Excess mortality among children discharged from hospital after treatment for diarrhoea in rural Bangladesh.

Five hundred and fifty one children aged between 3 months and 3 years were followed up at home for 12 months after treatment of diarrhoea in a rural treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. During follow up the children were found to have a significantly higher mortality than generally observed in the community. The first three months after discharge appeared to be crucial, some 70% of the deaths occurring in that period. Severely malnourished children (nutritional state below 56% of the American National Center for Health Statistics (NCHS) standard of weight for age ratio) had a risk of death 14 times that of their well nourished counterparts (nutritional state 66% or more of the NCHS standard). The highest mortality occurred in 2 year olds, one in three of the severely malnourished children dying compared with one in 10 of the moderately malnourished. This pattern was not seen in children aged under 2 years. Immediate priority should be given to providing nutritional rehabilitation for malnourished children who contract diarrhoea.     

Association of antecedent malnutrition with persistent diarrhoea: a case-control study.

To determine the effect of nutritional state on persistent diarrhoea a case-control study was carried out on 756 children followed up prospectively for 18 months. Children who developed persistent diarrhoea were compared with population controls and controls with acute diarrhoea. The mean weight for age in the children with persistent diarrhoea (69.9%) was significantly lower than that in the population controls (77.0%) and the diarrhoeal controls (76.2%). Weight for age of less than or equal to 70% was associated with persistent diarrhoea in both case-control analyses (population controls, matched odds ratio 3.25; diarrhoeal controls, matched odds ratio 2.46). The corrected odds (multiple logistic regression) in the two analyses were 3.2 (95% confidence interval 1.3 to 8.1) and 3.4 (1.2 to 9.1). Weight for age of less than or equal to 70% increases the risk of persistent diarrhoea. In an underweight child there is a higher risk of diarrhoea becoming persistent. Prevention of malnutrition and intensive management of acute diarrhoea in malnourished children should help reduce the risk of the diarrhoea persisting.     

Breast feeding,nutritional state,and child survival in rural Bangladesh

The effect of breast feeding on nutritional state, morbidity, and child survival was examined prospectively in a community in rural Bangladesh. Every month for six months health workers inquired about breast feeding and illness and measured arm circumference in an average of 4612 children aged 12-36 months. Data from children who died within one month of a visit were compared with those from children who survived. Roughly one third of the deaths in the age range 18-36 months were attributable to absence of breast feeding. Within this age range protection conferred by breast feeding was independent of age but was evident only in severely malnourished children.In communities with a high prevalence of malnutrition breast feeding may substantially enhance child survival up to 3 years of age.     

Admissions for protein-calorie malnutrition at the National Children's Hospital, Costa Rica, 1975]

The hospital records of 478 children with protein-calorie malnutrition (PCM) were reviewed. These represented all children diagnosed as malnourished during 1975 (3.6 per cent of all hospital admittances in the National Children's Hospital); 52% of the cases were infants less than 6 months of age; 28% had low birth weight, a rate much in excess of the prevalence of low birth weight in the general population of Costa Rica (7%). In general, malnourished children had been weaned early, 75% during the first month of life. A considerable number of children belonged to "malnourishing families" which have particular characteristics favorable to establishment of malnutrition in the family. Thus, 36% of their siblings had also been admitted with malnutrition at a previous date to that of this study.     

Vision screening at 8 and 18 months. Steering Committee of Oxford Region Child Development Project.

