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Background In low-resource settings, urbanization may contribute to the individual-level double burden of malnutrition (DBM), whereby under- and overnutrition co-occur within the same individuals. Objective We described DBM prevalence among Malawian women by urban-rural residence, examined whether urban residence was associated with DBM, and assessed whether DBM prevalence was greater than the prevalence expected by chance given population levels of under- and overnutrition, which would suggest DBM is a distinct phenomenon associated with specific factors. Methods We analyzed nationally representative data of 723 nonpregnant women aged 15-49 y from the 2015-2016 Malawi Micronutrient Survey. DBM was defined as co-occurring overweight or obesity (OWOB) and ≥1 micronutrient deficiency or anemia. We used Poisson regression models to examine the association between urban residence and DBM and its components. The Rao-Scott modified chi-square test compared the observed and expected DBM prevalence. Results Nationally, 10.8% (95% CI: 7.0, 14.5) of women had co-occurring OWOB and any micronutrient deficiency and 3.4% (95% CI: 1.3, 5.5) had co-occurring OWOB and anemia. The prevalence of co-occurring OWOB and any micronutrient deficiency was 2 times higher among urban women than rural women [urban 32.6 (24.1, 41.2) compared with rural 8.6 (5.2, 11.9), adjusted prevalence ratio: 2.0 (1.1, 3.5)]. Co-occurring OWOB and anemia prevalence did not significantly differ by residence [urban 6.9 (0.6, 13.2) compared with rural 3.0 (0.8, 5.3)]. There were no statistically significant differences in observed and expected prevalence estimates of DBM. Conclusions This analysis shows that co-occurring OWOB and any micronutrient deficiency was higher among women in urban Malawi compared with rural areas. However, our finding that co-occurring OWOB and any micronutrient deficiency or anemia may be due to chance suggests that there may not be common causes driving DBM in Malawian women. Thus, there may not be a need to design and target interventions specifically for women with DBM.

ObjectivesAssess differences in movement behaviours within the 24-hour cycle, including light intensity physical activity (LPA), moderate-to-vigorous physical activity (MVPA), sedentary time and sleep, before and during the COVID-19 pandemic and assess these differences stratified by several relevant factors in a subcohort of the Cancer Prevention Study-3.Design and settingUS-based longitudinal cohort study (2018–August 2020).ParticipantsN=1992 participants, of which 1304 (65.5%) are women, and 1512 (75.9%) are non-Latino white, with a mean age 57.0 (9.8) years.MeasuresAge, sex, race/ethnicity, education; self-reported LPA, MVPA, sedentary time and sleep duration collected before and during the pandemic; pandemic-related changes in work, childcare and living arrangement; COVID-19 health history.ResultsCompared to 2018, participants spent an additional 104 min/day sedentary, 61 fewer min/day in LPA and 43 fewer min/day in MVPA during the pandemic. Time spent sleeping was similar at the two time points. Differences in movement behaviours were more pronounced among men, those with a higher level of education, and those who were more active before the pandemic.ConclusionsFrom 2018 to Summer 2020, during the COVID-19 pandemic, US adults have made significant shifts in daily time spent in LPA, MVPA and sedentary. There is an urgent need to promote more physical activity and less sedentary time during this public health crisis to avoid sustaining these patterns long-term.

Background Diabetes poses a heavy burden on patients due to its progressive and chronic nature; it requires continuous management to promote a high-quality and long life. Disease management is especially challenging in emergency settings. We examined how displaced people with diabetes experienced managing their illness before and throughout the process of fleeing their home communities and seeking resettlement in Europe. Design We designed an interview instrument with closed- and open-ended questions about diabetes diagnosis and management before fleeing the home country, during migration, stays in transit countries, and reception in the European Union. We interviewed 20 asylum seekers living in Belgian reception centres with diagnosed diabetes mellitus. Results Primary topics emerging from interviews were availability, accessibility, and quality. Belgium was described as a setting with high availability, accessibility, and quality of diabetes management components (medication, tools, care) compared to other settings before and during migration. Even in Belgium, maintaining a healthy diet as an asylum seeker was difficult. Other concerns such as safety, other health issues, and the asylum request itself often outweighed diabetes management. Conclusions Displaced people in non-western countries need attention for nutrition and diabetes medicine, so aid agencies should consider providing for those needs. For people seeking asylum in the West and living in temporary facilities, care should be paid to the dietary options available for those with diabetes. For irregular migrants, diabetes can be deadly, and resources should be made available for their basic diabetes needs, even if they are not eligible for regular health services.

Low socioeconomic position (SEP) across the lifecourse is associated with Type 2 diabetes (T2DM). We examined whether these economic disparities differ by race and sex. We included 5448 African American (AA) and white participants aged ≥45 years from the national (United States) REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort without T2DM at baseline (2003–07). Incident T2DM was defined by fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or using T2DM medications at follow-up (2013–16). Derived SEP scores in childhood (CSEP) and adulthood (ASEP) were used to calculate a cumulative (CumSEP) score. Social mobility was defined as change in SEP. We fitted race-stratified logistic regression models to estimate the association between each lifecourse SEP indicator and T2DM, adjusting for covariates; additionally, we tested SEP-sex interactions. Over a median of 9.0 (range 7–14) years of follow-up, T2DM incidence was 167.1 per 1000 persons among AA and 89.9 per 1000 persons among white participants. Low CSEP was associated with T2DM incidence among AA (OR = 1.61; 95%CI 1.05–2.46) but not white (1.06; 0.74–2.33) participants; this was attenuated after adjustment for ASEP. In contrast, low CumSEP was associated with T2DM incidence for both racial groups. T2DM risk was similar for stable low SEP and increased for downward mobility when compared with stable high SEP in both groups, whereas upward mobility increased T2DM risk among AAs only. No differences by sex were observed. Among AAs, low CSEP was not independently associated with T2DM, but CSEP may shape later-life experiences and health risks.

ObjectivesTo describe temporal trends in child marriage between 1990 and 2019 in a rural sub-district of Bangladesh and characterize relationships between age, time to pregnancy, complications during delivery, and perinatal mortality.DesignHealth and demographic surveillance system.SettingBaliakandi sub-district, Bangladesh.Participants56,155 female residents.Main outcome measuresAnnual proportion of marriages to female residents under 18 years of age, time between first marriage and pregnancy, proportion of births with complications during delivery, and odds of perinatal mortality.ResultsBetween 1990 and 2010, the proportion of marriages to female residents under 18 years of age decreased from 71% to 57%. Most notably, marriages to females aged 10 to 12 years dropped from 22% of all marriages to 3%. In 2019, 53% of all marriages were to females under 18 years. The estimated time between first marriage and pregnancy did not differ by female age at marriage. By 365 days after marriage, the cumulative incidence of pregnancy was approximately 50% for each age group. Adolescent girls were more likely to experience complications during delivery with at least one complication reported for 36% of mothers aged 13 to 15 years, 32% of mothers aged 16 to 17 years, and 23% of mothers aged 18 to 34 years (χ2 test, PConclusionsChild marriage persists in Baliakandi. Over half of all marriages were to child brides and only minor reductions were seen over the past decade. Pregnancies were common among adolescent girls with no evidence of delayed pregnancy after marriage. Compared to adults, adolescents were more likely to experience complications during delivery and perinatal death. Preventing child marriage has substantial social and health benefits for girls and, by doing so, will also contribute to Bangladesh’s commitment to reduce child mortality.

