global University
A Study of Effects of Smoking in Pregnant Women
Smoking during pregnancy carries considerable dangers to both mother and the unborn baby. Prenatal exposure to maternal cigarette smoking (PEMCS) is linked, therefore, with many different obstetric complications such as an augmented danger of ectopic pregnancy, fetal development limitation, placental previa and abruption, preterm premature rip apart of the membranes, preterm delivery, unexpected newborn death syndrome, and oral facial clefts among others. Despite these risks, women still smoke during pregnancy. There is, therefore, a great need to develop policies and interventions such as discovering what can help the women to cease smoking, in order to reduce these risks. As such, alternatives such as the use of electronic cigarettes can be introduced to the pregnant smokers. Treatment for smoking can also be offered to women during pregnancy.
Background
The following section will discuss the background of the topic. Smoking during pregnancy exposes the mother and unborn child to great risks. Prenatal exposure to maternal cigarette smoking (PEMCS) is linked, therefore, with many different obstetric complications. According to Bauld (2017), the complications could range from an augmented danger of ectopic pregnancy, fetal development limitation, placental previa and abruption, preterm premature rip apart of the membranes, preterm delivery, unexpected newborn death syndrome, and oral facial clefts. Anblagan et al., (2013) includes more risks such as the development of respiratory diseases, gestational bleeding, obesity and obesity associated disorders like cardiovascular as well as diabetes results that start when the child reaches puberty. However, intrauterine growth restriction is the most common of them all. Considering all these risks and the fact that women who smoke carry on with this habit during pregnancy, there is a great need to develop policies and interventions that would address this matter. As such, there is need to discover what can be given to these women to help in cessation.
General Problem Statement
The general problem is that there are limited researches that detail about smoking patterns in pregnant women. A research by Eiden et al., (2013) indicates a shifting trajectory in pregnant smokers and major changes in due course within each trajectory. This element is important as it has the prospective to notify timing of smoking cessation intervention. Specific Problem Statement
The specific problem is that there is little information about the stability of cessation efforts on the elements that distinguish women who effectively minimize smoking during.
Pre-Pregnancy Care and Pregnancy Care to Improve Neonatal and Perinatal Morta...DerejeBayissa2
This systematic review and meta-analysis assessed the effectiveness of linking pre-pregnancy and pregnancy care in reducing neonatal and perinatal mortality in low- and middle-income countries. The analysis included 5 randomized controlled trials with outcomes of neonatal, perinatal, and maternal mortality. The meta-analysis found that interventions linking pre-pregnancy and pregnancy care effectively reduced neonatal mortality by 21% and perinatal mortality by 16%, but did not find an effect on maternal mortality. The review concluded that neonatal and perinatal mortality can be reduced by linking pre-pregnancy and pregnancy care as part of a continuum of care approach.
This document summarizes guidelines for predicting and preventing spontaneous preterm birth from the American College of Obstetricians and Gynecologists (ACOG). It defines preterm birth and discusses its increasing rates and racial disparities in the United States. It reviews factors associated with spontaneous preterm birth, including a history of preterm birth, short cervical length on ultrasound, and infections. It also discusses strategies for assessing risk, including cervical length screening via ultrasound in the mid-trimester.
2. Background
Smoking during pregnancy is a modifiable risk factor as-
sociated with adverse birth outcomes and may impart
long-term health consequences [1–3]. This relationship
however is confounded by the presence of many other
risk factors, including maternal age, education, alcohol
or drug use [4–6]. Furthermore, it’s been shown that
these individual-level risk factors have a dose-response
association with the level of smoking, with a distinction
between heavy smokers (greater than 10 cigarettes per
day) and moderate or light smokers [4]. For example,
while the prevalence of smoking during pregnancy de-
creases with increasing maternal age, the level of smok-
ing is heavier among the older mothers who do smoke.
As a result, the effect of smoking on birth weight has
been shown to be modified by maternal age or other
correlated risk factors [7, 8]. Similarly, neighbourhood-
level factors might directly or indirectly modify the effect
of smoking on birth weight such as neighbourhood
deprivation or levels of particulate air pollution [9–11].
Exposure to the fine fraction of particulate matter
(PM2.5, particles with aerodynamic diameter ≤ 2.5 μm)
has shown to be a consistent risk factor associated with
reduced birth weight [12]. The complex mixture of
PM2.5 includes elemental and organic carbon com-
pounds, metals and gases that stem predominantly from
vehicle exhaust, residential heating and industrial emis-
sions [13]. The mechanisms by which PM2.5 and its con-
stituents adversely affect the reproductive system are not
fully understood; however, evidence supports the poten-
tial for a shared mode of developmental toxicity with to-
bacco smoke exposure [14–16]. With similar chemical
components, both PM2.5 and tobacco smoke penetrate
deep into pulmonary alveolar tissues and translocate to
extrapulmonary tissues causing systemic cardiovascular
and immunological alterations, including platelet activa-
tion, coagulation, endothelial dysfunction, DNA damage
and mutagenesis [13, 16, 17].