OBJECTIVE--To determine the effectiveness of an existing screening programme based in the community for ocular and vision defects in infants considered at increased risk of such defects. DESIGN--Children with ocular or vision defect by the age of 2 were ascertained by searching records. Those from populations at high risk were matched with their results from screening tests. The characteristics of the cases among this population were compared with those of the cases in the remainder of the population. Patterns of referral and age at referral were studied in both groups. SETTING--The study was conducted within Oxfordshire Health District. SUBJECTS--433 Children at high risk born in 1984 to mothers living in the health district at delivery and who either weighed less than 2000 g or weighed 2000 g and over and required admission to a special care nursery for longer than 24 hours. The low risk population (6254) were infants without these characteristics who were resident in the health district at the time of referral. INTERVENTIONS--Screening tests for vision or ocular defects already routinely used were applied by health visitors at 8 and 18 months to the children at high risk. MAIN OUTCOME MEASURE--Comparison of results of screening tests with vision and ocular defects detected by the age of 2. RESULTS--Screening tests in current use for vision loss and squint in this age group were insensitive and had a low positive predictive value when applied to a high risk population. Defects that were not apparent on direct inspection were unlikely to be detected by these tests. In the high risk group the relative risk of having a defect was 2.8 (95% confidence interval 1.8 to 4.5) but 85% of all cases detected by the age of 2 were in children at low risk. Referral patterns and age of referral differed in the two groups. CONCLUSIONS--Screening by health visitors of high risk populations contributes little to the detection of vision and ocular defects. This type of evaluation needs to be applied also to low risk populations, who have different referral patterns and contribute most of the cases.     

Prolonged breast feeding,diarrhoeal disease,and survival of children in Guinea-Bissau.

OBJECTIVE--To analyse the impact of breast feeding on diarrhoeal disease and survival in children above 1 year of age in Guinea-Bissau, west Africa. DESIGN--A community study of an open cohort followed up weekly by interviews over 15 months. Data on feeding practices, anthropometry, and survival were recorded for three years. SETTING--301 randomly selected houses in a semiurban area in the capital, Bissau. SUBJECTS--849 children aged less than 3 years. MAIN OUTCOME MEASURES--Incidence and duration of diarrhoea, weight for age, and death of a child. RESULTS--The incidence of diarrhoea was higher in weaned children than in partially breast fed children, both in 1 year olds (relative risk 1.41; 95% confidence interval 1.23 to 1.62) and in 2 year olds (1.67; 1.29 to 2.15). The mean duration of an episode of diarrhoea was 5.3 days in breast fed children compared with 6.3 days in weaned children (P = 0.001). Independent of the age of weaning, a similar increase was found in an analysis comparing, for each child, the rate and duration of diarrhoea one month before and one month after weaning. Children with low weight for age were breast fed longer than the better nourished children (P = 0.02). Children aged 12-35 months who were not breast fed had a 3.5 times higher mortality (1.4 to 8.3) than breast fed children. CONCLUSIONS--The beneficial effects of breast feeding are not restricted to infancy. Though children who are partially breast fed after infancy may have a lower state of nutrition than the weaned ones, the benefit in terms of lower morbidity may be more important for child survival in places with a high morbidity from diarrhoea and with high mortality.     

Nutrition survey in an elderly population following admission to a tertiary care hospital

BACKGROUND: Malnutrition in elderly patients in institutions has become an issue of clinical concern, but it remains largely unrecognized in acute care hospitals. The demonstrated benefits of intervention emphasize the need for routine nutritional assessment. The objectives of this study were to determine the prevalence of malnutrition in elderly patients admitted to a tertiary care centre and to test the sensitivity and specificity of 3 nutrition screening tools. METHODS: Between July and November 1996 patients 65 years and older were consecutively recruited from the general medicine, orthopedics, general surgery and neurosciences services of The Ottawa Hospital--General Campus within 72 hours of admission. They were interviewed using 3 nutritional screening tools: one developed by Chandra and colleagues (Chandra), the Nutrition Screening Initiative (NSI) and the Mini Nutritional Assessment (MNA). A detailed nutrition assessment was then undertaken, which included anthropometric assessment, laboratory tests, determination of risk factors and assessment of dietary intake. A dietitian blinded to the screening results classified each patient as being well nourished, at risk for malnutrition or malnourished. The prevalence of malnutrition was assessed, and screening results were compared with the results of the detailed nutrition assessment for sensitivity and specificity. RESULTS: In total, 160 patients (86 women) were recruited. Detailed nutrition assessments were completed for 152 patients, of which 62 (40.8%) were found to be well nourished, 67 (44.1%) at moderate risk for malnutrition and 23 (15.1%) malnourished. Matched comparisons showed that, of the 23 malnourished patients, 1 was found to be at high risk for malnutrition using the Chandra screening tool, 9 using the NSI and 4 using the MNA, giving sensitivities of 32%, 54% and 57%, and specificities of 85%, 61% and 69%, respectively. INTERPRETATION: Given the high rate of malnutrition or risk of malnutrition in this study, admitting physicians need to be aware of this problem and its scope. The 3 screening tools tested performed poorly in comparison with the detailed nutrition assessment. This may have been because the score thresholds for the screening tools were set for screening purposes and because the screening tools were designed for different settings and a wider population.     