Background: Pregnancy identification and follow-up surveillance can enhance the reporting of pregnancy outcomes, including stillbirths and perinatal and early postnatal mortality. This paper reviews pregnancy surveillance methods used in Health and Demographic Surveillance Systems (HDSSs) in low- and middle-income countries. Methods: We searched articles containing information about pregnancy identification methods used in HDSSs published between January 2002 and October 2019 using PubMed and Google Scholar. A total of 37 articles were included through literature review and 22 additional articles were identified via manual search of references. We reviewed the gray literature, including websites, online reports, data collection instruments, and HDSS protocols from the Child Health and Mortality Prevention Study (CHAMPS) Network and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). In total, we reviewed information from 52 HDSSs described in 67 sources. Results: Substantial variability exists in pregnancy surveillance approaches across the 52 HDSSs, and surveillance methods are not always clearly documented. 42% of HDSSs applied restrictions based on residency duration to identify who should be included in surveillance. Most commonly, eligible individuals resided in the demographic surveillance area (DSA) for at least three months. 44% of the HDSSs restricted eligibility for pregnancy surveillance based on a woman’s age, with most only monitoring women 15-49 years. 10% had eligibility criteria based on marital status, while 11% explicitly included unmarried women in pregnancy surveillance. 38% allowed proxy respondents to answer questions about a woman’s pregnancy status in her absence. 20% of HDSSs supplemented pregnancy surveillance with investigations by community health workers or key informants and by linking HDSS data with data from antenatal clinics. Conclusions: Methodological guidelines for conducting pregnancy surveillance should be clearly documented and meticulously implemented, as they can have implications for data quality and accurately informing maternal and child health programs.

Purpose: This study contributes to the growing literature on the association between sleep and obesity by examining the associations between hours of sleep, consistency of bedtime, and obesity among children in the US. Design: Analysis of a nationally representative sample of non-institutionalized children from the 2016-17 National Survey of Children’s Health. Setting: US, national. Subjects: Children ages 10-17 years (n = 34,640) Measures: Parent reported weeknight average hours of sleep and consistency of bedtime. Body mass index classified as underweight, normal, overweight or obesity using parent-reported child height and weight information, classified using CDC BMI-for-Age Growth Charts. Analysis: Multivariate logistic regression models were used to estimate associations between measures of sleep and body mass index weight category adjusting for individual, household and neighborhood characteristics. Results: An additional hour of sleep was associated with 10.8% lower odds of obesity, net of consistency in bedtime. After controlling for sleep duration, children who usually went to bed at the same time on weeknights had lower odds of obesity (24.8%) relative to children who always went to bed at the same time. Conclusion: Sleep duration is predictive of lower odds of obesity in US children and adolescents. Some variability in weeknight bedtime is associated with lower odds of obesity, though there were no additional benefits to extensive variability in bedtime.

Health and demographic surveillance systems (HDSSs) provide a foundation for characterizing and defining priorities and strategies for improving population health. The Child Health and Mortality Prevention Surveillance (CHAMPS) project aims to inform policy to prevent child deaths through generating causes of death from surveillance data combined with innovative diagnostic and laboratory methods. Six of the 7 sites that constitute the CHAMPS network have active HDSSs: Mozambique, Mali, Ethiopia, Kenya, Bangladesh, and South Africa; the seventh, in Sierra Leone, is in the early planning stages. This article describes the network of CHAMPS HDSSs and their role in the CHAMPS project. To generate actionable health and demographic data to prevent child deaths, the network depends on reliable demographic surveillance, and the HDSSs play this crucial role.

Introduction: The persistence of obesity from adolescent to adult ages is associated with risk of cardiovascular disease later in life. Data from cohorts that passed through childhood before 1980 show that when obesity is first observed in youth it often persists into adulthood. However, less is known about current weight trajectories of adolescents transitioning to adulthood. We examined the changes in weight status from adolescence to adulthood and baseline predictors of normal weight in adulthood. Methods: Study used data from the National Longitudinal Study of Adolescent Health (AddHealth) (n=14,135), a nationally representative sample of adolescents recruited in 1994 and followed up in 1996, 2001, and 2008. Weight and height measurements collected at each visit were used to classify weight status; we identified 4 trajectories between mean ages 16 and 30: 1) maintained normal weight, 2) achieved normal weight, 3) gained weight to enter the obesity category, and 4)maintained overweight or obesity. Logistic regression models included individual and family characteristics. Results: Among adolescents with normal weight, 56% gained weight to enter overweight or obesity categories 14 years later. Of those with overweight at baseline, 68% gained weight to enter obesity and 8% achieved normal weight; among adolescents with obesity, 89% maintained obesity, and only 2% achieved normal weight. After controlling for sex, age, race-ethnicity, and baseline weight status, adolescents who were trying to lose weight, skipped breakfast, ate dinner with their parents, had a mother with diabetes or obesity, a father with obesity, parents with less than high-school education, or married in high-school were less likely to have normal weight as adults. Independent of baseline weight status, adolescents who reported feeling loved were more likely to have normal weight in adulthood. Conclusion: Findings shed light on individual and family factors associated with normal weight outcomes after the transition from adolescence to adulthood.

OBJECTIVE We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse’s diabetes. RESEARCH DESIGN AND METHODS We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999–2017 (n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse’s diabetes status overall and by severity of diabetes. RESULTS Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes. CONCLUSIONS People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse’s diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.

Recent studies in the U.S. have shown that incidence of diagnosed diabetes decreased and prevalence plateaued after 2010 despite a modest increase in obesity prevalence. If the reduction in diabetes incidence is driven by changing obesity levels, prevalence may be an inadequate metric. Therefore, we investigated changes in prevalence and incidence of obesity and diabetes in adults in the United States during a 17 year period, 2001-2017. We analyzed adult (≥20years) anthropometric records and diabetes status (prediabetes and diabetes combined) from the U.S. national representative Panel Study of Income Dynamics, 2001-2017. We used Poisson models to estimate the prevalence biannually from 2001-2017 and incidence of obesity (cases/1000 person years, PY) over 4 periods (2001-2005; 2005-2009; 2009-2013; 2013-2017). All rates were age- and sex-adjusted; survey weights were applied. Prevalence of obesity increased from 20.9% (95% CI, 19.4-22.5) in 2001 to 26.4 (95% CI, 25.0-27.8) in 2009 to 29.5% (95% CI, 28.1-31.0) in 2017 (p The incidence of obesity changed over time: Compared to an obesity incidence of 29.3/1000 PY (95% CI, 26.0-35.5) in 2001-2005, the incidence increased to 31.7/1000 PY (95% CI,29.7-33.7) in 2005-2009, decreased to 28.8/1000 PY (26.3-31.4) in 2009-2013, and increased to 34.0/1000 PY (95% CI, 31.1-36.7) in 2013-2017 (p In contrast to other U.S. studies of diabetes incidence, our results show no decline during the 2010s. This may be explained by our findings of an increasing incidence of obesity in the same population. Disclosure J. NIelsen: None. E. Gregg: None. K. Narayan: None. S.A. Cunningham: None. Funding Independent Research Fund Denmark (DFF-7025-00053B); National Institute of Diabetes and Digestive and Kidney Diseases (P30DK111024, 1R01DK115937)