Low SES remains one of the most robust predictors of
adverse pregnancy outcomes such as fetal growth re-
striction despite universal health care programs in
Canada and Europe [9, 18, 19]. The society-level deter-
minants such as poverty, poor education, income in-
equality and social discrimination and marginalization
act indirectly on the placenta and fetus through the pro-
motion of ‘downstream’ or mediating exposures, stresses
and behaviours [20, 21]. In studies of cardiovascular dis-
ease, neighbourhood-level factors were associated with
increased levels of smoking and other risk factors such
as obesity, lack of exercise, lower health knowledge and
lower positive behaviour changes [11, 22]. These epi-
demiological observations have been shown with the use
of multilevel statistical models capable of separating the
individual-level effects from the context of their social
and physical environments [23]. The use of multilevel
models in perinatal epidemiology has uncovered
neighbourhood-level factors that interact with maternal-
level risk factors to either buffer or mediate adverse birth
outcomes [21, 24].
We present a multilevel cross-sectional analysis of
birth registry data in British Columbia, Canada (popula-
tion 4.6 million) to investigate neighbourhood-level dif-
ferences in the effect of cigarette smoking during
pregnancy on birth weight and to quantify the degree to
which individual and neighbourhood-level variables ex-
plain any observed differences. Specifically, we sought to
determine whether exposure to PM2.5 and living in low
SES neighbourhoods explain between-neighbourhood
differences in the effect of maternal smoking on birth
weight. We also examine whether these neighbourhood-
level factors modify the direct effect of maternal smok-
ing on birth weight. Birth weight is among the most
important factors affecting neonatal mortality and is a
significant determinant of post-neonatal infant mortality
and childhood morbidity [25]. Understanding the under-
lying individual and interactive effects of exposures on
birth weight is crucial for effective community planning
and strategic interventions to improving reproductive
health outcomes.
Methods
This was a population-based cross-sectional study of
singleton births in British Columbia from 2001 to 2006
(N = 237,470). Data from the BC Perinatal Database
Registry were provided by Perinatal Services BC (PSBC),
and included information on individual-level maternal-
infant health status and outcomes, reproductive history,
socio-demographics, risk factors, and residential postal
codes. The Registry accounts for nearly 100 % of births
and stillbirths in BC of at least 20 weeks gestation or at
least 500 g birth weight. Research data access is provided
by a Partnership Accord /Memorandum of Agreement
between all BC Health Authorities and PSBC through
the Freedom of Information and Privacy Protection Act
[26]. Research ethics board approval was granted by the
University of Victoria (protocol #11-043).
The outcome variable was continuous birth weight of
singleton births. Included were all births (stillbirth and
live) for gestational ages of 20 to 42 weeks. Excluded
birth records included: out-of-province and invalid pos-
tal codes (n = 1096), non-viable births prior to 20 weeks
gestation or less than 500 g (n = 15), and the list-wise de-
letion of births missing important data including: ciga-
rettes smoked per day (cigarettes/day, n = 2510), PM2.5
(n = 1512), birth weight (n = 46). Table 1 provides the full
list of covariates used along with their summary statis-
tics. All continuous independent variables, except ciga-
rettes/day, were grand-mean centred and standardized
Erickson et al. BMC Public Health (2016) 16:585 Page 2 of 12
3. to ease interpretation and aid model convergence. Thus,
a value of zero represents the transformed variable’s
mean and reference value and has a standard deviation
equal to one. The variable cigarettes/day was kept un-
transformed since the value zero (i.e. non-smokers) was
the desired reference level. Smoking levels were capped
at 20 cigarettes/day with higher values assigned a value
of 20 to stabilize the distribution tail (n = 245, min.21
max.80). Two variables indicating the use of alcohol or
drugs (prescription, non-prescription, illicit) to be a risk
factor in pregnancy as identified by a physician were
combined into a single dichotomous variable.
Birth records were geocoded based on the latitude-
longitude coordinate of the mother’s residential postal
code at the time of delivery using GeoRef by DMTI [27].
Birth records were then linked to their corresponding
census dissemination area (DA) by performing a point-
in-polygon spatial join procedure in ArcGIS 10.2 [28].
DAs represent the smallest geographical unit for which
census data are available with a spatial coverage ranging
between 200 and 800 people depending on the level of
urban development. While DAs do not necessarily rep-
resent existing neighbourhood communities [29], they
can act as proxies for a general catchment area of per-
sonal home-life activities [21, 30]. Birth records were
identified as being either rural or urban using the Statis-
tics Canada Metropolitan Influence Zone (MIZ) codes
which are based on commuting flows of small towns
into larger cities and metropolitan areas [31].
PM2.5 exposure was estimated using a national land-
use regression (LUR) model developed to estimate PM2.5
at the census street block-face level [32]. The model
used a number of predictors including satellite measures,
proximity to major roads and industry to account for
46 % of the variability in measured annual PM2.5 con-
centrations. Individual birth records were related to the
block-face point estimates using a nearest-point proced-
ure in ArcGIS10.2. Street block-face point estimates were
related to individual birth records using a nearest-point
procedure in ArcGIS10.2 and then aggregated to their
DA-level mean to represent an area-level air pollution
variable on individual births.
