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BackgroundThe United States (US) data suggest fewer-than-expected preterm births in 2020, but no study has examined the impact of exposure to the early COVID-19 pandemic at different points in gestation on preterm birth.ObjectiveOur objective was to determine-among cohorts exposed to the early COVID-19 pandemic-whether observed counts of overall, early and moderately preterm birth fell outside the expected range.MethodsWe used de-identified, cross-sectional, national birth certificate data from 2014 to 2020. We used month and year of birth and gestational age to estimate month of conception for birth. We calculated the count of overall (<37 weeks gestation), early (<33 weeks gestation) and moderately (33 to <37 weeks gestation) preterm birth by month of conception. We employed time series methods to estimate expected counts of preterm birth for exposed conception cohorts and identified cohorts for whom the observed counts of preterm birth fell outside the 95% detection interval of the expected value.ResultsAmong the 23,731,146 births in our study, the mean prevalence of preterm birth among monthly conception cohorts was 9.7 per 100 live births. Gestations conceived in July, August or December of 2019-that is exposed to the early COVID-19 pandemic in the first or third trimester-yielded approximately 3245 fewer moderately preterm and 3627 fewer overall preterm births than the expected values for moderate and overall preterm. Gestations conceived in August and October of 2019-that is exposed to the early COVID-19 pandemic in the late second to third trimester-produced approximately 498 fewer early preterm births than the expected count for early preterm.ConclusionsExposure to the early COVID-19 pandemic may have promoted longer gestation among close-to-term pregnancies, reduced risk of later preterm delivery among gestations exposed in the first trimester or induced selective loss of gestations.

BackgroundThe United States (US) data suggest fewer-than-expected preterm births in 2020, but no study has examined the impact of exposure to the early COVID-19 pandemic at different points in gestation on preterm birth.ObjectiveOur objective was to determine-among cohorts exposed to the early COVID-19 pandemic-whether observed counts of overall, early and moderately preterm birth fell outside the expected range.MethodsWe used de-identified, cross-sectional, national birth certificate data from 2014 to 2020. We used month and year of birth and gestational age to estimate month of conception for birth. We calculated the count of overall (<37 weeks gestation), early (<33 weeks gestation) and moderately (33 to <37 weeks gestation) preterm birth by month of conception. We employed time series methods to estimate expected counts of preterm birth for exposed conception cohorts and identified cohorts for whom the observed counts of preterm birth fell outside the 95% detection interval of the expected value.ResultsAmong the 23,731,146 births in our study, the mean prevalence of preterm birth among monthly conception cohorts was 9.7 per 100 live births. Gestations conceived in July, August or December of 2019-that is exposed to the early COVID-19 pandemic in the first or third trimester-yielded approximately 3245 fewer moderately preterm and 3627 fewer overall preterm births than the expected values for moderate and overall preterm. Gestations conceived in August and October of 2019-that is exposed to the early COVID-19 pandemic in the late second to third trimester-produced approximately 498 fewer early preterm births than the expected count for early preterm.ConclusionsExposure to the early COVID-19 pandemic may have promoted longer gestation among close-to-term pregnancies, reduced risk of later preterm delivery among gestations exposed in the first trimester or induced selective loss of gestations.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero. Lay Summary Our findings suggest that the risk of spontaneously aborting a slow-growing fetus will increase during relatively stressful times.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero. Lay Summary Our findings suggest that the risk of spontaneously aborting a slow-growing fetus will increase during relatively stressful times.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero. Lay Summary Our findings suggest that the risk of spontaneously aborting a slow-growing fetus will increase during relatively stressful times.

BACKGROUND AND OBJECTIVES: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. METHODOLOGY: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. RESULTS: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. CONCLUSIONS AND IMPLICATIONS: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero. Lay Summary Our findings suggest that the risk of spontaneously aborting a slow-growing fetus will increase during relatively stressful times.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero. Lay Summary Our findings suggest that the risk of spontaneously aborting a slow-growing fetus will increase during relatively stressful times.