Introduction: Neighborhood economic conditions are important predictors of incident stroke. Neighborhood economic conditions can be characterized differently but studies have not identified which characterizations are most predictive of incident stroke. Previous work has suggested that the income distribution within the population may be more relevant for chronic disease than the absolute value of median income of the population. This project aims to estimate the effects of neighborhood income and neighborhood income inequality on incidence stroke. Hypothesis: Neighborhood income inequality and absolute neighborhood income will predict incident stroke above and beyond demographic characteristics and individual socioeconomic status. Methods: We used data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national longitudinal study of black and white older adults (N=29,443). Baseline median household income and the Gini coefficient of income inequality at the Census Tract level were obtained from the 2000 decennial census. Both variables were standardized to have a mean of 0 and a standard deviation of 1; z-score of median household income was multiplied by -1 (representing neighborhood income deprivation) to allow for comparability. Using Cox Proportional Hazards analysis we examined the risk of stroke associated with these exposures in separate models. Model 1 was unadjusted, Model 2 was adjusted for demographic characteristics (age, race, sex, marital status), and Model 3 was adjusted for individual socioeconomic characteristics (household income and education). Results: Within Model 1, neighborhood income deprivation (HR: 1.18; 95% CI 1.11-1.24) and neighborhood income inequality (HR: 1.10; 95% CI: 1.05-1.16) were both significantly associated with risk of stroke. The association persisted in Model 2: neighborhood income deprivation (HR: 1.13; 95% CI 1.07-1.20) and neighborhood income inequality (HR: 1.06; 95% CI: 1.00-1.11). Within Model 3, neighborhood income deprivation maintained its positive association (HR: 1.06; 95% CI 1.00-1.13), while neighborhood income inequality was no longer predictive of stroke risk (HR:1.04; 95% CI 0.99-1.10). Conclusions: Neighborhood income deprivation and neighborhood income inequality were similar predictors of incident stroke. The effect of absolute economic resources in a Census Tract was slightly larger than the relative economic standards within a Census Tract. There is a need to investigate other characterizations of neighborhood economic conditions, such as residential income segregation. The findings from this project suggest that there are multiple policy levels that can be used to decrease incident stroke, through decreasing income inequality and improving the absolute economic conditions of deprived neighborhoods.

Background In India, the prevalence of overweight and obesity has increased rapidly in recent decades. Given the association between overweight and obesity with many non-communicable diseases, forecasts of the future prevalence of overweight and obesity can help inform policy in a country where around one sixth of the world's population resides. Methods We used a system of multi-state life tables to forecast overweight and obesity prevalence among Indians aged 20-69 years by age, sex and urban/rural residence to 2040. We estimated the incidence and initial prevalence of overweight using nationally representative data from the National Family Health Surveys 3 and 4, and the Study on global AGEing and adult health, waves 0 and 1. We forecasted future mortality, using the Lee-Carter model fitted life tables reported by the Sample Registration System, and adjusted the mortality rates for Body Mass Index using relative risks from the literature. Results The prevalence of overweight will more than double among Indian adults aged 20-69 years between 2010 and 2040, while the prevalence of obesity will triple. Specifically, the prevalence of overweight and obesity will reach 30.5% (27.4%-34.4%) and 9.5% (5.4%-13.3%) among men, and 27.4% (24.5%-30.6%) and 13.9% (10.1%-16.9%) among women, respectively, by 2040. The largest increases in the prevalence of overweight and obesity between 2010 and 2040 is expected to be in older ages, and we found a larger relative increase in overweight and obesity in rural areas compared to urban areas. The largest relative increase in overweight and obesity prevalence was forecast to occur at older age groups. Conclusion The overall prevalence of overweight and obesity is expected to increase considerably in India by 2040, with substantial increases particularly among rural residents and older Indians. Detailed predictions of excess weight are crucial in estimating future non-communicable disease burdens and their economic impact.

Objective Unhealthy weight is a major global health concern. This study examines unhealthy weight among children in Spain and the role of the home environment therein. Data are from a 2010 national survey of families with children. We examined unhealthy weight among children ages 5–10 years using the WHO Child Growth Standards and used multivariate logistic regression to assess associations with family characteristics. Results There was a high prevalence of unhealthy weight, with only 46% of children at normal weight. Both underweight and obesity were higher among boys (14%; 22%) than girls (13%; 12%). Underweight and obesity were higher among children of mothers with obesity and those with unemployed parents. Obesity was higher among children of mothers who were less educated (35%) and among children of immigrants (19%). We find high levels of unhealthy weight in children, with both underweight and obesity being predicted by the same family environment characteristics. Electronic supplementary material The online version of this article (10.1186/s13104-018-3665-2) contains supplementary material, which is available to authorized users.

Purpose: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent knowledge of SSB-related health risks. Design: Quantitative, cross-sectional. Setting: 2014 SummerStyles survey. Subjects: Nine hundred and ninety parent and adolescent (12-17 years) pairs. Measures: The outcome was self-reported adolescent intake (0, >0 to 0 to Analysis: Separate multinomial logistic regression models were used to estimate adjusted odds ratios (aORs) for adolescent SSB intake ≥1 time/day (ref: 0 times/day), according to (1) parent SSB intake and (2) parent and (3) adolescent knowledge. Results: About 31% of adolescents consumed SSBs ≥1 time/day, and 43.2% of parents consumed SSBs ≥2 times/day. Adolescent and parent knowledge that SSB intake is related to health conditions ranged from 60.7% to 80.4%: weight gain (75.0% and 80.4%, respectively), diabetes (60.7% and 71.4%, respectively), and dental caries (77.5% and 72.9%, respectively). In adjusted models, adolescent SSB intake ≥1 time/day was associated with parent intake ≥2 times/day (aOR = 3.30; 95% confidence interval = 1.62-6.74) but not with parent or adolescent knowledge of health risks. Conclusion: Parental SSB intake may be an important factor in understanding adolescent behavior; knowledge of SSB-related health conditions alone may not influence adolescent SSB behavior.

People socially connected with each other often share health risks, possibly due to shared environments and behaviors. In a retrospective cohort study, we examined whether incidence of diabetes was different for individuals with recently diagnosed partners compared to individuals similar on other characteristics but whose partners were never diagnosed with diabetes. We analyzed 2007–11 data from Kaiser Permanente Northern California (KNPC), an integrated health system with >3.5 million members. We estimated annual diabetes incidence controlling for demographic, socio-economic, behavioral, and health characteristics. Using propensity score matching and multivariate logistic regression, we compared odds of incident diabetes among co-residing partners ages 18–89 years of people who had been diagnosed with diabetes during the previous year (in robustness checks up to the previous three years) and people who had never been diagnosed but were similar on observed characteristics. Partners of newly-diagnosed people had annual diabetes incidence of 16.4/1,000, equivalent to10.8 times higher (95%CI: 9.2–12.6) than people whose spouses had never been diagnosed (1.5/1,000). Odds remained higher three years after a spouses’ diagnosis (45.4 vs. 11.7/1,000). Adjusting for other characteristics, odds of diabetes for those with a partner diagnosed in the previous year were 8.7 times higher CI: 7.4–10.2) than among those whose partner had never been diagnosed. Partners of persons with recently-diagnosed diabetes developed diabetes at much higher rates than partners of persons with similar characteristics who were never diagnosed with diabetes. Individuals with a recently diagnosed partner could be considered a high-risk population for screening and prevention.