Three related but independent datasets all based on
the 2006 Statistics Canada national census were used to
represent the DA-level SES and demographic data. The
first was a Canadian SES index (SESi) developed by
Chan et al. which provides a measure of overall socio-
economic neighbourhood well-being [33]. The second
was the proportion of population over 15 with any post-
secondary education, including college, trades, or univer-
sity representing higher DA-level education attainment
levels. The third was the proportion of continental Asian
immigrants by DA. It’s been shown in BC and elsewhere
that healthy babies from Asian and South Asian back-
grounds are constitutionally smaller compared to
Caucasian babies [34, 35]. Asian and South Asian eth-
nicities are well-represented throughout BC but par-
ticularly in concentrated pockets throughout the
major urban center of Metro Vancouver where levels
of PM2.5 are also high and could therefore confound
any PM2.5 effect. Furthermore, concentrated ethnic
communities may impart buffering mechanisms
through enhanced social interactions and support net-
works [21, 24]. A sequential regression technique was
used to remove the collinearity between sets of DA-
level variables [36]. Here, immigrant density was
regressed against SESi and PM2.5 with the saved residuals
representing the uncorrelated and independent contribu-
tion of immigrant density on birth weight freed from its
collinearity with SESi and PM2.5 (r = −0.62 and 0.53 re-
spectively). This method was repeated for SESi and educa-
tion (r = 0.26) creating a residual immigrant density and
residual education variable. The education and immigrant
data were obtained by access to ABACUS via the Data
Liberation Initiative [37].
Imputation for missing SES, education and immigrant
density values was performed in order to avoid data loss
of rural DAs with low population counts. Taking advan-
tage of the nested hierarchical structure of the adminis-
trative census and health boundaries, the mean SESi
value for a larger encompassing census subdivision
Table 1 Descriptive statistics#
for individual (Level-1) and DA
(Level-2) covariates on term birth weight
Variable Mean (sd) Min-max
Level-1 (individual)
Maternal age 29.8 (5.60) 11 – 55
Nulliparous 0.45 (0.50) 0 – 1
Drug/Alcohol flag 0.02 (0.15) 0 – 1
Cigarettes/day 0.79 (2.91) 0 – 20
Fall/Winter season 0.48 (0.50) 0 – 1
Level-2 (DA) Variables
SESi -0.08 (0.58) -2.22 – 1.18
Education 0.50 (0.12) 0 – 0.95
Immigrant density 0.16 (0.19) 0 – 0.86
PM2.5 7.30 (0.86) 4.41 – 10.23
Rural address 0.11 (0.32) 0 – 1
# values shown are unstandardized, non-centered; Nulliparous: patient has
never delivered a baby of at least 500 g birth weight or at least 20 weeks
gestation in a previous pregnancy; Drug or Alcohol Flag: physician indicated
use of drugs (prescription, non-prescription, illicit) or alcohol as risk factor in
pregnancy; Cigarettes/day: number of cigarettes smoked daily at 1st
prenatal
visit (self-reported); Fall/Winter Season: month or birth between September to
February; SESi: socioeconomic status index; Education: proportion of population
over 15 with any post-secondary education (trade, college, university); Immigrant
Density: proportion of the population identified as immigrant status from
continental Asia; PM2.5: Particulate Matter less than 2.5 μm; Rural: those
having a rural residential address
Erickson et al. BMC Public Health (2016) 16:585 Page 3 of 12
4. (CSD) or local health area (LHA) was imputed for a
nested DA with a missing value. There were 1441 values
imputed in 52 DAs for SESi (0.6 % of final N, 0.8 % of
DAs), and 3170 values imputed in 108 DAs for both
education and immigrant density (1.4 % of final N, 1.7 %
of DAs). Sensitivity analyses were performed using only
the non-imputed data.
Hierarchical (multilevel) linear regression models were
used to test our research questions, thereby accounting
for the clustering, or non-independence, of individuals
(level-1) belonging to a given DA neighbourhood (level-
2). The multilevel model allows the intercept and slope
to act as random parameters having between-area (DA)
variability from an overall (BC-wide) mean intercept and
slope. Therefore each DA has its own intercept and
slope in which their variability from the overall mean
intercept and slope can be investigated with the addition
of individual (level-1) and DA-level (level-2) variables
and their interactions [38]. We followed a bottom-up ap-
proach to model building to quantify the explained pro-
portional change in variance (PCV) with the addition of
sets of variables, the multilevel model equivalent to an
R2
[23]. We started with the empty (Null) random inter-
cept model without any independent variables in which
birth weight is only a function of the mother’s residential
DA. The presence of significant random intercept vari-
ance indicates there are unexplained differences between
neighbourhood means of birth weight. The proportion
of the total variance in birth weight that arises due to
neighbourhood differences can be quantified by comput-
ing the intra-class correlation (ICC) which represents
the degree of clustering of individual birth weight within
neighbourhoods [23].
The Null model was followed by Model that included
the individual-level covariates as well as the addition of a
random slope for the continuous variable of maternal
smoking (cigarettes/day, self-reported at the first prenatal
visit). By allowing cigarettes/day to be random, the mean
within-DA effect of maternal smoking is allowed to differ
between DAs. The presence of a significant random slope
indicates that its effect on birth weight is not constant (or
equal) for all DAs; that is, there are important unexplained
differences between the within-DA group effects of mater-
nal smoking on birth weight. Subsequent models included
the DA-level variables along with cross-level interactions
to assess their fixed effects on birth weight but to also de-
termine if their inclusion addresses any unexplained slope
variance. Several models were tested using the Akaike In-
formation Criterion (AIC) to evaluate model performance.
