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Objective:To evaluate the utility of three validated food responsiveness scales in measuring recall of, and responsiveness to, food marketing exposure on social media.Design:Cross-sectional survey among adolescents and adults who used the social media platform Twitch.tv (Twitch). Responsiveness to food marketing was self-reported as craving or purchasing any brands participants observed on Twitch. Participants completed three validated scales of food responsiveness: the revised 18-question Three Factor Eating Questionnaire (TFEQ), the external eating subscale of the Dutch Eating Behavior Questionnaire (DEBQ) and the External Food Cue Responsiveness (EFCR) scale. Adjusted linear regression models assessed the predictive ability of each scale on recall and responsiveness outcomes.Setting:Online survey.Participants:Five hundred and sixty-eight Twitch users (90·1 % male, 60·6 % White, 43·7 % aged 18–24, 25·9 % under 18).Results:In separate adjusted linear regression models, scores on the TFEQ were not related to any outcome, while DEBQ scores related to product cravings (OR: 1·10, 95 % CI 1·01, 1·19, P = 0·02). In contrast, scores on the EFCR scale were significantly associated with higher brand recall (incident rate ratio: 1·42, 95 % CI 1·20, 1·68, P < 0·001), product craving (OR: 3·93, 95 % CI 2·22, 7·17, P < 0·001) and purchasing behaviour (OR: 3·97, 95 % CI 1·99, 8·26, P < 0·001). A subset of three EFCR scale items related to influencer marketing were similarly associated with each outcome with greater precision in the point estimates than the overall EFCR.Conclusions:The EFCR scale predicted recall of and responsiveness to food marketing via Twitch, suggesting its utility in monitoring the effects of food marketing on social media.

Nutrition may impact bladder cancer survival. We examined the association between diet quality and overall and bladder cancer-specific survival. Bladder cancer cases from a population-based study reported pre-diagnosis diet. Diet quality was assessed using the 2010 Alternate Healthy Eating Index (AHEI-2010). Vital status was ascertained from the National Death Index. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) were estimated using proportional hazards and competing risks regression models. Overall AHEI-2010 adherence was not associated with overall or bladder cancer-specific survival among non-muscle invasive bladder cancer (NMIBC) cases (HR, 1.00; 95% CI, 0.98–1.01; HR, 1.00; 95% CI, 0.97–1.02) or muscle invasive bladder cancer (MIBC) cases (HR, 0.99; 95% CI, 0.96–1.03; HR, 1.01, 95% CI 0.97–1.06). AHEI-2010 sugar-sweetened beverages adherence was associated with poorer overall survival (HR, 1.04; 95% CI, 1.01–1.08) and AHEI-2010 sodium adherence was associated with better overall and bladder cancer-specific survival after NMIBC diagnosis (HR, 0.92, 95% CI, 0.85–1.00; HR, 0.82; 95% CI, 0.68–0.98). AHEI-2010 fruit adherence was associated with poorer overall and bladder cancer-specific survival after MIBC diagnosis (HR, 1.17; 95% CI, 1.02–1.33; HR, 1.26; 95% CI, 1.03–1.55). Consumption of sugar-sweetened beverages, sodium, and fruit, not overall AHEI-2010 adherence, may be associated with bladder cancer survival.

OBJECTIVE Rural-residing children in the United States experience higher suicide mortality than urban-residing children but are underrepresented in research. We examined changes in emergency department (ED) utilization and subsequent hospitalization for suicide or self-harm in a rural hospital after the coronavirus disease 2019 pandemic onset. METHODS This retrospective cohort study involved children aged 5 to 17 years visiting a rural, Northeastern hospital from January 1, 2017 to May 31, 2021. We used autoregressive integrated moving average modeling, an interrupted time series analysis, to examine monthly changes after the pandemic onset (March 2020) in ED visits with a primary mental health diagnosis, number of mental health visits with a suicide or self-harm diagnosis, proportion of patients with suicide or self-harm admitted to hospital, and length of stay for suicide or self-harm. RESULTS Prepandemic, there was an average of 20.6 visits per month for mental health conditions, with 23.3 visits per month postpandemic (P = .16). Monthly visits for suicide or self-harm were greater in the postpandemic (15.6 visits per month) versus prepandemic months (11.4 visits per month, P CONCLUSIONS Pediatric ED visits for suicide or self-harm increased at a significant rate during the coronavirus disease 2019 pandemic and a greater proportion resulted in hospitalization, highlighting the acute mental health needs of rural-residing children.