The gut microbiome is a critical component of an individual’s metabolism and overall health. The prenatal period is marked by unique inflammatory and immune changes that alter maternal gut function and bacterial composition as the pregnancy advances. The composition of the maternal gut microbiome contributes to obstetric outcomes with long-term health sequelae for mother and child. Estrogen and progesterone also impact gut function, especially during the prenatal period. These physiologic changes in pregnancy allow for adjustments in maternal metabolism and weight necessary to support the pregnancy. This article will review the normal hormonal, metabolic and immunologic changes to the maternal gut microbiome throughout the prenatal period, in addition to relevant implications for nurses providing care for pregnant women.

Background The prevalence of obesity and other chronic diseases is increasing in India and around the world. As globalization and social changes are believed to be at the root of these epidemiological changes, these factors must be better understood. This study engaged older adults to gain an important perspective on globalization and health. Methods A free-list instrument and a structured survey were developed and used to gather data on changes in diet, activity, and women’s roles from ten grandmothers in rural India. Results Grandmothers indicated that household chores and food preparation are less labor-intensive and time-consuming due to mechanization and the availability of prepared foods than a generation earlier. Families are more often eating food out, bringing prepared food home, and using ready-made food mixes; adolescents are continuing to eat meals at home, but now snack with friends outside the home more frequently. Conclusions Using both a free-list instrument and a structured survey, grandmothers were able to provide insights about the changing context of dietary patterns and family roles arising with globalization that may be contributing to the rise in chronic disease. Electronic supplementary material The online version of this article (doi:10.1186/s13104-017-2583-z) contains supplementary material, which is available to authorized users.

Weight-related behaviors such as sedentary activity, physical activity, and diet have been the focus of efforts to prevent and reduce the occurrence of obesity and overweight in children, but few longitudinal studies have examined the effects of weight-related behaviors on changes in weight status over time in children. This study examines the effects of weight-related behaviors on subsequent changes in weight during childhood. We used the Early Childhood Longitudinal Study Kindergarten Cohort (ECLS-K), a nationally representative prospective cohort of children in the United States. Data, including anthropometric measures, were collected six times across 1998–2007 (analytic sample = 4938). We employed an autoregressive cross-lagged model in a structural equation model framework to assess the effects of behavioral factors -intake of fruit, vegetables, fast food and sugar-sweetened beverages, television viewing, and physical activity - on weight stability over time. BMI z-scores were highly stable throughout childhood: the standardized parameter estimates of BMI z-scores on subsequent-period BMI z-scores ranged from 0.79 to 0.86. BMI z-scores were least stable between Kindergarten and 1st grade but became highly stable between 3rd and 5th grades. After accounting for prior weight, behavioral factors had little effect on subsequent weight. The most important behavioral factor was TV viewing in the 1st and 3rd grades: an additional hour of daily TV viewing was associated with 0.04 higher BMI z-score. It is important to prevent excessive weight gain early in childhood, as weight patterns are long-lasting; the most important behavioral factor may be limiting children's screen time.

Evidence is accumulating that obesity risks become established early in life. The goal of this systematic review is to assess whether there is evidence that rapid postnatal growth holds different implications for childhood obesity risks for children who experienced different patterns of prenatal growth. We conducted systematic database searches in PubMed and Embase in October 2014 for studies assessing the implications of prenatal and postnatal growth for childhood obesity. The 18 studies meeting inclusion criteria indicated that risks of obesity increased with birthweight; risks of obesity also increased with rapid postnatal growth for children across the birthweight distribution. Fifteen studies indicated that rapid postnatal growth is linearly associated with obesity for children and adolescents of all sizes at birth, with no interaction effect. Three studies reported interaction effects with postnatal growth, conferring additional increased risk of obesity among children and adolescents who were small at birth. Both prenatal and postnatal growth are important risk factors for obesity, and their combined effects should be analyzed further to understand how obesity risks develop early in life.

Objectives This study examines the relationship between alcohol consumption and incident stroke among older adults and tests whether alcohol consumption contributes to observed race and sex differences in stroke. Method Data are from a U.S. national cohort of black and white adults aged 45 and older, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Current and past drinking levels were reported at baseline (2003-2007). Participants who had never had a stroke were followed for adjudicated stroke events through September 2015 (n = 27,265). We calculated Cox proportional hazard models for stroke, adjusting for demographic, socioeconomic, behavioral, and health characteristics. Results Participants, mean age 64.7 years, consumed on average 2.2 drinks/week and experienced 1,140 first-time stroke events over median 9.1 years follow-up. Nondrinkers had a 12% higher risk of stroke than current drinkers; the risk of stroke among nondrinkers largely reflected high risks among past drinkers; these differences were explained by socioeconomic characteristics. Among current drinkers, light drinkers had significantly lower stroke risks than moderate drinkers after accounting for demographic, socioeconomic, behavioral, and health characteristics. Implications of alcohol did not differ between blacks and whites but did differ by sex: Especially among women, nondrinkers, and specifically past drinkers, had higher risks; these differences were largely explained by health characteristics and behaviors. Alcohol did not explain race and sex differences in stroke incidence. Discussion Among older adults, those who used to, but no longer, drink had higher risks of stroke, especially among women; current light drinkers had the lowest risk of stroke.

ObjectiveTo develop and evaluate a Nutrition Transition-FFQ (NT-FFQ) to measure nutrition transition among adolescents in South India.DesignWe developed an interviewer-administered NT-FFQ comprising a 125-item semi-quantitative FFQ and a twenty-seven-item eating behaviour survey. The reproducibility and validity of the NT-FFQ were assessed using Spearman correlations, intra-class correlation coefficients (ICC), and levels of agreement using Bland–Altman and cross-classification over 2 months (NT-FFQ1 and NT-FFQ2). Validity of foods was evaluated against three 24-h dietary recalls (24-HR). Face validity of eating behaviours was evaluated through semi-structured cognitive interviews. The reproducibility of eating behaviours was assessed using weighted kappa (κw) and cross-classification analyses.SettingVijayapura, India.SubjectsA representative sample of 198 adolescents aged 14–18 years.ResultsReproducibility of NT-FFQ: Spearman correlations ranged from 0·33 (pulses) to 0·80 (red meat) and ICC from 0·05 (fruits) to 1·00 (tea). On average, concordance (agreement) was 60 % and discordance was 7 % for food groups. For eating behaviours,κwranged from 0·24 (eating snacks while watching television) to 0·67 (eating lunch at home) with a mean of 0·40. Validity of NT-FFQ: Spearman correlations ranged from 0·11 (fried traditional foods) to 0·70 (tea) and ICC ranged from 0·02 (healthy global foods) to 1·00 (grains). The concordance and discordance were 48 % and 8 %, respectively. Bland–Altman plots showed acceptable agreement between NT-FFQ2 and 24-HR. The eating behaviours had acceptable face validity.ConclusionsThe NT-FFQ has good reproducibility and acceptable validity for food intake and eating behaviours. The NT-FFQ can quantify the nutrition transition among Indian adolescents.