We report the results of three models to compare the
degree of change between the level-1 and level-2 homoge-
neous (non-interaction) models and a model with effect-
measure variation. All statistical analyses were conducted
in Stata 13IC [39].
Results
After exclusions, the final dataset included 232,291 single-
ton (live and stillborn) births located in 6338 neighbour-
hood DAs (min. = 1, max. = 782, avg. = 37). Table 1
summarizes the untransformed individual and neighbour-
hood covariates (non-centered, non-standardized). The
prevalence of maternal smoking in this population was
10.3 % (n = 23,836) with an average of 7.5 cigarettes/day
among smokers. Table 2 reports the adjusted coefficients
for the individual and DA-level covariate fixed effects on
continuous birth weight (Model 1 and 2). Model 1 was a
level-1 model that included only the maternal-level covari-
ates. The relationship between birth weight and ciga-
rettes/day was found to be non-linear and was best
modeled using a quadratic term indicating a subdued
dose-response with increasing exposure (Fig. 1). Model 2
added the DA-level variables. Their fixed effects show that
DAs with higher SES and higher proportion of post-
secondary education were significantly associated with
higher birth weights; whereas DAs with increased levels of
PM2.5, higher Asian immigrant density and rural DAs
were all significantly associated with lower birth weights.
Season of birth (fall or winter) was also significantly asso-
ciation with reduced birth weight. The results in Table 2
represent the fixed effects from homogeneous models (i.e.
those without any modeled heterogeneity of the effect
measure for maternal smoking).
Model 3 tested interactions with cigarettes/day includ-
ing cross-level (level-1 by level2) and level-1 by level-1
interactions to explain the between-DA random inter-
cept and random slope variability. The model results are
presented in Table 3 including the main effects as well
as the interaction effects with cigarettes/day. The degree
Table 2 Adjusted fixed effects for level-1 and level-2 covariates
on continuous term birth weight
Variables Model 1
β (95 % CI)
Model 2
β (95 % CI)
Maternal age -16.9 (-19.3 – -14.4) -14.9 (-17.4 – -12.4)
Nulliparous -107.7 (-112.5 – -103.0) -105.5 (-110.3 – -100.7)
Drug/Alcohol flag -171.6 (-186.9 – -156.3) -172.2 (-187.5 – -157.0)
Cigarettes/day -23.5 (-25.8 – -21.2) -26.2 (-28.5 – -23.9)
cigarettes/daya
0.66 (0.51 – 0.80) 0.75 (0.61 – 0.90)
Fall/Winter season -9.6 (-14.1 – -5.0) -8.8 (-13.3 – -4.3)
SESi – 42.7 (39.8 – 45.6)
Education – 6.3 (3.5 – 9.1)
Immigrant density – -35.8 (-38.5 – -33.2)
Rural address – -18.8 (-28.4 – -9.2)
PM2.5 – -25.0 (-28.2 – -21.8)
PM2.5
a
– 3.3 (1.5 – 5.2)
See Table 1 caption for variable definitions
a
Modeled as a quadratic
Erickson et al. BMC Public Health (2016) 16:585 Page 4 of 12
5. of heterogeneity across levels of maternal smoking
modified by the DA-level contextual factors is graphic-
ally presented in Fig. 2. The five graphs show the pre-
dicted conditional fixed effects of SESi, education, PM2.5,
Asian immigrant density and rural residence on birth
weight and their interactions with specified levels of ma-
ternal smoking (Fig. 2a–e respectively). For example,
Table 3 and Fig. 2a show that higher SES has a signifi-
cant positive association with birth weight but is less
pronounced with increased levels of maternal smoking
whereby very heavy smokers (≥20 cigarettes/day) do not
incur any benefit of higher SES. Conversely, very heavy
smokers showed the greatest gains in birth weight in
DAs with higher proportions of post-secondary educated
people (Fig. 2b). Recall that the higher education variable
was an uncorrelated residual variable independent of
SESi, and therefore these observed associations are in
addition to the education-related effect captured by
SESi.
