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Interference from metal hardware (piercings; buttons on clothing; and ingested material, e.g. barium) is well documented in bone health assessments by dual-energy X-ray absorptiometry (DXA). It is unknown if iron in hepatic tissue of highly iron-loaded patients could be mistakenly assessed by DXA as bone, and if this would lead to increased areal bone mineral density (aBMD) lumbar spine Z-scores derived by DXA. Our hypothesis is that iron in the liver of heavily loaded patients will artificially raise aBMD in the spine, and thereby lead to an error in the DXA scan. This study consisted of a retrospective chart review and re-analysis of DXA scans from patients with sickle cell disease and thalassemia combined with prospective DXA and liver iron concentration (LIC) measurements from healthy controls. Patients who previously had both a DXA and LIC measurement were compared with controls. aBMD of individual vertebrae were analyzed and grouped by those that may be covered by the liver (L1 or L1/2) with those typically not (L3/4). Subjects were grouped by diagnosis and LIC severity. Phantoms were created to mimic the geometry of iron loaded liver tissue, and analyzed by DXA. A significant effect was observed in the difference of BMD Z-score of L1 and L 3/ 4 when patients with LIC < 1000 were compared to those with >5000 µg Fe/g wet tissue (p = 0.043). A significant relationship was also observed in the difference in aBMD Z-score of L1 and 3/4 when controls were compared to the high iron group (p = 0.037). These findings were supported by phantom experiments. These results suggest that there is a relationship between hepatic iron and increased L1 aBMD Z-scores in highly iron-loaded patients. Given patients with hemoglobinopathies are at increased risk for osteoporosis, clinicians should maintain a higher index of suspicion when diagnosing low bone mass.

Background During 2008, we conducted a statewide survey on beverages served to preschool-aged children in California child care that identified a need for beverage policy. During 2011, the US Department of Agriculture began requiring that sites participating in the Child and Adult Care Food Program (CACFP) make drinking water available throughout the day and serve only low-fat or nonfat milk to children aged 2 years and older. During 2012, the California Healthy Beverages in Childcare law additionally required that all child-care sites eliminate all beverages with added sweetener and limit 100% juice to once daily. Design To assess potential policy effects, we repeated the statewide survey in 2012. During 2008 and 2012, a cross-sectional sample of ∼1,400 licensed child-care sites was randomly selected after stratifying by category (ie, Head Start, state preschool, other CACFP center, non-CACFP center, CACFP home, and non-CACFP home). Results Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P =0.008) and made water available indoors for children to self-serve (77% vs 69%; P =0.001), and fewer sites served whole milk usually (9% vs 22%; P =0.006) and 100% juice more than once daily (20% vs 27%; P =0.038). During 2012, 60% of sites were aware of beverage policies and 23% were judged fully compliant with the California law. Conclusions A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation.

Background: Factors affecting bone calcium deposition across pregnancy and lactation are not well characterized. Objective: The impact of maternal age, calcium intake, raceethnicity, and vitamin D status on the rate of bone calcium deposition (VO+) was assessed across pregnancy and lactation. Design: Stable calcium isotopes were given to 46 women at pre- or early pregnancy (trimester 1), late pregnancy (trimester 3), and 3–10 wk postpartum. Three cohorts were included: 23 adolescents from Baltimore (MD), aged 16.5 6 1.4 y( mean6 SD; Baltimore cohort); 13 adults from California, aged 29.5 6 2.6 y (California cohort); and 10 adults from Brazil, aged 30.4 6 4.0 y( Brazil cohort). The total exchangeable calcium pool, VO+, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D [1,25(OH)2D], parathyroid hormone, and calcium intake were evaluated. Results: At trimester 3, inverse associations between 1,25(OH)2D and VO+ were evident in the Baltimore (P = 0.059) and Brazil (P = 0.008) cohorts and in the whole group (P = 0.029); calcium intake was not a significant determinant of VO+ in any group during pregnancy. At postpartum, a significant positive association was evident between VO+ and calcium intake (P 0.002) and between VO+ and African ethnicity (P 0.004) in the whole group and within the Baltimore and Brazil cohorts. Conclusions: Elevated 1,25(OH)2D was associated with decreased rates of bone calcium deposition during late pregnancy, a finding that was particularly evident in pregnant adolescents and adult women with low calcium intakes. Higher dietary calcium intakes and African ethnicity were associated with elevated rates of bone calcium deposition in the postpartum period. Am J Clin Nutr 2012;96:64–72.

Background The FLU–FOBT Program is an intervention in which nurses provide home fecal occult blood tests (FOBTs) to eligible patients during annual influenza vaccination (FLU) campaigns. The effectiveness of the FLU–FOBT Program when implemented during primary care visits has not been extensively studied. Purpose The effectiveness of the FLU–FOBT Program was tested as adapted for use during primary care visits in community clinics serving multiethnic patients with low baseline colorectal cancer (CRC) screening rates. Design Randomized clinical trial. During intervention weeks, nurses routinely initiated the offering of FOBT to eligible patients who were given FLU (FLU–FOBT group). During control weeks, nurses provided FOBT with FLU only when ordered by the primary care clinician during usual care (FLU-only group). Setting/participants The study was conducted in six community clinics in San Francisco. Participants were patients aged 50–75 years who received FLU during primary care visits during an 18-week intervention beginning on September 28, 2009. Main outcome measures The primary outcome was the change in CRC screening rates in the FLU–FOBT group compared to the FLU-only group at the end of the study period, on March 30, 2010. Multivariate logistic regression analysis was used to determine predictors of becoming up-to-date with CRC screening. Results Data were analyzed in 2010. A total of 695 participants received FLU on FLU–FOBT dates, and 677 received FLU on FLU-only dates. The CRC screening rate increased from 32.5% to 45.5% (+13.0 percentage points) in the FLU–FOBT group, and from 31.3% to 35.6% (+4.3 percentage points) in the FLU-only group (p=0.018 for change difference). For those due for CRC screening, the OR for completing CRC screening by the end of the measurement period was 2.22 (95% CI=1.24, 3.95) for the FLU–FOBT group compared to the FLU-only group. Conclusions FLU–FOBT Program participants were twice as likely to complete CRC screening as those receiving usual care. The FLU–FOBT Program is a practical strategy to increase CRC screening in community clinics. Trial registration # NCT01211379