Purpose While high levels of obesity prevalence and incidence have been well documented, there is less research on obesity dynamics over time. In this article, we sought to understand the body mass index (BMI) trajectories in and out of obesity from adolescence to adulthood. Methods We used the National Longitudinal Study of Adolescent to Adult Health to explore American obesity dynamics from mean ages 15–28 years. We analyzed six BMI trajectories from 1994 to 2008 and examined their contextual sociodemographic correlates using ordinal logistic regression models. Results More than 50% of adolescents with normal BMI moved to overweight/obesity by adulthood; only 8% of overweight and 2% of obese adolescents achieved normal BMI in adulthood. While some sociodemographic characteristics such as sex, race/ethnicity, place of residence, and parents’ education were associated with being in certain BMI trajectories among adolescents with normal BMI, they were not so associated among adolescents starting at obesity. Conclusions Transitioning to higher BMI categories was common, whereas the opposite direction was rare. Pathways to obesity prevention might be easier to identify than those to reversal, as contextual factors had more explanatory power for youths with normal BMI than for those with obese BMI.

Background The effectiveness of school-based physical activity interventions for improving cardiopulmonary fitness (CPF) of overweight and obese children is not well established. In this study, we evaluated whether overweight and obese children had similar changes in body mass index (BMI) and CPF as normal weight children after participating in a program for one academic year. Methods Using purposive sampling at the school level, we selected 16 program and 7 control schools in a large metropolitan area in the Southeast during the 2015-2016 academic year. In these schools, 3396 fourth-graders participated with parental consent. Of these, 2332 (68.7%) participated in BMI measures and 1780 (52.4%) in Progressive Aerobic Cardiovascular Endurance Run (PACER) measures for CPF at two time points. Results Students of all weight statuses pre-program did not show changes in BMI after program implementation. All students showed statistically significant improvements in the PACER test at follow-up, regardless of their participation in the program. However, overweight and obese children showed less improvement in CPF level than their normal weight classmates, regardless of their participation in the program. Conclusion Special attention for improving engagements of overweight and obese children may be needed to achieve improvements in their CPF level similar to that of normal weight students.

Background Adolescence is a critical phase of human development that lays the foundation for health in later life. Of the 1.8 billion adolescents in the world, roughly 90% live in low and middle-income countries. Yet most longitudinal studies of adolescent physical activity, sedentary behavior, and sleep come from high-income countries. There is a need for a better understanding of these behaviors to inform obesity and chronic disease prevention strategies. Aims The aim of this study is to identify longitudinal patterns and associations between physical activity, sedentary behavior and sleep in urban South African adolescents. Methods We analyzed data from the Birth-to-Twenty Plus Cohort (Bt20+), a longitudinal study of children in Soweto, Johannesburg, South Africa. Behaviors were self-reported annually between ages 12 and 17 y. We used Latent Class Growth Analysis to group participants into classes based on common longitudinal trajectories of time spent in informal physical activity, organized sports, walking to and from school, sedentary behavior, and school-night and weekend sleep, respectively. We performed group-based multi-trajectory modeling to identify latent clusters of individuals who followed similar trajectories of informal physical activity, organized sports and walking to and from school, and who followed similar trajectories of these three domains together with sedentary behavior and sleep. Results The large majority of males (82%) and all females failed to meet the World Health Organization (WHO) physical activity recommendation for adolescents of 60 min of moderate-vigorous intensity physical activity per day. The physical activity domains clustered together in three multi-trajectory groups that define individuals’ overall physical activity pattern. While two patterns indicated decreases in physical activity throughout adolescence, one pattern, including 29% of the sample in males and 17% of the sample in females, indicated higher levels of activity throughout adolescence. Sedentary behavior and sleep trajectories did not cluster together with the physical activity domains. Conclusion Most adolescents in this South African population did not meet WHO recommendations for physical activity. In this population, trajectories of sedentary behavior and sleep were independent of physical activity. Electronic supplementary material The online version of this article (10.1186/s12887-019-1619-z) contains supplementary material, which is available to authorized users.

Introduction: The increasing global burden of CVD mortality is primarily attributable to the rising number of deaths in developing countries; India alone accounted for 15% of global CVD deaths in 2016. Little is known about patterns and predictors of physical activity (PA), a key modifiable risk factor for CVD, among Indian adolescents. Existing research has focused on play- and travel-related PA, which do not fully capture adolescent activity, and socio-demographic differences in PA are not well understood. We examined independent and joint associations of gender and socio-economic status (SES) with PA across multiple activity domains. Hypothesis: We assessed the hypotheses that 1) the types of PA in which adolescents engage will differ by gender and SES, and 2) gender differences in PA will vary by SES. Methods: We recruited 395 adolescents, ages 13-16, from six schools in Vijayapura, India. We classified public school students as low SES and private school students as high SES. We measured PA using adolescent-reported 24-hour time-use surveys. Activities were categorized into three domains: chores, errands, and jobs; play; and travel. We assigned each activity a metabolic equivalent (MET) value to assess moderate-to-vigorous PA (MVPA). Negative binomial regression modeled the adjusted count of PA minutes per day in each domain, and logistic regression modeled the probability of engaging in ≥60 minutes of MVPA in the prior 24 hours (WHO recommended level for ages 5-17). We assessed additive interaction between gender and SES with the relative excess risk due to interaction (RERI). Results: The proportion of adolescents engaging in ≥60 minutes of MVPA was higher among low SES (79.8% boys, 76.8% girls) than high SES (50.0% boys, 32.3% girls) adolescents. In adjusted models, there were no gender differences in the likelihood of engaging in ≥60 minutes of MVPA. However, girls had twice the PA minutes in chores, errands, and jobs (e(β)=1.98, 95% CI:1.32-2.98), while boys had twice the PA minutes in play (e(β)=2.11, 95% CI:1.23-3.62). Low versus high SES adolescents had higher PA across domains. Additive interaction between gender and SES was present in chores, errands, and jobs: while girls were more active in this domain across SES, gender differences were greater among low SES adolescents (RERI=2.53, 95% CI: 0.31-4.76). Conclusions: A far greater proportion of low SES adolescents engaged in recommended levels of MVPA. While there were no gender differences in the likelihood of engaging in ≥60 minutes of MVPA, girls and boys may accrue different advantages as a result of engaging in substantively different types of PA. Interaction in the chores, errands, and jobs domain suggests that gender hierarchies may emerge in the presence of socio-economic constraints, and lose salience as available resources increase. PA interventions must consider the role of gender- and SES-based facilitators and barriers.

Introduction: Childhood obesity is a growing epidemic in the United States with approximately 1 in 5 children being obese. Although prevalence estimates for childhood obesity are regularly updated, little is known about the current incidence of childhood obesity among a nationally representative population, since initial estimates were provided by the Early Childhood Longitudinal Study Kindergarten (ECLS-K) Class of 1998. Methods: We estimated the annual incidence of obesity and the cumulative incidence of obesity over 5 years using the contemporary ECLS-K Class of 2011 (analytic sample = 7019). Height and weight were measured at eight time points between kindergarten (2010) and fourth grade (2015). We defined normal weight (th percentile), overweight (85 th -95 th percentile), and obesity (>95 th percentile) using Centers for Disease Control and Prevention sex-and age-specific growth curves. Results: At kindergarten entry (mean age 5.6 years), 15.5% of children were overweight and 14.7% of children were obese; in fourth grade (mean age 10.1 years) overweight prevalence had increased to 17.3% and obesity prevalence had increased to 20.1%. Kindergarteners who were overweight were 6 times as likely as normal-weight kindergarteners to become obese by fourth grade (5-year cumulative incidence, 30.5% vs. 5.2%). In early elementary school, annualized obesity incidence proportions were higher over summer breaks (5.6% and 5.4% during summer breaks from Kindergarten to first grade and first grade to second grade, respectively) than during the school year (3.8% and 3.8% during Kindergarten and first grade school years, respectively). Incident obesity was higher among boys compared girls, non-Hispanic black and Hispanic children compared to non-Hispanic white children, and among those from the poorest socioeconomic quintiles compared to the highest socioeconomic quintile. Conclusions: Incident obesity between the ages of 5 and 10 years was more likely to have occurred during summer breaks and primarily among children who had entered kindergarten overweight. Childhood obesity prevention efforts should focus on the prevention of overweight prior to kindergarten and investigate causes of summer weight gain during elementary school.