Teacher delivered food and nutrition education (FNE) can be effective in improving children’s food literacy and eating habits. However, teachers are known to face some barriers to the delivery of FNE globally. To obtain a deeper understanding of Australian primary school teachers’ experiences and views, 17 teachers were interviewed. The results of the thematic analysis showed that teachers acknowledged the importance of FNE and were willing to include more FNE content into their teaching. We also identified the FNE topics taught, resources used, their teaching partners, and barriers encountered. The discussion presents strategies to overcome these barriers.

ABSTRACT Background Young Australian adults exhibit poor food behaviors. These include increased consumption of Energy-Dense, Nutrient-Poor (EDNP) foods, sugar-sweetened beverages, and low consumption of fruit and vegetables. However, little is known about how the coronavirus disease 2019 (COVID-19) pandemic affected young Australian adults’ pre-existing adverse food behaviors. Objectives The present study aimed to understand the impact of the COVID-19 pandemic on food practices by exploring views of young adults living in Australia. Methods Through qualitative descriptive methods, data gathered through individual interviews were thematically analyzed. Participants included 38 young adults aged 18–30 y with a mean age of 24.1 y (76% female). Results Five themes emerged: 1) disruption of routines, 2) increased flexibility, 3) changes in food practices, 4) heightened psychological distress, and 5) impact on future behaviors. Disruption of routines and increased flexibility associated with working/learning from home resulted in both positive and negative changes in food practices. Negative changes included increased consumption of EDNP foods, increased consumption of foods prepared outside of home, decreased purchases and consumption of fresh foods, meal skipping, and a lack of meal planning. Positive changes included an increase in home cooking; consistent weekly eating patterns; decreased consumption of EDNP foods; smaller, more frequent meals; and decreased consumption of foods prepared outside of home. Conclusions Young Australian adults reported more negative and fewer positive changes in food practices. The observed negative cha

Young Australian adults’ exhibit high consumption of Energy Dense and Nutrient Poor (EDNP) foods; however, there is limited research concerning the factors influencing their consumption. This study aimed to explore socio-psychological factors associated with young Australian adults’ (18–30 years) consumption of EDNP foods with consideration of the Food Related Lifestyle Model (FRLM) as a potential framework. Through qualitative descriptive research methodology, 38 young adults were interviewed. Data were thematically analyzed. Participants were classified into three groups based on their living arrangements namely, parental, shared and independent households. Five themes emerged, (1) psychological factors (2) intrinsic qualities of EDNP foods, (3) social factors, (4) accessibility and affordability and (5) health related beliefs. The FRLM takes into consideration some of the factors reported in this study as influencers of EDNP food intakes. However, the FRLM omits important psychological factors (motivation, restraint, cravings, coping strategies and habits) identified by participants as influencers over their EDNP food intakes. The FRLM may need to be extended in its application to EDNP food intakes of young Australian adults. Social marketing campaigns highlighting health risks, addressing social and environmental factors are suggested. The social desirability of healthier alternatives in social gatherings of young adults could be increased.

Parents and teachers have a major influence in the formation of primary school children’s eating behaviours. Although the cooperation of parents and teachers has frequently been recommended in the promotion of healthy eating habits among primary school children, little is known about the communication between these two groups regarding food- and nutrition-related issues. This paper reports findings from semi-structured interviews with primary school parents (n = 19) and primary teachers (n = 17), as well as findings from a survey of 787 parents in Australia. Audio-recorded interviews were analysed using NVivo and descriptive statistics were calculated for the survey questions. The results indicated that their communications involved various topics, including allergies, lunchbox content, and supervision requests, through diverse communication channels. The risk of offending each other and time scarcity were reported as communication barriers. Parents mainly expected teachers to ensure that their children were given enough time to eat their lunch, teach healthy eating, and be good role models of healthy eating. This study highlights the need to overcome communication barriers between parents and teachers and support teachers in their multifaceted professional roles.