Increasing PM2.5 levels had a significant non-linear
association with reduced birth weight; however, it
showed a positive interaction with maternal smoking
such that the effect of increased smoking on birth
weight was attenuated in DAs with higher levels of
PM2.5 (Fig. 2c). Similarly, higher Asian immigrant
density was significantly associated with lower birth
weights but had a positive interaction with increased
cigarette use demonstrating a protective effect of
Fig. 1 Adjusted Predicted Effects of Maternal Smoking on Birth Weight. Predicted effects of maternal smoking (cigarettes/day) on birth weight
with 95 % confidence intervals are conditional on model covariates included in Model 3. Black vertical lines represent the frequency distribution
of cigarettes/day (non-smokers, 0 cigarettes/day, have been omitted for display purposes)
Table 3 Adjusted individual and DA-level fixed effects on continuous birth weight and their modification by maternal smoking
(Model 3)
Variables Main effect
β (95 % CI)
Modification by cigs/day
β (95 % CI)
Corresponding figure
Cigarettes/daya
-25.7 (-28.1 – -23.3) 0.83 (0.68 – 0.98) 1
SESi 43.8 (40.9 – 46.8) -2.7 (-3.7 – -1.6) 2A
Education 5.2 (2.3 – 8.1 1.3 (0.3 – 2.3) 2B
PM2.5 -26.3 (-29.6 – -23.0) 1.8 (0.9 – 2.7) 2C
PM2.5
a
3.4 (1.5 – 5.3) – –
Immigrant density -36.5 (-39.2 – -33.7) 2.6 (1.5 – 3.7) 2D
Rural address -15.0 (-25.1 – -5.0) -2.9 (-5.6 – -0.2) 2E
Maternal age -12.1 (-14.8 – -9.5) -2.9 (-3.6 – -2.1) 3A
Drug/Alcohol flag -161.2 (-180.4 – -142.1) -3.7 (-6.3 – -1.2) 3B
See Table 1 caption for variable definitions
a
Modeled as a quadratic, value for Cigarettes/day listed under ‘Modification by cigs/day’; Model 3 covariates not listed above include: nulliparous and season
of birth
Erickson et al. BMC Public Health (2016) 16:585 Page 5 of 12
6. higher immigrant density DAs (Fig. 2d). Rural DAs
had a significant negative interaction with maternal
smoking indicating a further reduction in birth weight
with increased cigarette use among rural residents
(Fig. 2e).
Two level-1 interactions with maternal smoking were
significant, maternal age and suspected drug or alcohol
use. The predicted conditional marginal effects of these
two interactions are show in Fig. 3a and 3b respectively
indicating that the reduction of birth weight among
Fig. 2 Adjusted Predicted Effects of Maternal Smoking on Birth Weight across DA-level Factors. a Socioeconomic Status Index (SESi) b Proportion
of Population with Post-secondary Education c Particulate Matter ≤ 2.5 μm (PM2.5) d Asian Immigrant Density e Rural Residence. Predicted effects
on birth weight with 95 % confidence intervals are conditional on model covariates included in Model 3. Black vertical lines represent the frequency
distribution of the variable on the x-axis (except Fig. 2e which shows the frequency distribution of cigarettes/day)
Erickson et al. BMC Public Health (2016) 16:585 Page 6 of 12
7. heavier smokers is exasperated by older maternal age
and those suspected of drug or alcohol use. A variable
for neighbourhood-level smoking (DA-average ciga-
rettes/day) was created and tested in models along with
a cross-level interaction with maternal-level cigarettes/
day but neither parameters were significant nor ex-
plained any additional variability.
The random effects, the explained proportional change
in variance (PVC), and model diagnostics are presented
in Table 4. The unadjusted ICC for the Null random-
intercept model was 0.019, indicating that 1.9 % of the
total residual differences in birth weight are attributable
to DA-level contextual factors. However, the ICC in-
creased to 2.2 % for Model 1 with the inclusion of the
level-1 covariates and random slope for cigarettes/day.
This was due to the reduction in the level-1 residual
variance (560.5 to 554.7) relative to the increase in the
level-2 random intercept variance (78.7 to 83.4). The
(now adjusted) ICCadj is conditional for the individual
composition of the DAs including the random slope for
cigarettes/day held constant at 0 (i.e. non-smokers). The
addition of DA-level variables in Model 2 removed a lot
of the DA-level variance reducing the ICCadj to 0.6 %.
The level-2 random intercept variance term (reported
as standard deviations in Table 4) indicates that the
mean birth weight for every DA has a degree of variabil-
ity from the overall (BC-wide) mean birth weight. For
the Null model, the overall birth weight intercept is
3434.3 g with a standard deviation of 78.7 giving an 8.6
% difference in range between 95 % of the DAs (3434.3
± (1.96 × 78.7) = 3280.0 and 3588.6 g). The quadratic
form of the random slope for cigarettes/day in Model 1
prevents a similar calculation to be performed, but Fig. 4
gives an indication of the large between-DA slope
Fig. 3 Adjusted Predicted Effects of Maternal Smoking on Birth Weight across Maternal-level Factors. a Maternal age b Suspected Drug or Alcohol
Use. Predicted effects on birth weight with 95 % confidence intervals are conditional on model covariates included in Model 3. Black vertical lines
represent the frequency distribution of the variable on the x-axis (except Fig. 3b which shows the frequency distribution of cigarettes/day)
Erickson et al. BMC Public Health (2016) 16:585 Page 7 of 12
8. variability which shows the DA-specific slopes of mater-
nal smoking on birth weight. The intercept-slope correl-
ation shown in Table 4 indicates the presence of DA-
level heterogeneity signifying that DAs with higher aver-
age birth weights from non-smoking mothers have a
lower within-DA effect of smoking (i.e. higher average
DA intercepts tend to have lower average slopes for
smoking) [23, 38].