Who is nutritionally vulnerable in Bosnia-Hercegovina?

OBJECTIVE--To monitor nutritional status and food security in order to identify nutritionally vulnerable groups. DESIGN--Members of five different household groups (urban and rural residents, displaced people in collective centres and private accommodation, elderly people living without younger family) and all residents of two old people''s homes were prospectively followed. Households were selected from 20 local communities and nine collective centres. SETTING--Monitoring carried out in three besieged areas of Bosnia-Hercegovina (Sarajevo, Tuzla, and Zenica). SUBJECTS--1739 individuals sampled. INTERVENTIONS--Data collected every month from December 1993 to May 1994. Information on household food security was collected through structured questionnaires. All subjects were weighed and their heights measured. Weight for age Z scores were calculated for children; body mass index was calculated for adults and elderly people. RESULTS--From December 1993 to February 1994, before a temporary cease fire, access to food was reduced. In February 1994 no significant signs of undernutrition were detected among children or adults, but elderly people had higher than expected levels of undernutrition (15.5% with body mass index < 18.5), a higher rate of weight loss than adults (1.2 kg over two months), and a higher prevalence of self reported illness. CONCLUSIONS--Elderly people in Bosnia-Hercegovina are at greater risk of undernutrition than other age groups. Undernutrition may be precipitated in elderly people by sickness, cold, stress, and problems related to food preparation. The health and welfare of elderly people during the emergency in Bosnia-Hercegovina require special attention, and integrated age care programmes are needed.     

Young Children's Probability of Dying Before and After Their Mother's Death: A Rural South African Population-Based Surveillance Study

Background

There is evidence that a young child''s risk of dying increases following the mother''s death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother''s death, as well as for several months after her death. Therefore we investigated the relationship between young children''s likelihood of dying and the timing of their mother''s death and, in particular, the existence of a critical period of increased risk.

Methods and Findings

Data from a health and socio-demographic surveillance system in rural South Africa were collected on children 0–5 y of age from 1 January 1994 to 31 December 2008. Discrete time survival analysis was used to estimate children''s probability of dying before and after their mother''s death, accounting for moderators. 1,244 children (3% of sample) died from 1994 to 2008. The probability of child death began to rise 6–11 mo prior to the mother''s death and increased markedly during the 2 mo immediately before the month of her death (odds ratio [OR] 7.1 [95% CI 3.9–12.7]), in the month of her death (OR 12.6 [6.2–25.3]), and during the 2 mo following her death (OR 7.0 [3.2–15.6]). This increase in the probability of dying was more pronounced for children whose mothers died of AIDS or tuberculosis compared to other causes of death, but the pattern remained for causes unrelated to AIDS/tuberculosis. Infants aged 0–6 mo at the time of their mother''s death were nine times more likely to die than children aged 2–5 y. The limitations of the study included the lack of knowledge about precisely when a very ill mother will die, a lack of information about child nutrition and care, and the diagnosis of AIDS deaths by verbal autopsy rather than serostatus.

Conclusions

Young children in lower income settings are more likely to die not only after their mother''s death but also in the months before, when she is seriously ill. Interventions are urgently needed to support families both when the mother becomes very ill and after her death. Please see later in the article for the Editors'' Summary     

Long-Term Survival of Individuals Born Small and Large for Gestational Age

Background

Little is known on long-term survival and causes of death among individuals born small or large for gestational age. This study investigates birth weight in relation to survival and causes of death over time.

Methods

A national cohort of 1.7 million live-born singletons in Denmark was followed during 1979–2011, using the Danish Civil Registration System, the Medical Birth Registry and the Cause of Death Registry. Cox proportional hazards were estimated for the impact of small (SGA) and large (LGA) gestation weight and mortality overall, by age group and birth cohort.