BackgroundPreliminary studies suggest that the SARS-CoV-2 pandemic and associated social, economic and clinical disruptions have affected pregnancy decision-making and outcomes. Whilst a few US-based studies have examined regional changes in birth outcomes during the pandemic's first months, much remains unknown of how the pandemic impacted perinatal health indicators at the national-level throughout 2020, including during the 'second wave' of infections that occurred later in the year.ObjectivesTo describe changes in monthly rates of perinatal health indicators during the 2020 pandemic for the entire US.MethodsFor the years 2015 to 2020, we obtained national monthly rates (per 100 births) for four perinatal indicators: preterm (<37 weeks' gestation), early preterm (<34 weeks' gestation), late preterm (34-36 weeks' gestation) and caesarean delivery. We used an interrupted time-series approach to compare the outcomes observed after the pandemic began (March 2020) to those expected had the pandemic not occurred for March through December of 2020.ResultsObserved rates of preterm birth fell below expectation across several months of the 2020 pandemic. These declines were largest in magnitude in early and late 2020, with a 5%-6% relative difference between observed and expected occurring in March and November. For example, in March 2020, the observed preterm birth rate of 9.8 per 100 live births fell below the 95% prediction interval (PI) of the rate predicted from history, which was 10.5 preterm births per 100 live births (95% PI 10.2, 10.7). We detected no changes from expectation in the rate of caesarean deliveries.ConclusionsOur findings provide nationwide evidence of unexpected reductions in preterm delivery during the 2020 SARS-CoV-2 pandemic in the US. Observed declines below expectation were differed by both timing of delivery and birth month, suggesting that several mechanisms, which require further study, may explain these pattern

The epidemiologic literature estimating the indirect or secondary effects of the coronavirus disease 2019 (COVID-19) pandemic on pregnant people and gestation continues to grow. Our assessment of this scholarship, however, leads us to suspect that the methods most commonly used may lead researchers to spurious inferences. This suspicion arises because the methods do not account for temporal patterning in perinatal outcomes when deriving counterfactuals, or estimates of the outcomes had the pandemic not occurred. We illustrate the problem in 2 ways. First, using monthly data from US birth certificates, we describe temporal patterning in 5 commonly used perinatal outcomes. Notably, for all but 1 outcome, temporal patterns appear more complex than much of the emerging literature assumes. Second, using data from France, we show that using counterfactuals that ignore this complexity produces spurious results. We recommend that subsequent investigations on COVID-19 and other perturbations use widely available time-series methods to derive counterfactuals that account for strong temporal patterning in perinatal outcomes.

Teacher delivered food and nutrition education (FNE) can be effective in improving children’s food literacy and eating habits. However, teachers are known to face some barriers to the delivery of FNE globally. To obtain a deeper understanding of Australian primary school teachers’ experiences and views, 17 teachers were interviewed. The results of the thematic analysis showed that teachers acknowledged the importance of FNE and were willing to include more FNE content into their teaching. We also identified the FNE topics taught, resources used, their teaching partners, and barriers encountered. The discussion presents strategies to overcome these barriers.

OBJECTIVE:Suicide mortality rates in rural areas of the United States are twice that of rates in urban areas, and identifying which factors-eg, higher rates of suicidal distress, lower rates of help-seeking behaviors, or greater access to firearms-contribute to this rural/urban disparity could help target interventions. METHOD:Using 2015-2016 data on adult respondents to the California Health Interview Survey (n = 40,041), we examined associations between residence in a rural (vs nonrural) census tract and nonfatal suicidal ideation and attempt. RESULTS:We found that living in a rural area was not associated with nonfatal suicidal behavior (OR for past-year suicidal ideation = 0.87, 95% CI: 0.63-1.20; OR for past-year suicide attempt = 0.55, CI: 0.20-1.48). Women living in rural areas had higher odds of lifetime suicidal ideation compared to women living in nonrural areas, but this difference was not significant (OR = 1.17, CI: 0.94-1.44). We also found that, among individuals reporting suicidal behavior, there were few rural/nonrural differences in perceived need for treatment, such as seeing a physician or taking a prescription for mental health problems. CONCLUSIONS:Our results do not suggest higher suicidal distress or lower treatment-seeking behaviors as explanations for the rural/urban disparity in suicide mortality rates. Further attention is needed to the unique risk factors driving suicidality in rural areas, as well as exploring heterogeneity in these factors across different rural contexts.