The level-1 and level-2 explained PCV (L1-PCV &
L2-PCV) summarizes the relative degree of explained
variance at the different levels between the different
models (Table 4). Using the Null model as the refer-
ence, the Model 1 resulted in an L1-PCV of 2.0 %, and
the L2-PCV in the random intercept was−12.3 %. The
negative L2-PVC is a result of the larger level-2 inter-
cept variance relative to the Null model. The addition
of the DA-level variables in Model 2 explained 68.2 %
of the DA-level variance compared to the Null model.
Model 3 accounted for an additional 0.3 % of the L2-
PCV.
Sensitivity analyses using only the non-imputed DAs
(N1 = 229,067 in 6230 DAs) showed very minor differ-
ences in magnitude of significant variables. Most of the
DAs that were missing data were in rural areas with
small population numbers, the likely reason why their
data were suppressed from the census tables. While
some parameters were slightly attenuated, many of the
interaction terms increased in magnitude. The random-
intercept standard deviation was also slightly smaller
than that of the same model using the full dataset while
random-slope standard deviation showed no difference.
In a second sensitivity analysis, we restricted the sample
to only term births excluding stillbirths and congenital
anomalies. As expected, there was a large reduction in
the random slope variability (L2 slope (sd) = 5.7) and a
small decrease in the random intercept variability (L2
intercept (sd) = 43.0) due to using only term births.
Changes in the coefficients for the DA-level variables as
well as their cross-level interactions with cigarettes/day
were minor, within their 95 % confidence intervals re-
ported in Table 3. The exception was the main effect of
education which was no longer significant (p = 0.151),
but its interaction with cigarettes/day did remain signifi-
cant (p = 0.025). The maternal-level variables were atten-
uated but remained significant with the exception of the
interaction between drug/alcohol flag and cigarettes/day
which was no longer significant (p = 0.106).
Table 4 Random Effects and Model Diagnostics
Null
model
Model 1 Model 2 Model 3
L1 residual (sd) 560.5 554.7 555.0 554.9
L2 intercept (sd) 78.7 83.4 44.4 44.2
L2 slope (sd) – 10.7 9.8 9.0
Intercept 3434.3 3505.9 3501.8 3500.9
AIC 602672 598513 596639 596514
L1-PCV Ref. 2.0 % 2.0 % 2.0 %
L2-PCV Ref. -12.3 % 68.2 % 68.5 %
ICC/VPC#
0.019 0.022 0.006 0.006
Int-slope corr. – -0.53 -0.28 -0.28
Abbreviations: L1 residual (sd) Level-1 residual standard deviation, L2 intercept
(sd) Level-2 random intercept standard deviation, L2 slope (sd) Level-2 random
slope standard deviation, PCV proportional change in variance, #
VPC (variance
partition coefficient) is equivalent to the ICC but conditional on the random-
slope variable, thus values in table represent intercepts for non-smoking
individuals, Int-slope corr intercept-slope correlation
Fig. 4 Neighbourhood-specific slopes of maternal smoking on birth weight. Empirical Bayes predictions of DA-specific regression lines for Model 1
Erickson et al. BMC Public Health (2016) 16:585 Page 8 of 12
9. Discussion
This study employed multilevel random coefficient
models to assess whether neighbourhood-level context-
ual factors can modify the effect of maternal smoking on
birth weight. Our results show that the effect of mater-
nal smoking on birth weight, self-reported as the num-
ber of cigarettes smoked per day, is modified by both
individual-level and neighbourhood-level variables.
However, the observed direction of the effect modifica-
tion was not always as expected. Furthermore, through
the use of random-slope models we show that the aver-
age effect of maternal smoking on birth weight can vary
considerably between neighbourhoods which was only
partially explained by the cross-level interactions. After
adjusting for individual-level covariates and DA-level
socio-economic, socio-demographic and air quality vari-
ables, there was a significant non-linear effect between
cigarettes/day and birth weight in BC for singleton
births from 2001 to 2006. This association was robust to
the exclusion of stillbirths and congenital anomalies as
well as the use of only term births demonstrating that
selection bias does not likely affect the observed results.
The observed non-linear association between ciga-
rettes/day and birth weight shown in Fig. 1 suggests that
the largest potential effects are seen at the low to middle
range of smoking levels. England et al. [40] found a very
similar non-linear association of maternal smoking on
term birth weight using self-reported cigarettes/day as
well as using urine cotinine concentrations. Therefore,
efforts to reduce the number of cigarettes smoked dur-
ing pregnancy may have limited results for moderate
and heavy smokers without substantial reductions or full
cessation [41]. Interestingly, we found a similar curvilin-
ear relationship with increasing levels of modeled PM2.5
and birth weight (Fig. 2c), a dose-response phenomenon
observed in other exposure-disease contexts [42].
Beyond the non-linear association between ciga-
rettes/day and birth weight, other factors were able to
modify this relationship both positively and negatively.
Our analysis confirm previously shown modification of
the smoking-birth weight relationship by maternal risk
factors [7, 8]; however, to our knowledge this is the first
study to show that neighbourhood-level factors are able
to modify this relationship. We found a significant
negative interaction between cigarettes/day and
neighbourhood-level SESi that resulted in the attenu-
ation of the beneficial role of rising neighbourhood-
level SES on birth weight with increased levels of
maternal smoking (Fig. 2a). The predicted effects pre-
sented in Fig. 2a suggests is that maternal smoking may
have little relevance in affecting birth weight in very
low SES neighbourhoods, but becomes more prominent
as neighbourhood-level SES increases and perhaps
other stressors negatively impacting birth weight are
reduced. Hence interventions focusing exclusively on indi-
vidual behaviours may have limited success without ad-
dressing the contextual influences at the neighbourhood-
level [9, 43–45].