Results

Compared to normal weight children, SGA children were associated with increased risk of dying over time. Though most of the deaths occurred during the first year of life, the cumulative mortality risk was increased until 30 years of age. The hazard ratios [HR] for dying among SGA children ages <2 years were: 3.47 (95% CI, 3.30–3.64) and 1.06 (95% CI, 0.60–1.87) in 30 years and older. HR for dying among SGA adults (20–29 years) were: 1.20 (95% CI, 0.99–1.46) in years 1979–1982 and 1.61 (95% CI, 1.04–2.51) in years 1989–1994. The SGA born had increased risk of dying from infection, heart disease, respiratory disease, digestive disease, congenital malformation, perinatal conditions, and accidents, suicide, and homicide. Individuals born LGA were associated with decreased mortality risk, but with increased risk of dying from malignant neoplasm.

Conclusions

Survival has improved independently of birth weight the past 30 years. However, children born SGA remain at significantly increased risk of dying up till they turn 30 years of age. Individuals born LGA have lower mortality risk but only in the first two years of life.     

Plasma fibronectin levels in acute and recovering malnourished children

58 malnourished children (mean age 18 months) with a clinical diagnosis of marasmus or kwashiorkor were studied with respect to plasma fibronectin levels, plasma total solids, spun hematocrits, heights, weights, mid-arm circumferences, and head circumferences. Bimodal distributions were demonstrated for plasma fibronectin versus weight deficits, total solids, hematocrits, and mid-arm circumference in children 12 months of age and older (p less than 0.003 for all). The mean plasma fibronectin level for controls was 253 micrograms/ml. The mean level for the malnourished group was 96 micrograms/ml (p less than 0.0001). Malnourished children with initial plasma fibronectin levels above 100 micrograms/ml had a higher survival rate than those with levels less than 100 (92 versus 69%). With successful therapy, plasma fibronectin levels rose quickly in most children often before detectable changes were noted in clinical and other laboratory parameters. An overshoot of the mean normal levels was observed with successful treatment wherein the mean levels rose to 315 micrograms/ml (p less than 0.05). Plasma fibronectin determinations on malnourished children can serve as an important prognostic marker as well as a reliable indicator of successful therapy and recovery.     

Dramatic Rise in Overweight and Obesity in Adult Filipino Women and Risk of Hypertension

Objective:To assess trends in BMI of adult Filipino women over a 16‐year period of rapid socioeconomic change; to identify factors associated with those trends; and to estimate the risk of hypertension associated with overweight, obesity, and high waist‐to‐hip ratio (WHR). Research Methods and Procedures:Women from randomly selected urban and rural communities of Metro Cebu, Philippines were recruited during a 1983 to 1984 index pregnancy, then followed prospectively for 16 years. Overweight and obesity were defined using BMI cut‐off points of 25 and 30, respectively. The analysis sample included women 15 to 45 years of age when measured 4 months postpartum. Weight change in subsequent intervals from 1985 to 1999 was modeled using linear regression. The relationship of BMI and WHR to risk of hypertension in the last survey was modeled using logistic regression. Results:The prevalence of overweight and obesity combined increased nearly 6‐fold from ～6% in 1983 to 1984 to 35% in 1998 to 1999. Weight gain was positively associated with urban residence, improved socioeconomic status, fewer pregnancies and months of lactation, and more away‐from‐home work hours. Risk of hypertension was independently elevated by high WHR and overweight/obesity. Discussion:The dramatic trend of increasing overweight and obesity in this sample of women represents a serious health concern, especially in light of the strong association of excess weight, particularly in the truncal region, to risk of hypertension.     