BackgroundPreliminary studies suggest that the SARS-CoV-2 pandemic and associated social, economic and clinical disruptions have affected pregnancy decision-making and outcomes. Whilst a few US-based studies have examined regional changes in birth outcomes during the pandemic's first months, much remains unknown of how the pandemic impacted perinatal health indicators at the national-level throughout 2020, including during the 'second wave' of infections that occurred later in the year.ObjectivesTo describe changes in monthly rates of perinatal health indicators during the 2020 pandemic for the entire US.MethodsFor the years 2015 to 2020, we obtained national monthly rates (per 100 births) for four perinatal indicators: preterm (<37 weeks' gestation), early preterm (<34 weeks' gestation), late preterm (34-36 weeks' gestation) and caesarean delivery. We used an interrupted time-series approach to compare the outcomes observed after the pandemic began (March 2020) to those expected had the pandemic not occurred for March through December of 2020.ResultsObserved rates of preterm birth fell below expectation across several months of the 2020 pandemic. These declines were largest in magnitude in early and late 2020, with a 5%-6% relative difference between observed and expected occurring in March and November. For example, in March 2020, the observed preterm birth rate of 9.8 per 100 live births fell below the 95% prediction interval (PI) of the rate predicted from history, which was 10.5 preterm births per 100 live births (95% PI 10.2, 10.7). We detected no changes from expectation in the rate of caesarean deliveries.ConclusionsOur findings provide nationwide evidence of unexpected reductions in preterm delivery during the 2020 SARS-CoV-2 pandemic in the US. Observed declines below expectation were differed by both timing of delivery and birth month, suggesting that several mechanisms, which require further study, may explain these pattern

Background and objectives: The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts. Results: We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020. Conclusions and implications: Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected. Lay Summary: Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

Background and objectives: The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts. Results: We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020. Conclusions and implications: Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected. Lay Summary: Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

Background and objectives: The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts. Results: We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020. Conclusions and implications: Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected. Lay Summary: Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

Background and objectivesThe suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts.MethodologyWe apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts.ResultsWe find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020.Conclusions and implicationsConsistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected.Lay summaryOur finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

Background and objectives: The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts. Results: We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020. Conclusions and implications: Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected. Lay Summary: Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

Background and objectives: The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts. Results: We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020. Conclusions and implications: Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected. Lay Summary: Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.

BACKGROUND: Investigating effects of whole diets on blood pressure (BP) can contribute to development of diet-based recommendations for health. Our aim was to assess the relationship between dietary patterns and BP in a sample of free-living Australian adults. METHODS: Usual dietary patterns of participants recruited to dietary intervention studies were assessed using factor analysis (two 24-h recalls). The mean of seven days of daily, seated BP measurements were used. RESULTS: Complete data from 251 participants (112 males; mean age 55.1(9.1) (SD) years; body mass index (BMI) 29.5(3.9) kg/m2) was included. Three dietary patterns were identified. Only Dietary Pattern 2 was positively associated with home systolic BP (β = 1.88, 95% CI 0.16, 3.60) after adjusting for age, sex, BMI, anti-hypertensive medication, smoking, education, physical activity and energy intake. This dietary pattern was characterised by high consumption of low-fibre bread, pasta, noodles and rice, meat dishes, poultry dishes and egg dishes, mixed cereal dishes, salted nuts and low consumption of milk and yoghurt (low-fat), vegetable juice, vegetables and high-fibre bread. Dietary Pattern 2 was also positively associated with intakes of energy (P = 0.002) and sodium (P = 0.005) and inversely associated with potassium intake (P = 0.002). After adjustment for energy, only the inverse association with potassium remained (P <  0.001). CONCLUSIONS: In this sample of Australian adults, Dietary Pattern 2 was associated with higher BP and thus chronic disease risk, supporting the evidence that diets high in energy and sodium, and low in potassium from vegetables and dairy, are detrimental to cardiovascular health.