We examined food subsidies and dietary intake in a remote district of India in the context of globalizing food environments. We used bespoke quantitative instruments to collect data on frequency of intake of 69 foods and a dietary variety score among 937 adults. We compared frequency of intake between urban and rural people receiving and not receiving subsidies. Subsidy recipients, who live in poverty, had slightly less varied diets and less frequent consumption of expensive foods, especially fruits and dairy, than non-recipients. However, there were no differences between poor and non-poor in frequency of intake of rice and pulses, both of which are provided through the subsidies to the poor.

Background:We examined the relationship between parents’ perception of neighborhood safety and children’s physical activity and use of recreation facilities in a US nationally representative sample of fifth grade children.Methods:We used data from the Early Childhood Longitudinal Study Kindergarten cohort, fifth grade sample (N = 9827). Multivariate logistic and linear regression models were used to examine associations between parents’ perception of neighborhood safety for outside play and number of days children engage in physical activity, as well as children’s use of recreational facilities for physical activity.Results:Children who used recreational facilities engaged in physical activity on more days of the week compared with children who did not use a facility (3.3 days vs. 3.8 days, P < .0001). Children from neighborhoods perceived as unsafe by parents engaged in almost 1 less day per week in physical activity (β = –.89, P < .0001). Children from neighborhoods perceived as unsafe were less likely to use recreational facilities compared with children from neighborhoods perceived as safe (odds ratio = 0.72, P < .0001). Children from less affluent families across rural and urban areas had half the odds of using recreational facilities compared with children from the wealthiest families living in urban areas.Conclusions:Parents’ perception of neighborhood safety for outside play can deter or promote children’s physical activity and use of recreational facilities. Children from less affluent families are less likely to use facilities than children from wealthy families, regardless of place of residence.

Summary Background In the USA, half of children are regularly cared for before or after school by someone other than a parent. Objective Describe the relationship between childcare arrangements and obesity among school-aged children. Methods Data are from the fifth-grade wave of the Early Childhood Longitudinal Study – Kindergarten Cohort 1998–1999, a nationally representative study of US children who were in kindergarten in 1998–1999 or first grade in 1999, collected in spring 2004 (analytic sample = 9617). We estimated survey-adjusted logistic regression models to examine the association between childcare arrangements before and after school and obesity. Results The prevalence of obesity was highest among fifth graders who received care from multiple sources and lowest among children who received care from adults not related to them in either the child's or the caregiver's home [29.9%, 95% confidence interval {CI}: 18.7%, 44.3%; and 17.3%, 95% CI: 12.1%, 24.0%]. Childcare arrangement was not an independent risk factor for obesity for most children. However, Hispanic children who were cared for by a person who was not a relative had significantly higher odds of obesity compared with non-Hispanics in similar care arrangements (odds ratio: 5.11, 95% CI: 2.00, 13.06). Conclusion Type of childcare before or after school was not an independent risk factor for obesity in most fifth graders, but implications of childcare for Hispanic children should be explored further.

Body mass index (BMI) is generally used to classify adiposity. Despite the fact that the consequences of adiposity for chronic health accumulate and manifest over time, most population health research exploring the implications of high BMI measures only its recent intensity. Some studies have used retrospective measures involving maximum weight, and even fewer have used BMI at multiple time points to estimate cumulative exposure to adiposity. The goal of this study was to compare BMI exposure metrics that captured different dimensions of body mass – intensity, history, and duration – in models of health indicators linked with adiposity. We used self-reported BMI of young adults (ages 18 – 33 years, n = 8,608) across 11 waves of data from the National Longitudinal Survey of Youth 1997 to evaluate eight BMI exposure metrics: most recent, maximum, mean, and median BMI, proportion of time with overweight/obesity, and excess BMI-years with overweight/obesity. We used these metrics in models of self-reported general health, chronic condition, and diabetes, and ascertained how most recent BMI performed when compared with other metrics that better capture the dynamics of BMI. The Akaike information criteria and Vuong tests were used for model comparison, and the strengths of associations were also compared. Most recent BMI was the best metric for explaining general health. Median BMI was best for explaining diabetes, with most recent BMI under-estimating the association by 13% relative to median BMI. For chronic condition, there was no clear best metric. We concluded that most recent BMI is useful for explaining health outcomes, though other metrics should also be given consideration, particularly for conditions that develop over time. Metrics that accounted for both intensity and history performed quite well, but the duration measures might be less useful., Highlights • BMI is dynamic, so researchers need to consider beyond BMI at the time of survey. • We calculated 8 BMI-based metrics accounting for intensity, history, and duration. • Most recent BMI was the best metric, based on AIC, for explaining general health. • Most recent BMI understated the association for diabetes, relative to median BMI.

India faces a dual burden of increasing obesity and persistent underweight as it experiences the nutrition transition—the dietary and lifestyle changes that accompany globalization, economic development, and technological change. Yet, the nutrition transition is not solely a top-down process; rather, global forces converge with local practices at multiple levels of the social ecology. The family environment, a key site for the transmission of local customs and norms, remains largely unexplored in India. We examined the extent to which opposite-gender siblings and mother–child pairs were concordant or discordant in body weight, and whether domains of the family environment, specifically, food practices, food-related gender norms, and household resources, were associated with patterns of unhealthy weight within and between families. Multilevel dyadic analysis and logistic regression were conducted using survey data from a representative sample of 400 families in a Southern Indian city. We identified substantial clustering of weight among opposite-gender sibling pairs (ICC = 0.43) and mother–child pairs, as well as important patterns of discordance, including 11% of families experiencing a dual burden of underweight and overweight. Household resources, including mother’s education and income, were salient in explaining the distribution of body weight within and between families. Importantly, less examined domains of the family environment were also relevant, including food practices (e.g., grocery shopping frequency), and food-related gender norms (e.g., mother’s control of food served at home). Continued exploration of how global and local practices converge in households will be necessary to develop programming that effectively addresses India’s dual burden of unhealthy weight.