Premature parental heart attack is heralding elevated risk in their offspring

A small subgroup of children, whose parents have suffered a heart attack in their late thirties and early forties, may be at particularly high cardiovascular risk. University Hospital "Split" gives tertiary health care to some 700,000 people in southern Croatia and treats about 300 acute myocardial infarctions per year, with a 3-5% share in the age under 45 years. This cross-sectional, clinical and laboratory study included all the patients below the age limit of 45 years, treated for acute myocardial infarction between 1990 and 1995, complexively 55 of them, and their natural children, 97 all in all. The results were compared to those of a stratified children's sample taken from the population of the same region. The relative weight, blood pressure, and plasma cholesterol were significantly higher in these children than in the control group (p < 0.05). In 50 of these offspring (51.5%), in addition to the obviously positive family history, detected were further cardiovascular risk factors, defined as values above the 95th distribution percentile for age and gender. The average blood pressure, relative weight and cholesterol levels were even higher in these, "risky" children than in the studied sample (p < 0.05), and much more elevated than in the matching control pupils (p < 0.001). The most often detected risk factors were elevated cholesterol (in 44%), arterial hypertension (in 40%), obesity (in 32%), and smoking (in 24%). Most of the children (64%) had only one additional risk factor, while in the remaining 36% the most prevalent risk factors were overweight (in 14 out of 18) and arterial hypertension (in 11 out of 18). It is concluded that cardiovascular risk factor screening among children with a positive family history of premature atherosclerotic complications is appropriate and cost-effective.     

Cholesterol screening of children at high risk: behavioural and psychological effects

OBJECTIVE: To assess the behavioural and psychosocial effects of screening asymptomatic children at high risk for hyperlipidemia. DESIGN: Observational study involving prospective longitudinal and cross-sectional portions. SETTING: Two tertiary care pediatric lipid clinics in Montreal. SUBJECTS: Longitudinal portion: all children aged 4 to 17 years who presented for screening at the lipid clinics between April 1990 and June 1991. Of the 56 eligible children 52 (93%) (and their mothers) agreed to participate, 34 with hyperlipidemia (case subjects) and 18 without hyperlipidemia (control subjects). Thirty-five children (67%) completed 3 assessments over 12 months. Cross-sectional portion: all children aged 4 to 17 years in whom hyperlipidemia had been diagnosed 2 to 5 years earlier at one of the lipid clinics. Of the 58 eligible children 48 (83%) (and their mothers) participated. OUTCOME MEASURES: For children, mean scores on the Child Behavior Checklist (Behavior Problems subscale) (CBCL), the Children''s Depression Inventory (CDI) and the State-Trait Anxiety Inventory for Children (STAIC); for mothers, mean scores on the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI). RESULTS: In the longitudinal portion of the study, there was no significant difference between the case and control subjects in the mean CDI or STAIC scores at 1 or 12 months. At 1 month after diagnosis the case subjects in the longitudinal portion had a significantly higher mean CBCL score than the children in the cross-sectional component (p = 0.01). With the control group as the reference group, the adjusted odds ratios for a high CBCL score (greater than 62) for the case subjects were 15.5 (95% confidence interval [CI] 2.4 to 99.8) at 1 month and 15.8 (95% CI 1.1 to 223.4) at 12 months. The corresponding values for the children in the cross-sectional component were 1.3 (95% CI 0.3 to 6.2) and 5.0 (95% CI 0.5 to 50.9). CONCLUSIONS: The observed behavioural problems in children with a recent diagnosis of hyperlipidemia were independent of other risk factors, such as age and sex of child and mother''s age and BDI score. Our results suggest that identification of hyperlipidemia in children may have harmful psychological effects in the families involved. This evidence strengthens arguments for the exclusion of cholesterol measurement from the periodic health examination of children at moderately high risk.     

Reliability and effectiveness of screening for hearing loss in high risk neonates.

OBJECTIVE--To establish the reliability and effectiveness of screening for hearing loss by brainstem auditory evoked potential testing in high risk neonates. DESIGN--Seven year investigation of newborn babies admitted to a special care baby unit and monitored through a regional children''s audiology unit. SETTING--Special care baby unit and children''s audiology department, Belfast. SUBJECTS--405 neonates admitted to the baby unit, during 1 October 1982 to 31 March 1987. MAIN OUTCOME MEASURES--Presence of hearing impairment, type and severity of hearing impairment, mortality. RESULTS--85 children failed the screening test, 62 of whom were followed up. Five children had severe bilateral sensorineural impairment and 12 had conductive impairment requiring surgical intervention. A further 18 had severe neurological disorder detected. The sensitivity of screening was 100% and specificity was 88%. If the procedure was introduced into routine clinical practice the mean age at diagnosis for all children with severe perinatal hearing impairment would be 11 (median 1) months. The mean age at diagnosis with the health visitor screening service was 23 (19) months (difference 10 months, 95% confidence interval 6 to 16 months; p < 0.0001). CONCLUSION--Screening for hearing loss in high risk neonates is highly reliable and cost effective. It also provides valuable neurophysiological information. Routine testing of these infants would result in over half of all children with severe bilateral perinatal sensorineural hearing impairment being identified by 2 months of age. This would make an important contribution to the habilitation of this socially, emotionally, and educationally vulnerable group.     