Background/AimsSalt intake among Australian adults exceeds recommendations, increasing the risk of cardiovascular disease. Knowledge, attitudes and behaviours (KABs) are modifiable factors that may influence salt consumption. It is not known whether salt-related KABs among parents and caregivers of children under 18 years of age differ from other adults who do not care for children under 18 years of age. Therefore, we aimed to determine whether salt-related KABs differed between parents and caregivers and other adults. This information can be used to inform messages included in salt reduction consumer awareness campaigns.MethodsAdults, aged 18–65 years, were recruited from four shopping centres, Facebook and a consumer research panel in the state of Victoria, Australia. Participants indicated if they were a parent or a caregiver of a child/children <18 years (‘parents/caregivers’) or not (‘other adults’). Regression models, adjusted for covariates, assessed differences in KABs between the two groups. Construct scores for KABs were developed, with high scores for knowledge indicative of high salt-related knowledge, for attitude indicative of lower importance of using salt to enhance the taste of food, and for behaviours indicative of higher frequency of engaging in behaviours to reduce salt in the diet.ResultsA total of 840 parents/caregivers and 1558 other adults completed the survey. Just over half of the parents/caregivers and other adults were female, with a mean (SD) age of 41.1 (10.3) years and 44.3 (15.3) years, respectively. Mean construct scores for salt-related KABs were similar between the two groups. Parents/caregivers were less likely to be aware of the relationship between salt and sodium (OR=0.73, p=0.002) and more likely to report difficulty in interpre

BACKGROUND: Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages, which may positively impact their own salt-related knowledge, attitudes, and behaviors (KABs). OBJECTIVE: This pilot study aimed to determine whether parents' salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) Web-based education program. METHODS: The DELISH program was a 5-week, home-delivered, Web-based intervention, with a pre- and posttest design, targeting schoolchildren aged 7 to 10 years and their parents. Parents received weekly Web-based educational newsletters and text messages and completed online pre- and postprogram surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar tests and paired t tests. RESULTS: Of the 80 parents that commenced the program, 73 parents (mean age 41.0, SD 7.0 years; 86% (63/73) females) completed both pre- and postsurveys. Overall, mean score for salt-related knowledge improved (+3.6 [standard error (SE) 0.41] points), and mean behavior score also improved (+4.5 [SE 0.61] points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet, and mean attitude score decreased (-0.7 [SE 0.19] points), representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% (29/73) to 74% (54/73) (P<.001), and awareness of bread as the main source of salt increased from 58% (42/73) to 95% (69/73) (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% (22/73)

BackgroundReducing maternal mortality is a priority in the United States and worldwide. Drug-related deaths and suicide may account for a substantial and growing portion of maternal deaths, yet information on the incidence of and sociodemographic variation in these deaths is scarce.ObjectiveWe sought to examine incidence of drug-related and suicide deaths in the 12 months after delivery, including heterogeneity by sociodemographic factors. We also explored maternal decedents' health care utilization prior to death.Study designThis retrospective, population-based cohort study followed up 1,059,713 women who delivered a live-born infant in California hospitals during 2010-2012 to ascertain maternal death. Analyses were conducted using statewide, all-payer, longitudinally-linked hospital and death data.ResultsA total of 300 women died during follow-up, a rate of 28.33 deaths per 100,000 person-years. The leading cause of death was obstetric-related problems (6.52 per 100,000 person-years). Drug-related deaths were the second leading cause of death (3.68 per 100,000 person-years), and suicide was the seventh leading cause (1.42 per 100,000 person-years); together these deaths comprised 18% of all maternal deaths. Non-Hispanic white women, Medicaid-insured women, and women residing in micropolitan areas were especially likely to die from drugs/suicide. Two thirds of women who died, including 74% of those who died by drugs/suicide, made ≥1 emergency department or hospital visit between their delivery and death.ConclusionDeaths caused by drugs and suicide are a major contributor to mortality in the postpartum period and warrant increased clinical attention, including recognition by physicians and Maternal Mortality Review Committees as a medical cause of death. Importantly, emergency department and inpatient hospital visits may serve as a point of identification of, and eventually prevention for, women at risk for these deaths.