Background Diet is important for chronic disease management, with limited research understanding dietary choices among those with multi-morbidity, the state of having 2 or more chronic conditions. The objective of this study was to identify associations between packaged food and drink purchases and diet-related cardiometabolic multi-morbidity (DRCMM). Methods Cross-sectional associations between packaged food and drink purchases and household DRCMM were investigated using a national sample of U.S. households participating in a research marketing study. DRCMM households were defined as household head(s) self-reporting 2 or more diet-related chronic conditions. Separate multivariable logistic regression models were used to model the associations between household DRCMM status and total servings of, and total calories and nutrients from, packaged food and drinks purchased per month, as well as the nutrient density (protein, carbohydrates, and fat per serving) of packaged food and drinks purchased per month, adjusted for household size. Results Among eligible households, 3795 (16.8%) had DRCMM. On average, households with DRCMM versus without purchased 14.8 more servings per capita, per month, from packaged foods and drinks (p p = 0.002, p = 0.000, respectively). DRCMM households averaged fewer grams per serving of protein, carbohydrates, and fat per month across all food and drink purchases (all p p Conclusions DRCMM households purchased greater quantities of packaged food and drinks per capita than non-DRCMM households, which contributed to more fat, carbohydrates, and sodium in the home. However, food and drinks in DRCMM homes on average were lower in nutrient-density. Future studies are needed to understand the motivations for packaged food and drink choices among households with DRCMM to inform interventions targeting the home food environment.

Background Super-utilizers represent approximately 5% of the population in the United States (U.S.) and yet they are responsible for over 50% of healthcare expenditures. Using characteristics of hospital service areas (HSAs) to predict utilization of resource intensive healthcare (RIHC) may offer a novel and actionable tool for identifying super-utilizer segments in the population. Consumer expenditures may offer additional value in predicting RIHC beyond typical population characteristics alone. Methods Cross-sectional data from 2017 was extracted from 5 unique sources. The outcome was RIHC and included emergency room (ER) visits, inpatient days, and hospital expenditures, all expressed as log per capita. Candidate predictors from 4 broad groups were used, including demographics, adults and child health characteristics, community characteristics, and consumer expenditures. Candidate predictors were expressed as per capita or per capita percent and were aggregated from zip-codes to HSAs using weighed means. Machine learning approaches (Random Forrest, LASSO) selected important features from nearly 1,000 available candidate predictors and used them to generate 4 distinct models, including non-regularized and LASSO regression, random forest, and gradient boosting. Candidate predictors from the best performing models, for each outcome, were used as independent variables in multiple linear regression models. Relative contribution of variables from each candidate predictor group to regression model fit were calculated. Results The median ER visits per capita was 0.482 [IQR:0.351–0.646], the median inpatient days per capita was 0.395 [IQR:0.214–0.806], and the median hospital expenditures per capita was $2,302 [1$,544.70-$3,469.80]. Using 1,106 variables, the test-set coefficient of determination (R2) from the best performing models ranged between 0.184–0.782. The adjusted R2 values from multiple linear regression models ranged from 0.311–0.8293. Relative contribution of consumer expenditures to model fit ranged from 23.4–33.6%. Discussion Machine learning models predicted RIHC among HSAs using diverse population data, including novel consumer expenditures and provides an innovative tool to predict population-based healthcare utilization and expenditures. Geographic variation in utilization and spending were identified.

The purpose of this study is to validate the seven-item wheezing module from the International Study of Asthma and Allergies in Children (ISAAC) in the nationally representative Population Assessment of Tobacco and Health Study. Adult participants with complete Wave 2–3 data were selected, including those with asthma but excluding those with COPD and other respiratory diseases (n = 16,295). We created a nine-point respiratory symptom index from the ISAAC questions, assessed the reliability of the index, and examined associations with self-reported asthma diagnosis. Threshold values were assessed for association with functional outcomes. The weighted prevalence for one or more respiratory symptom was 18.0% (SE = 0.5) for adults without asthma, 70.1% (SE = 1.3) for those with lifetime asthma, 75.7% (SE = 3.7) for adults with past-year asthma not on medications, and 92.6% (SE = 1.6) for those on medications. Cronbach’s alpha for the respiratory symptom index was 0.86. Index scores of ≥2 or ≥3 yielded functionally important respiratory symptom prevalence of 7–10%, adequate sensitivity and specificity for identifying asthma, and consistent independent associations with all functional outcomes and tobacco use variables. Respiratory symptom index scores of ≥2 or ≥3 are indicative of functionally important respiratory symptoms and could be used to assess the relationship between tobacco use and respiratory health.