Impact of Weight Loss and Regain on Quality of Life: Mirror Image or Differential Effect?

Objective: To compare the impact of weight regain and weight loss on health‐related quality of life. Research Methods and Procedures: Subjects were 122 (106 women, 16 men) overweight and obese participants in a weight reduction program (phentermine‐fenfluramine and dietary counseling) who had initially lost at least 5% of their total body weight and then regained at least 5% of their weight during the follow‐up period. Follow‐up periods ranged from 10 to 41 months (mean, 28 months). Participants completed the Impact of Weight on Quality of Life‐Lite, an obesity‐specific health‐related quality of life (HRQOL) measure, at 3‐month intervals. Results: Mean BMI at baseline was 40.9 ± 6.6 kg/m² (range, 29.2 to 63.7 kg/m²). Average weight loss from entry was 18.8 ± 6.7% (range, 6.0% to 43.7%), and average regain was 10.1 ±4.4% of baseline weight (range, 5.0% to 30.6%). The effects of weight regain on HRQOL mirrored the effects of weight loss—rates of HRQOL change were similar in magnitude but different in direction for comparable weight loss and regain. Those with more severe initial impairments in HRQOL experienced greater improvements in HRQOL during weight loss as well as greater deterioration during weight regain than those with less severe impairments. Discussion: Weight loss and regain produced mirror image changes in HRQOL. The initial severity of HRQOL impairment had a greater impact on the magnitude of HRQOL change than the direction of weight change. Findings underscore the importance of maintaining weight loss for the purposes of retaining obesity‐specific HRQOL benefits.     

Teenage motherhood and infant mortality in Bangladesh: maternal age-dependent effect of parity one

Nuptiality norms in rural Bangladesh favour birth during the teenage years. An appreciable proportion of teenage births are, in fact, second births. This study examines the relationship between teenage fertility and high infant mortality. It is hypothesized that if physiological immaturity is responsible, then the younger the mother, the higher would be the mortality risk, and the effect of mother's 'teenage' on mortality in infancy, particularly in the neonatal period, would be higher for the second than the first births. Vital events recorded by the longitudinal demographic surveillance system in Matlab, Bangladesh, in 1990-92 were used. Logistic regression was used to estimate the effects on early and late neonatal (0-3 days and 4-28 days respectively) and post-neonatal mortality of the following variables: mother's age at birth, parity, education and religion, sex of the child, household economic status and exposure to a health intervention programme. The younger the mother, the higher were the odds of her child dying as a neonate, and the odds were higher for second children than first children of teenage mothers. First-born children were at higher odds of dying in infancy than second births if mothers were in their twenties. Unfavourable mother's socioeconomic conditions were weakly, but significantly, associated with higher odds of dying during late neonatal and post-neonatal periods. The results suggest that physical immaturity may be of major importance in determining the relationship between teenage fertility and high neonatal mortality.     

Factors influencing prereproductive mortality in the isolated and preindustrial western Mediterranean population of La Alpujarra, 1900-1950