Aim: Competency standards are widely adopted as a framework to describe standards of performance required in the workplace. Little is known, however, about how students construct competence. This qualitative study aimed to explore how dietetics students ready to graduate construct the concept of competence and the role of assessment in developing professional competence. Methods: A qualitative description was used to gather data from a convenience sample of students ready to graduate from universities with accredited dietetics programs across Australia (10 out of 15 at the time of the study). A total of 11 focus groups were conducted to explore perspectives of competence and experiences of ‘competency‐based’ assessment. Data were audio‐recorded, transcribed and analysed using a thematic analysis approach. Results: A total of 81 (n = 81) participants across 10 universities representing 22% of total students participated in the focus groups. Themes revealed that: (i) there is no shared understanding of competence; (ii) current work placement experiences may not reflect current standards or workforce needs; (iii) assessment approaches may not fully support the development of competence; and (iv) the competent performance of supervising dietitians/clinical educators in the workplace influences the construction of competence. Conclusions: There is a need to work towards a shared understanding of dietetic entry‐level competence in the profession. ‘Work‐based’ learning experiences may need to be modified to ensure students meet current competency standards. Practitioners involved in student supervision need to acknowledge the influential role they have in the development of the future workforce.

Salt intake in adults and children exceeds recommended levels. Salt-related knowledge, attitudes, and behaviours (KABs) may influence the amount of salt consumed. The aims of this study were to assess salt-related KABs among parents, and investigate whether salt-related knowledge and attitudes are associated with salt-specific behaviours. Parents with children <18 years were recruited from four shopping centers across Victoria, Australia; Facebook; and an online consumer research panel; they then completed an online questionnaire assessing salt-related KABs and salt use in children. Eight hundred and thirty-seven parents (mean age 41.0 (10.0) (SD) years) provided valid responses. Most (77%) parents were aware that eating too much salt damages children’s health and that reducing the amount of salt in their children’s diet was important (70%), and 46% reported adding salt to food prepared for their children. Parents who were aware that eating too much salt damages children’s health were less likely to report that their child added salt at the table (OR = 0.51, p < 0.001), and that they added salt to food prepared for the child (OR = 0.46, p < 0.001). Educational messages that highlight the adverse health effects of salt during childhood are likely to be useful in reducing discretionary salt use in the home environment.

Aim: Competency standards are widely adopted as a framework to describe standards of performance required inthe workplace. Little is known, however, about how students construct competence. This qualitative study aimed toexplore how dietetics students ready to graduate construct the concept of competence and the role of assessment indeveloping professional competence.Methods: A qualitative description was used to gather data from a convenience sample of students ready to gradu-ate from universities with accredited dietetics programs across Australia (10 out of 15 at the time of the study).A total of 11 focus groups were conducted to explore perspectives of competence and experiences of 'competency-based' assessment. Data were audio-recorded, transcribed and analysed using a thematic analysis approach.Results: A total of 81 (n = 81) participants across 10 universities representing 22% of total students participated inthe focus groups. Themes revealed that: (i) there is no shared understanding of competence; (ii) current work place-ment experiences may not reflect current standards or workforce needs; (iii) assessment approaches may not fullysupport the development of competence; and (iv) the competent performance of supervising dietitians/clinical edu-cators in the workplace influences the construction of competence.Conclusions: There is a need to work towards a shared understanding of dietetic entry-level competence in the pro-fession. 'Work-based' learning experiences may need to be modified to ensure students meet current competencystandards. Practitioners involved in student supervisionneed to acknowledge the influential role they have inthe development of the future workforce