PURPOSE When a person is given a diagnosis of diabetes, the changes in his or her health behaviors may influence the behaviors of his or her partner. The diabetes diagnosis may affect household members’ perceptions of their own health risks, which could trigger behavioral change. The purpose of this study was to assess whether partners of persons with newly diagnosed diabetes changed their health behaviors compared with partners of persons without diabetes. METHODS The study population consisted of Kaiser Permanente Northern California health plan members from 2007 to 2011. This cohort study assessed differences in change of 8 health behaviors. The study compared coresiding partners of persons with newly diagnosed diabetes before and after a diabetes diagnosis with a 5 to 1 matched sample of coresiding partners of persons without diabetes. RESULTS A total of 180,910 couples were included in the analysis. After adjusting for baseline characteristics, partners of persons with newly diagnosed diabetes had significantly higher rates of participation in weight management–related health education classes (risk ratio [RR] = 1.50; 95% CI, 1.39-1.63); smoking cessation medication use (RR = 1.25; 95% CI, 1.05-1.50); glucose screening (RR = 1.07; 95% CI, 1.05-1.08); clinically meaningful weight loss (RR = 1.06; 95% CI, 1.02-1.11); lipid screening (RR = 1.05; 95% CI, 1.04-1.07); influenza vaccination (RR = 1.03; 95% CI, 1.02-1.04); and blood pressure screening (RR = 1.02; 95% CI, 1.02-1.03) compared with partners of persons without diabetes. CONCLUSIONS There were small but significant differences in health-related behavioral changes among partners of persons with newly diagnosed diabetes compared with partners of persons without diabetes, even when no intervention occurred. This finding suggests a diabetes diagnosis within a family may be a teachable moment to improve health behaviors at the household level.

Due to shared genes and environment, the home setting may be an effective context to provide multiple individuals at risk of type 2 diabetes (T2D) with preventive efforts. The aim of this study is to investigate whether having a parent with T2D affects the BMI development from childhood through adolescence and into early adulthood. This analysis used the Panel Study of Income Dynamics (PSID), a nationally longitudinal study of families in the U.S. We used information on diabetes status in parents, household socio-economic characteristics and sex, age and anthropometrics in children and adolescent from 2001-2015 (n=5981). Body mass index (BMI) trajectories in children were fitted using mixed-effects models. Random intercept and slope were included to account for the within-person correlation arising from the repeated measures in the dataset. We used age as the time axis and modeled change with linear, quadratic and cubic terms to account for the non-linear change in BMI. At baseline, (mean age 12.2 years) children with a parent with T2D were 1.2 years older, had a 3.0 kg/m2 higher BMI than children with no parental T2D (p Children with a parent with T2D as compared to children without parental T2D exhibit a faster increasing BMI trajectory that leads to significant differences in adolescent BMI. This difference persists in early adulthood, when most children no longer live with their parents. Once a parent is diagnosed with T2D, obesity and diabetes prevention may be a priority for the children as well. Disclosure J. NIelsen: None. A. Hulman: None. S.A. Cunningham: None.

Summary Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation. Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the fi rst of a series of annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the fi rst level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular fi ltration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation.

Objectives. We examined the relationship between children’s weight and social competence. Methods. We used data from the third- and fifth-grade waves of the nationally representative Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999 (n = 8346) to examine changes in children’s weight and social competence. Results. Obesity in third grade was not associated with subsequent changes in social competence between third and fifth grade, but social competence in third grade was associated with subsequent development of obesity. Among normal-weight children, having higher social competence in third grade was associated with lower odds of becoming overweight (odds ratio [OR] = 0.80 ±0.09; P Conclusions. Obesity and impaired social competence often occur together and have serious implications for children's well-being. More knowledge about how weight and social competence affect one another could inform interventions to promote children’s social development and reduce obesity.

This article reviews the biology, prevalence and risks for obesity in people and companion dogs and cats, and explores the links between obesity and diabetes mellitus and cancer across these species. Obesity is a major healthcare problem in both human and veterinary medicine and there is an increasing prevalence of obesity in people and pets. In people and animals, obesity is a complex disorder involving diet, level of physical activity, behavioural factors, socioeconomic factors, environment exposures, genetics, metabolism and the microbiome. Pets and people share a number of obesity-related comorbidities. Obesity is a major risk factor for type 2 diabetes mellitus in people and in cats, but this association is not recognized in dogs. Obesity is a recognized risk factor for a number of human cancers, but there are fewer data available describing this association with canine neoplastic disease. One approach to addressing the problem of obesity is by taking a 'One Health' perspective. Comparative clinical research examining shared lifestyle and environmental risk factors and the reasons underlying species differences should provide new perspectives on the fundamental biology of obesity. One Health programmes involving human healthcare professionals and veterinarians could help address obesity with simple interventions at the community level.

Clinical trials show lifestyle change programs are beneficial, yet large-scale, successful translation of these programs is scarce. We investigated the association between participation in the largest U.S. lifestyle change program, MOVE!, and diabetes control outcomes.This longitudinal, retrospective cohort study used Veterans Health Administration databases of patients with diabetes who participated in MOVE! between 2005 and 2012, or met eligibility criteria (BMI ≥25kg/mThere were 400,170 eligible patients with diabetes, including 87,366 (22%) MOVE!Included patients were 96% male, 77% white, with mean age 58years and BMI 34kg/mIf able to overcome participation challenges, lifestyle change programs in U.S. health systems may improve health among the growing patient population with diabetes.

This commentary describes the recent reversal of health gains in the United States due to increases in midlife mortality rates among many groups. The authors' solution is to equally emphasize resea...

Objective: To assess whether there are differences in the strength of association with incident stroke for specific periods of life in the Stroke Belt (SB). Methods: The risk of stroke was studied in 24,544 black and white stroke-free participants, aged 45+, in the Reasons for Geographic and Racial Differences in Stroke study, a national population-based cohort enrolled 2003–2007. Incident stroke was defined as first occurrence of stroke over an average 5.8 years of follow-up. Residential histories (city/state) were obtained by questionnaire. SB exposure was quantified by combinations of SB birthplace and current residence and proportion of years in SB during discrete age categories (0–12, 13–18, 19–30, 31–45, last 20 years) and entire life. Proportional hazards models were used to establish association of incident stroke with indices of exposure to SB, adjusted for demographic, socioeconomic (SES), and stroke risk factors. Results: In the demographic and SES models, risk of stroke was significantly associated with proportion of life in the SB and with all other exposure periods except birth, ages 31–45, and current residence. The strongest association was for the proportion of the entire life in SB. After adjustment for risk factors, the risk of stroke remained significantly associated only with proportion of residence in SB in adolescence (hazard ratio 1.17, 95% confidence interval 1.00–1.37). Conclusions: Childhood emerged as the most important period of vulnerability to SB residence as a predictor of future stroke. Improvement in childhood health circumstances should be considered as part of long-term health improvement strategies in the SB.

Purpose Given the high levels of obesity among U.S. children, we examine whether obesity in childhood is a passing phenomenon or remains entrenched into adolescence. Methods Data are from the prospective nationally representative Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999 (analytic sample = 6600). Anthropometrics were measured six times during 1998–2007. Overweight and obesity were defined using CDC cut-points. Entrenched obesity was defined as obesity between ages 5–9 coupled with persistent obesity at ages 11 and 14. Results Almost 30% of children experienced obesity at some point between ages 5.6 and 14.1 years; 63% of children who ever had obesity between ages 5.6 and 9.1 and 72% of those who had obesity at kindergarten entry experienced entrenched obesity. Children with severe obesity in kindergarten or who had obesity at more than 1 year during early elementary were very likely to experience obesity through age 14, regardless of their sex, race, or socioeconomic backgrounds. Conclusions Prevention should focus on early childhood, as obesity at school entry is not often a passing phenomenon. Even one timepoint of obesity measured during the early elementary school years may be an indicator of risk for long-term obesity.