We study the effects of several variables on the prereproductive mortality pattern in the isolated and rural population of La Alpujarra, located on the western Mediterranean coast (southeast Spain), in the first half of the 20th century. The study is a retrospective analysis from a total sample of 2,200 deliveries, 2,085 of which were born alive and 171 of which did not survive to the 20th birthday. The potential influences of birthdate of children, twinning, firstborn, parental inbreeding, and sex on Alpujarran mortality were analyzed through logistic regression. Parity, family size, and birth interval effects were estimated through the difference between observed and expected mortality rates. In every case four age groups of mortality were considered because of the large influence of child growth: neonatal (less than 1 month of life), postneonatal infant (between 1 month and 1 year old), childhood (1-5 years old), and youth (5-20 years old). The Alpujarran prereproductive mortality pattern can be summarized as the result of three main risk factors: biodemographic, biomechanical, and social and health determinants. In general, every factor showed a decreased effect as children grew. The most significant determinants were birthdate of children, which is more related to increased mother's awareness of child care than to health improvement, and family size associated with decreasing alimentary resources as the sibling number increased. Male mortality was higher than female mortality in children older than 1 year but not for infant mortality, possibly as a result of a reproductive behavior favorable to males. Although firstborn status and twinning appeared associated with high mortality, maternal age and birth interval were related to low risk, but these influences always ceased after the first month of life. Parental inbreeding did not show any effect on infant, childhood, or youth mortality.     

Waist Circumference as a Screening Tool for Cardiovascular Risk Factors: Evaluation of Receiver Operating Characteristics (ROC)

To evaluate the receiver operating characteristics (ROC) to determine the cutoffs of waist circumference as a potential population directed screening tool for hypercholesterolaemia (≥6.5 mmol/L), low high density lipoprotein cholesterol (<0.9 mmol/L), and hypertension (treated and/or systolic ≥160 and/or diastolic blood pressure ≥95 mmHg), in 2183 men and 2698 women aged 20 to 59 years selected at random from Dutch civil registries. Main outcome measures: Height, weight, body mass index (BMI), waist circumference, total plasma cholesterol and high density lipoprotein cholesterol concentrations, and blood pressure. Results: ROC curves showed that sensitivity equalled specificity at waist circumferences between 93–95 cm in men and 81–84 cm in women for identifying individual risk factors, and 92 cm in men and 81 cm in women for identifying those with at least one risk factor. Sensitivity and specificity were equal at levels between 61% to 69% for identifying individual risk factors, with positive predictions (56.8% in men and 37.8% in women) within 2% of those using previously defined ‘Action Level 1’ of waist circumference 94 cm in men and 80 cm in women (58.8% in men and 37.4% in women). Risk prediction by anthropometric methods was relatively low: ROC areas for identifying each risk factor by waist varied from 55% to 60%, and reached about 65% for identifying at least one risk factor. Height accounted for less than 03% of variance in waist circumference. Using BMI at 25 kg/m² gave similar prediction to waist, but its combination with waist did not improve predictive values. Conclusions: Measurement of waist circumference ‘Action Level 1’ at 94 cm (37 inches) in men and 80 cm (32 inches) in women could be adopted as a simpler valid alternative to BMI for health promotion, to alert those at risk of cardiovascular disease, and as a guide to risk avoidance by self-weight management     

Obese women's barriers to mammography and pap smear: the possible role of personality

Obese women are at increased risk of developing and dying from cancer, but are less likely than nonobese women to receive cancer screening examinations. Our qualitative study explores obese women's barriers to Pap smears and mammograms in greater depth than previous research. We also seek to understand why some obese women undergo screening whereas others do not. A purposive sample of moderately to severely obese women over age 40 was recruited from community-based organizations, health clinics, and retail establishments. Semi-structured in-depth interviews (N = 33) informed by the Theory of Care-Seeking Behavior and three prior focus groups of obese women (N = 18) were recorded and transcribed. Qualitative analysis was iterative, using a grounded theory approach involving a series of immersion/crystallization cycles. Participants verified many barriers to cervical and breast cancer screening previously identified in the general population, including fear, modesty, competing demands, and low perceived risk. Participants also highlighted several weight-related barriers, including insensitive comments about weight and equipment and gowns that could not accommodate them. Comparison of participants who were up-to-date with both Pap smears and mammograms with those not up-to-date with either screening showed no discernable differences in these barriers, however. Instead, we found that the participants who followed through on their cancer screenings may share certain personality traits, such as conscientiousness or self-regulatory ability, that allow them to complete difficult or feared tasks. Our research therefore suggests that personality may act as an important mediator in health behavior, and should be taken into account in future theoretical models and health behavior interventions, particularly for obese women.