Conversely, the small but significant positive inter-
action between higher proportions of neighbourhood-
level post-secondary education and cigarettes/day
found that heavy smokers may benefit the most by liv-
ing in higher educated neighbourhoods (Fig. 2b). This
type of cross-level effect has been observed in other
epidemiological scenarios where higher risk individuals
have better outcomes than would be expected due to
some beneficial capacity of the neighbourhood context
[11, 22]. The mechanisms by which neighbourhood-
level factors affect individual health is indirectly exerted
through individual-level processes, such as behaviours,
adaptations and attitudes which may be transmitted be-
tween people [46, 47]. Meng et al. found that low edu-
cation neighbourhoods exert an impact on low birth
weight and preterm birth through unhealthy behav-
iours, psycho-social stress (i.e. sense of control) and
SES-related support [21]. Therefore it could be that
smoking cessation rates in pregnancy are higher in bet-
ter educated neighbourhoods where healthier behav-
iours are more common [48, 49]. Fig. 2b suggests that
living in higher educated neighbourhoods may encour-
age moderate and heavy smokers to reduce their smok-
ing frequency to less than five cigarettes/day.
Neighbourhood social supports and transmission of
behaviours could also explain the observed interactions
with higher immigrant density and rural address, albeit
in opposite directions. The positive interaction between
higher immigrant density and maternal smoking (Fig. 2d)
may reflect the buffering effect of strong community co-
hesiveness and beneficial cultural practices [21, 43, 47].
Conversely, the observed negative interaction between
rural address and cigarettes/day (Fig. 2e) could be due to
the transmission of negative behaviours due to such be-
haviours being more common [50], and where less sup-
port for cessation may lead to smoking throughout
pregnancy [51]. The dichotomized definition used to
represent rural residential addresses may obscure mech-
anisms which can be modified by maternal factors such
as education [52].
The buffering effect of PM2.5 with increased levels of
maternal smoking (Fig. 2c) is curious but could provide
evidence for a protective pre-conditioning stress that ac-
tivates an adaptive response and increases biological re-
sistance to cigarette-induced harms [53, 54]. We found a
similar positive interaction between suspected alcohol
and drug use and PM2.5 in a different analysis [55]. The
suspicion of survival bias due to competing risks was
partly mitigated by using a near full population sample
that included stillbirths, congenital anomalies and
Erickson et al. BMC Public Health (2016) 16:585 Page 9 of 12
10. preterm births, although we were not able to control for
fetal loss prior to 20 weeks gestation. Other explanations
require further scrutiny as evidence of the opposite
(negative and synergistic) effect between smoking and
air pollutants has been shown [10, 16].
We have shown in an earlier paper that women who
reported smoking 10 or more cigarettes/day at their first
prenatal visit were significantly more likely to have other
maternal risk factors, such as lower education, suspected
drug or alcohol use, and fewer prenatal care visits [4].
Our current results compliment the previous study by
showing that the cumulative impact of multiple risk fac-
tors can have more than an additive effect on birth
weight reduction. The negative association between
older maternal age and birth weight was markedly
greater with increased levels of maternal smoking, par-
ticularly among the heaviest smoking group (Fig. 3a).
Similarly, those who reported higher levels of smoking
who were also suspected of drug or alcohol use showed
a pronounced effect compared to those who reported to
not smoke (Fig. 3b). These results corroborate the estab-
lished literature showing similar synergistic interactions
between both maternal alcohol use and smoking on
lower birth weights [8, 56], as well as between maternal
smoking and older maternal age on birth weight [7, 57].
While the application of multilevel models in perinatal
epidemiology have become more common [58], most
have been random-intercept models with very few in-
cluding a random-slope parameter. Permitting the slope
for the maternal cigarettes/day exposure to be random
provides information on how its effect on birth weight
differs between neighbourhoods and enables the search
for neighbourhood-level variables to help explain the
between-neighbourhood variance [38]. For example, the
random-slope standard deviation presented in Table 4
drops from 10.7 in Model 1 to 9.0 in the fully adjusted
Model 3. This represents a 30 % change in explained
random-slope variance (10.72
–9.02
/10.72
). Furthermore,
the addition of the level-2 variables explained 68.5 % of
the random-intercept variance compared to the Null
(empty) model. However in light of these findings, sig-
nificant inter-DA variance remained for both the ran-
dom intercept and slope.
This study used self-reports of smoking (cigarettes/
day) recorded at the first prenatal visit; however, there
were no data on exposure to environmental tobacco
smoke or whether smoking reduction or cessation oc-
curred during the pregnancy. The self-reporting bias
of cigarette consumption can lead to the attenuation
of the true effect of smoking on birth weight [59], and
may therefore alter observed interactions. Studies of
smoking misclassification in the United States has es-
timated non-disclosure to be around 20 % [60, 61].