Introduction Lifestyle change programs implemented within healthcare systems could reach many Americans, but their impact on cardiovascular disease (CVD) remains unclear. The MOVE! program is the largest lifestyle change program implemented in a healthcare setting in the U.S. This study aimed to determine whether MOVE! participation was associated with reduced CVD incidence. Methods This retrospective cohort study, analyzed in 2013–2015, used national Veterans Health Administration databases to identify MOVE! participants and eligible non-participants for comparison (2005–2012). Patients eligible for MOVE!—obese or overweight with a weight-related health condition, and no baseline CVD—were examined (N=1,463,003). Of these, 169,248 (12%) were MOVE! participants. Patients were 92% male, 76% white, with mean age 52 years and BMI of 32. The main outcome was incidence of CVD (ICD-9 and procedure codes for coronary artery disease, cerebrovascular disease, peripheral vascular disease, and heart failure). Results Adjusting for age, race, sex, BMI, statin use, and baseline comorbidities, over a mean 4.9 years of follow-up, MOVE! participation was associated with lower incidence of total CVD (hazard ratio [HR]=0.83, 95% CI=0.80, 0.86); coronary artery disease (HR=0.81, 95% CI=0.77, 0.86); cerebrovascular disease (HR=0.87, 95% CI=0.82, 0.92); peripheral vascular disease (HR=0.89, 95% CI=0.83, 0.94); and heart failure (HR=0.78, 95% CI=0.74, 0.83). The association between MOVE! participation and CVD incidence remained significant when examined across categories of race/ethnicity, BMI, diabetes, hypertension, smoking status, and statin use. Conclusions Although participation was limited, MOVE! was associated with reduced CVD incidence in a nationwide healthcare setting.

Background Sweetened beverages of low nutritional quality might be displacing more nutritious beverages, such as 100% fruit juice and milk, from children's diets. However, previous research has not examined changes in beverage intake over time using nationally representative longitudinal data. Objective Our objective was to examine changes in sweetened beverage, milk, and juice consumption between 5th and 8th grade. Design We used a longitudinal analysis of self-reported beverage consumption. Participants/setting Data were from the Early Childhood Longitudinal Survey–Kindergarten Cohort 1998-1999 (ECLS-K), a nationally representative study of children followed from kindergarten through 8th grade. This analysis used data from Spring 2004 and 2007, when most children were in 5th and 8th grade, respectively (n=7,445). Main outcome measures Main outcome measures were changes in consumption of sweetened beverages, milk, and 100% fruit juice last week. Statistical analyses performed Survey-adjusted linear regression was used to estimate longitudinal relationships between servings of milk, sweetened beverages, and 100% fruit juice, controlling for child and family characteristics and food consumption. Results Children's milk consumption decreased between 5th and 8th grade, and these decreases were larger among children who drank sweetened beverages daily. However, after controlling for demographic characteristics, changes in children's milk consumption were not significantly related to changes in their consumption of sweetened beverages over time (β=.005; P =0.81), while changes in milk consumption were positively related to changes in juice consumption (β=.087; P Conclusions Observed decreases in average milk consumption from 5th to 8th grade were not related to changes in sweetened-beverage consumption. They were positively related to changes in fruit juice consumption, so not indicating displacement. Caloric beverages generally tended to increase or decrease in tandem, so focus must be placed on their role in children's entire diet and on balancing them with food and total beverage intake.

International migration is at an all-time high, with the largest numbers migrating to the US, making this an ideal setting to study migrant health. While previous studies have shown that foreign-born individuals in the US tend to be in better health than the native born with regard to several health outcomes, less is known about such advantages in terms of cardiovascular disease and diabetes, which are some of the leading causes of morbidity and mortality worldwide. In this paper, we highlight the main existing resources available for the study of cardiometabolic health among US immigrants that researchers have yet to fully utilize. Despite the limited literature on migration and cardiovascular disease and diabetes, there are several data sources that can be used to better understand the importance of location exposures and of predispositions to these diseases.

This article provides an overview for pediatricians and other health care providers of the role of added sugars (caloric sweeteners) in the diets of US children and the recent evidence linking added sugar consumption to increased obesity and other chronic disease risk in children. The hypothesized biologic mechanisms for these associations are summarized, and evidence-based strategies are provided that may help children and their families to reduce their sugar consumption. Primary health care providers play an important role in assessing the added sugar intake of their patients and in providing nutrition and behavior change counselling to high-risk children and their families.

In response to the increase in children’s weight in recent decades, many states, school districts, and schools in the United States have limited or eliminated the sale of sweetened beverages at school. These policies are promoted for their potential to reduce childhood overweight and obesity, but their effectiveness has not been evaluated. Using a large nationally representative longitudinal dataset, the Early Childhood Longitudinal Study-Kindergarten (ECLS-K), this study explores the relationship between children’s access to sweetened beverages at school in 5th and 8th grade, their purchases and total consumption of these beverages, and their weight. We find almost no evidence that availability of sweetened beverages for sale at school leads to heavier weight or greater risk of overweight or obesity among children. We also find limited evidence that availability of sweetened beverages for sale at school leads to higher total consumption of these beverages.

OBJECTIVE With increasing life expectancy in the U.S., it is important to know whether a longer life expectancy means a longer healthy life span or a prolonged period of later-life morbidity. This study examines changes in lifetime without diabetes, a leading cause of morbidity in later life. RESEARCH DESIGN AND METHODS Using demographic methods and nationally representative data, we estimated changes in diabetes-free life expectancy between 1980–1989 and 2000–2004 for adult men and women in the U.S., estimated the contribution of changes in age-specific diabetes rates, and examined the changing effects of weight status on diabetes risks. RESULTS While life expectancy at age 18 for men and women increased between the 1980s and the 2000s, diabetes-free life expectancy at age 18 decreased by 1.7 years for men and 1.5 years for women. The proportion of 18-year-olds who would develop diabetes in their lifetimes increased by almost 50% among women and almost doubled among men. Obese individuals experienced the greatest losses in diabetes-free life expectancy during this period, estimated at 5.6 years for men and 2.5 years for women. CONCLUSIONS Diabetes-free life expectancy decreased for both men and women between 1980–1989 and 2000–2004, and these decreases are almost entirely attributable to large increases in diabetes incidence among obese individuals.

This study uses secondary data from 2006 to assess the physical and mental health of rural, home-based sex workers and their young children in rural Andhra Pradesh state of India. The analyses of survey and clinical data show a high level of morbidity amongst sex worker women and their children. Women show high levels of nutritional deficiencies, anaemia, weight loss and hospitalisation. Women's mental health is particularly serious, with 92 per cent being depressed and 57 per cent having attempted suicide. The majority have experienced domestic and work-related violence, including rape. Clinical assessments of sex workers’ children show that most have received vaccinations, but almost half have parasites, dental problems and nutritional deficiencies. Both the physical and mental health of sex worker mothers are associated with the health of their children. Therefore, health interventions focusing on sex worker mothers have the potential to improve the health of their children.

Background— Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. Methods and Results— In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated by added sugar consumption level (P trend =0.001). Added sugars were positively correlated with low-density lipoproteins ( P trend =0.01) and geometric mean triglycerides ( P trend =0.05). Among the lowest and highest consumers, respectively, low-density lipoproteins (mmol/L) were 2.24 (95% CI 2.12 to 2.37) and 2.44 (95% CI 2.34 to 2.53), and triglycerides (mmol/L) were 0.81 (95% CI 0.74, 0.88) and 0.89 (95% CI 0.83 to 0.96). Among those overweight/obese (≥85th percentile body-mass-index), added sugars were positively correlated with the homeostasis model assessment ( P linear trend =0.004). Conclusion— Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.