Background Vietnamese-American women underutilize breast cancer screening. Design An RCT was conducted comparing the effect of lay health workers (LHWs) and media education (ME) to ME alone on breast cancer screening among these women. Setting/participants Conducted in California from 2004 to 2007, the study included 1100 Vietnamese-American women aged ≥40 years who were recruited through LHW social networks. Data were analyzed from 2007 to 2009. Intervention Both groups received targeted ME. The intervention group received two LHW educational sessions and two telephone calls. Main outcome measures Change in self-reported receipt of mammography ever, mammography within 2 years, clinical breast examination (CBE) ever, or CBE within 2 years. Results The LHW+ME group increased receipt of mammography ever and mammography in the past 2 years (84.1% to 91.6% and 64.7% to 82.1%, p Conclusions Increased breast cancer screening by LHWs among Vietnamese-American women. Future research should focus on how LHWs work and whether LHW outreach can be disseminated to other ethnic groups.

Can vision tests predict subsequent loss of acuity? The association between performance on several low contrast spatial vision measures, glare recovery, color discrimination, flicker sensitivity, stereopsis and ocular disease status at baseline and acuity loss 4.4 years later was examined in a large aged random sample with good initial acuity.In univariate analyses, several vision measures, retinal disease status and age were each significant predictors of subsequent acuity loss. In a multiple regression analysis, only low contrast spatial vision was a significant predictor, but the other vision measures, retinal disease status and age were not. For each doubling of low contrast spatial vision threshold at baseline, individuals were more than two times as likely to suffer subsequent significant visual acuity loss.Tests of low contrast spatial vision are strong predictors of significant subsequent visual acuity loss. These findings have implications for clinical trials, clinical management, and acceptance of these measures into clinical practice.

Objectives Determine cesarean delivery (CD) rates and associated demographics among military dependent teenagers. Methods United States military health care claims records of live births from 2003-2006 to 13- through 19-year-old dependent children were analyzed using logistic regression. Results The CD rate rose from 17% in 2003 to 20% in 2006. Rates were significantly higher for ages 18 and 19, for African American sponsors' children, and those who gave birth in a civilian facility. Rates did not differ significantly by sponsor's military rank. Conclusions Teenagers in the military health care system have increasing rates of CD. Independent demographic risk factors for teenage CD include age > 17 years, sponsor's race African American, and delivery at a civilian facility.

Background: Serum retinol decreases transiently during the acute phase response and can thus result in misclassification of vitamin A status. Objective: Our objective was to determine the prevalence of acute phase response activation in a representative sample of the US population, identify the factors associated with this activation, and determine whether persons with an active acute phase response have lower serum retinol concentrations. Design: Data from the third National Health and Nutrition Examination Survey (NHANES III) were analyzed. A serum C-reactive protein (CRP) concentration ≥ 10 mg/L indicated an active acute phase response. Results: Mean serum retinol was lowest in subjects aged < 10 y and increased with age. Concentrations were higher in males than in females aged 20‐59 y. The prevalence of a CRP concentration ≥ 10 mg/L was lowest in subjects aged < 20 y (≤ 4%) and increased with age to a maximum of nearly 15%. An elevated CRP concentration was 2.4-fold greater in females than in males aged 20‐59 y. Serum retinol was lower in subjects with elevated CRP concentrations. Conclusions: Serum retinol increases with age and males have higher mean values than do females aged 20‐59 y. The prevalence of a CRP concentration ≥ 10 mg/L also increases with age, is 2-fold greater in females than in males aged 20‐69 y, and is associated with common inflammatory conditions. Thus, inflammation appeared to contribute to the misclassification of vitamin A status in the NHANES III population, and serum CRP is useful in identifying subjects who may be misclassified. Am J Clin Nutr 2000;72:1170‐8.

Purpose Balancing needs for contraception and cervical cancer screening is challenging for clinicians. We assessed US obstetrician/gynecologists' practices regarding requirement of Pap testing before prescribing oral contraceptive or emergency contraceptive pills. Methods Questionnaires structured as clinical vignettes describing women desiring contraception with different risks of cervical dysplasia were mailed to a national sample of 355 obstetrician/gynecologists. Results A minority (3%) of the 185 obstetrician/gynecologists who responded would refill 12 months of oral contraceptives without requiring Pap testing. However, most would provide a limited supply of oral contraceptives until Pap testing could be performed. A substantial proportion (11–16%) would refuse to prescribe emergency contraception to women who they felt required Pap testing. Younger physicians, those practicing in academic settings and those who follow American Cancer Society guidelines were more willing to prescribe contraceptives without Pap testing. Conclusions Cervical cancer screening continues to limit prescription of routine and emergency contraception by many US obstetrician/gynecologists.