The demographic predictors of non-disclosure include
former smokers and younger maternal age which
could partially explain the observed interaction be-
tween maternal age and cigarettes/day [61]. Similarly,
recall bias and perceived stigma may result in under-
reporting of actual consumption habits. This could ac-
count for the observed curvilinear effect on birth
weight if women smoking 10 cigarettes/day report
only smoking 5 per day, although England et al. ob-
served a similar slope using urine-cotinine concentra-
tions [40]. While relatively small, sensitivity analyses
regarding the list-wise deletion of observations with
missing smoking data was to exclude potentially at-
risk pregnancies and could therefore alter coefficient
estimates (n = 2501, 1.1 % of sample).
Another limitation includes potential measurement
error and misclassification bias in the PM2.5 exposure
assessment which could affect its estimates. First, the
LUR PM2.5 concentrations may be underestimated
with less variability compared to compiled monitoring
data which could potentially underestimate its associ-
ation with birth weight in certain areas [62]. Also the
PM2.5 LUR model is cross-sectional based on 2006 air
quality monitoring data, and we therefore assume that
the study population was exposed to the same levels
of PM2.5 across 6 year study period based on their
residential DA. Finally, our analysis was based on ma-
ternal place of residence at delivery, and therefore
intra-urban commuting and potential inter-urban
relocation within the pregnancy period was not
accounted for. Time-activity patterns show that preg-
nant women spend more time at home in the later
stages of pregnancy, but mobility patterns may differ
by age, parity and SES [63, 64].
A main strength of this study is the quality of the
perinatal registry data [65]. The near 100 % ascertain-
ment of birth records for the province of BC and qual-
ity control measures used in database management
practices produces highly reliable data on maternal
and newborn health outcomes, co-morbidities and
exposures. However, the inability to control for
individual-level SES, particularly maternal education,
may influence the neighbourhood-level effect esti-
mates and interactions. Maternal education is a vari-
able provided in the PSBC Perinatal Registry, but was
only available for 10 % of our population cohort. The
adjustment for socially-patterned behavioural risk fac-
tors such as maternal smoking and suspected drug or
alcohol use will control for some individual-level SES
differences [4]. Notwithstanding, our results suggest
that reported number of cigarettes smoked correlates
with a substantial reduction in birth weight and is
modified by socioeconomic, demographic and envir-
onmental risk factors suggesting the information as
provided will help identify those at highest risk.
Erickson et al. BMC Public Health (2016) 16:585 Page 10 of 12
11. Conclusions
The effect of maternal smoking on birth weight is not
constant across geography, but rather is context specific
given the social and physical environment. The use of
random coefficient models revealed neighbourhood-level
differences in how maternal smoking negatively im-
pacted birth weight demonstrating effect modification by
neighbourhood and maternal-level factors. The inclusion
of the DA-level SES, demographic and PM2.5 variables
explained 68.5 % of the random intercept variability in
DA-mean birth weight. However, the random slope vari-
ability was only partially explained by the cross-level
interactions suggesting other contextual factors are in-
volved in determining the magnitude of maternal smok-
ing on birth weight. Further studies are needed to
corroborate our findings and to understand how
neighbourhood-level attributes interact with smoking to
affect birth outcomes.
Acknowledgements
We would like to acknowledge Dr. Scott Venners for his contributions in
obtaining the CIHR Operational grant. We acknowledge the staff at Perinatal
Services BC for their support regarding data access and review of
manuscript. All inferences, opinions, and conclusions drawn in this
publication are those of the authors and do not reflect the opinions or
policies of Perinatal Services BC.
Funding
This publication was funded in part by the Canadian Institute of Health
Research (CIHR) Operational Grant (protocol #: 200903-202069). Funders
provided no role in the design, conduct, data collection, management,
analysis, interpretation, preparation, review and approval of this study.
Availability of data and materials
The Data Sharing Agreement signed with Perinatal Services BC (PSBC) does
not allow for the data to be shared; however, permissions can be granted
under a formal request to and approval from PSBC.
Authors’ contributions
AE was primarily responsible for the study design, acquisition of data,
analysis and interpretation of results, drafting the article and making
revisions. LA critically assessed the concept, study design, analysis and
interpretation of results. LA provided critical edits of the content. Final
approval of submitted manuscript was provided by both authors. LC and AO
provided useful edits on draft manuscripts and input into the manuscript
framework. All authors give final approval of the version to be published.
Competing interests
The authors declare they have no competing financial interests.
Ethics approval and consent to participate
Research ethics board approval was granted by the University of Victoria
(protocol #11-043).
Author details
1
Division of Medical Sciences, University of Victoria, Medical Science Bld.
Rm-104, University of Victoria, PO Box 1700 STN CSC, Victoria V8W 2Y2, BC,
Canada. 2
Department of Geography, University of Victoria, David Turpin Bldg.
Rm-B203, University of Victoria, PO Box 1700 STN CSC, Victoria V8W 2Y2, BC,
Canada. 3
Center for Advanced Research in Environmental Genomics,
University of Ottawa, 20 Marie-Curie, Ottawa K1N 6 N5, ON, Canada.
4
Department of Medical Genetics, University of British Columbia, Vancouver,
BC, Canada.
Received: 30 January 2016 Accepted: 24 July 2016
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