Aim: Competency standards are widely adopted as a framework to describe standards of performance required inthe workplace. Little is known, however, about how students construct competence. This qualitative study aimed toexplore how dietetics students ready to graduate construct the concept of competence and the role of assessment indeveloping professional competence.Methods: A qualitative description was used to gather data from a convenience sample of students ready to gradu-ate from universities with accredited dietetics programs across Australia (10 out of 15 at the time of the study).A total of 11 focus groups were conducted to explore perspectives of competence and experiences of 'competency-based' assessment. Data were audio-recorded, transcribed and analysed using a thematic analysis approach.Results: A total of 81 (n = 81) participants across 10 universities representing 22% of total students participated inthe focus groups. Themes revealed that: (i) there is no shared understanding of competence; (ii) current work place-ment experiences may not reflect current standards or workforce needs; (iii) assessment approaches may not fullysupport the development of competence; and (iv) the competent performance of supervising dietitians/clinical edu-cators in the workplace influences the construction of competence.Conclusions: There is a need to work towards a shared understanding of dietetic entry-level competence in the pro-fession. 'Work-based' learning experiences may need to be modified to ensure students meet current competencystandards. Practitioners involved in student supervisionneed to acknowledge the influential role they have inthe development of the future workforce

Background: Salt intake of schoolchildren in the Australian state of Victoria is high. To protect future cardiovascular health, interventions that seek to reduce the amount of salt in children’s diets are required. Objective: We sought to develop and pilot test a Web-based program (Digital Education to Limit Salt Intake in the Home [DELISH]) that aims to reduce dietary salt intake among schoolchildren and to improve child and parent knowledge, attitudes, and behaviors related to salt intake. This paper presents the DELISH study protocol, along with pilot findings used to inform the development of the program. Methods: The DELISH program is a 5-week Web-based intervention that targets schoolchildren aged 7-10 years and their parents. This is a single-arm study with a pretest and posttest design. We will assess change in salt intake through analysis of 24-hour urinary sodium excretion. Children and parents will complete online surveys assessing knowledge, attitudes, and behaviors related to salt intake. We will assess feasibility of the program via process measures, which include metrics to describe intervention uptake (eg, number of children who complete Web-based sessions and of parents who view online newsletters) and evaluation surveys and interviews conducted with children, parents, and schoolteachers. The first 2 Web sessions developed for children were pilot tested in 19 children aged 8-12 years. Results: Findings from pilot testing indicated that most children (session 1: 18/19, 95%; and session 2: 19/19, 100%) enjoyed completing each session and liked the inclusion of comic strips and interactive games. Commonly reported areas of improvement related to sessions being text and content heavy. Based on these findings, we simplified sessions and developed 3 additional sessions for use in the DELISH program. The DELISH program was implemented during June-December 2016. We expect to have results fro

A sample of middle-aged Australians were consuming excessive amounts of salt from convenience foods and staple foods and consumed insufficient dietary potassium from fruits and vegetables. There needs increased awareness of the dietary sources of salt and potassium to assist in population blood pressure reduction.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (SD 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy (26·2 (SD 6·0) mmHg) than in those not on antihypertensive therapy (22·8 (SD 4·0) mmHg) (P¼0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy (29·5 (SD 6·4) mmHg) (interaction P¼0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall 21·1 (SD 6·2) mmHg; renin–angiotensin blocker therapy 24·2 (SD 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (SD 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy (26·2 (SD 6·0) mmHg) than in those not on antihypertensive therapy (22·8 (SD 4·0) mmHg) (P¼0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy (29·5 (SD 6·4) mmHg) (interaction P¼0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall 21·1 (SD 6·2) mmHg; renin–angiotensin blocker therapy 24·2 (SD 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55.6 (sd 9.9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy ( - 6.2 (sd 6.0) mmHg) than in those not on antihypertensive therapy ( - 2.8 (sd 4.0) mmHg) (P = 0.036), and this was greatest for those on renin-angiotensin system (RAS) blocker therapy ( - 9.5 (sd 6.4) mmHg) (interaction P = 0.007). The fall in SBP on the DASH-type diet, in those on therapy (overall - 1.1 (sd 6.2) mmHg; renin-angiotensin blocker therapy - 4.2 (sd 4.7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (SD 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy (26·2 (SD 6·0) mmHg) than in those not on antihypertensive therapy (22·8 (SD 4·0) mmHg) (P¼0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy (29·5 (SD 6·4) mmHg) (interaction P¼0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall 21·1 (SD 6·2) mmHg; renin–angiotensin blocker therapy 24·2 (SD 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (SD 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy (26·2 (SD 6·0) mmHg) than in those not on antihypertensive therapy (22·8 (SD 4·0) mmHg) (P¼0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy (29·5 (SD 6·4) mmHg) (interaction P¼0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall 21·1 (SD 6·2) mmHg; renin–angiotensin blocker therapy 24·2 (SD 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

Identifying dietary modifications that potentiate the blood pressure (BP)-lowering effects of antihypertensive medications and that are practical for free-living people may assist in achieving BP reduction goals. We assessed whether two dietary patterns were effective in lowering BP in persons on antihypertensive therapy and in those not on therapy. Ninety-four participants (38/56 females/males), aged 55·6 (SD 9·9) years, consumed two 4-week dietary regimens in random order (Dietary Approaches to Stop Hypertension (DASH)-type diet and low-Na high-K (LNAHK) diet) with a control diet before each phase. Seated home BP was measured daily for the last 2 weeks in each phase. Participants were grouped based on antihypertensive drug therapy. The LNAHK diet produced a greater fall in systolic BP (SBP) in those on antihypertensive therapy (26·2 (SD 6·0) mmHg) than in those not on antihypertensive therapy (22·8 (SD 4·0) mmHg) (P¼0·036), and this was greatest for those on renin–angiotensin system (RAS) blocker therapy (29·5 (SD 6·4) mmHg) (interaction P¼0·007). The fall in SBP on the DASH-type diet, in those on therapy (overall 21·1 (SD 6·2) mmHg; renin–angiotensin blocker therapy 24·2 (SD 4·7) mmHg), was not as marked as that observed on the LNAHK diet. Dietary modifications are an important part of all hypertension management regimens, and a low-Na and high-K diet enhances the BP-lowering effect of antihypertensive medications, particularly those targeting the RAS.

The age and developmental stage at which calcium supplementation produces the greatest bone effects remain controversial. We tested the hypothesis that calcium supplementation may improve bone accrual in premenarcheal females. Fifty-one pairs of premenarcheal female twins (27 monozygotic and 24 dizygotic; mean ± SD age, 10.3 ± 1.5 yr) participated in a randomized, single-blind, placebo-controlled trial with one twin of each pair receiving a 1200-mg calcium carbonate (Caltrate) supplement. Areal bone mineral density (aBMD) was measured at baseline and 6, 12, 18 and 24 months. There were no within-pair differences in height, weight, or calcium intake at baseline. Calcium supplementation was associated (P < 0.05) with increased aBMD compared with placebo, adjusted for age, height, and weight at the following time points from baseline: total hip, 6 months (1.9%), 12 months (1.6%), and 18 months (2.4%); lumbar spine, 12 months (1.0%); femoral neck, 6 months (1.9%). Adjusted total body bone mineral content was higher in the calcium group at 6 months (2.0%), 12 months (2.5%), 18 months (4.6%), and 24 months (3.7%), respectively (all P < 0.001). Calcium supplementation was effective in increasing aBMD at regional sites over the first 12–18 months, but these gains were not maintained to 24 months.