INTRODUCTION: Fast food (FF) advertising is a potential risk factor for FF consumption among children, yet the impact of such advertising on children’s FF intake has not been assessed in a longitudinal, naturalistic study. Whether parents’ FF consumption mitigates advertising effects is also unknown. METHODS: One-year, longitudinal study among 624 preschool-age children, 3–5 years old, and one parent each recruited from New Hampshire, 2014–2015. Parents completed six online surveys every eight weeks and, at each, reported the number of times their children consumed FF in the past week. Each child’s advertisement exposure was determined by counting the brand-specific FF advertisements aired within the programs they viewed on children’s TV networks during the study. At baseline, parents reported the frequency of their own FF consumption. Data were analyzed in 2017–2018. RESULTS: Three FF brands targeted TV advertising to children during the study: McDonald’s, Wendy’s and Subway. Few children were exposed to child-targeted advertising for Wendy’s or Subway. Results from adjusted Poisson regression models focused on McDonald’s showed a differential effect of advertisement exposure on children’s McDonald’s intake in the past week (any or mean intake) by parental FF consumption (P

Obesity is a pressing health concern within the United States (US). Obesity medicine "diplomates" receive specialized training, yet it is unclear if their accessibility and availability adequately serves the need. The purpose of this research was to understand how accessibility has evolved over time and assess the practicality of serving an estimated patient population with the current distribution and quantity of diplomates.Population-weighted Census tracts in US counties were mapped to the nearest facility on a road network with at least one diplomate who specialized in adult (including geriatric) care between 2011 and 2019. The median travel time for all Census tracts within a county represented the primary geographic access measure. Availability was assessed by estimating the number of diplomates per 100 000 patients with obesity and the number of facilities able to serve assigned patients under three clinical guidelines.Of the 3371 diplomates certified since 2019, 3036 were included. The median travel time (weighted for county population) fell from 28.5 min [IQR: 13.7, 68.1] in 2011 to 9.95 min [IQR: 7.49, 18.1] in 2019. There were distinct intra- and inter-year travel time variations by race, ethnicity, education, median household income, rurality, and Census region (all P 0.001). The median number of diplomates per 100 000 with obesity grew from 1 [IQR: 0.39, 1.59] in 2011 to 5 [IQR: 2.74, 11.4] in 2019. In 2019, an estimated 1.7% of facilities could meet the recommended number of visits for all mapped patients with obesity, up from 0% in 2011.Diplomate geographic access and availability have improved over time, yet there is still not a high enough supply to serve the potential patient demand. Future studies should quantify patient-level associations between travel time and health outcomes, including whether the number of available diplomates impacts utilization.

BACKGROUND: Fast-food intake is a modifiable obesity risk factor in early childhood, and child-directed fast-food marketing is common. Per self-regulatory guidelines regarding deception, premiums (ie, incentives or toy giveaways) in child-directed advertisements must be secondary to the advertised product. METHODS: Content analyses were performed of all child-directed fast-food television (TV) advertisements aired on four national US children’s TV networks, February 1, 2019, through January 31, 2020, to assess the emphasis of premiums relative to food. We quantified the percent of the audio transcript (word count) and visual airtime (seconds) that included premiums or food and the on-screen size of premiums relative to food in randomly selected frames from each advertisement. RESULTS: There were 28 unique child-directed advertisements for children’s fast-food meals in the study year; 27 advertisements were from one restaurant and accounted for nearly all (99.8%) of the total airtime for the 28 advertisements. Premiums were present in 27 of the 28 unique advertisements. On average, premiums (versus food) accounted for 53.0% (vs 16.0%) of words in the audio transcript and 59.2% (vs 54.3%) of the visual airtime per advertisement. In the random subset of frames that includes both premiums and food imagery, imagery of premiums accounted for 9.7% (95% CI: 6.4%–13.0%) of the on-screen area, whereas imagery of food accounted for 5.7% (95% CI: 4.4%–7.0%), an average ratio of 1.9:1 within each frame when excluding one large outlier. CONCLUSIONS: Child-directed fast-food TV advertisements emphasize premiums over food in violation of self-regulatory guidelines, counter to childhood obesity prevention efforts.

Objectives Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention. Materials and methods Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery. Results Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more. Conclusion A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits. Trial registration The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Objective:To evaluate the prevalence of food and beverage marketing on Twitch.tv (Twitch), a social media platform where individuals broadcast live audiovisual material to millions of daily users.Design:Observational analysis of the prevalence of 238 food and beverage brands in five distinct categories (processed snacks; food delivery services and restaurants; candies, energy drinks/coffees/teas; and sodas and other sugar-sweetened beverages) over the course of 18 months.Setting:Twitch streamer profiles and stream titles between January 2018 and July 2019. Twitch chat room messages during July 2019.Participants:None.Results:There was a significant increase in brand exposure on Twitch both in stream titles (sodas and candies, P < 0·05) and on streamer profiles (sodas, restaurants/food delivery services, candies, and energy drinks/coffees/teas, P < 0·05) over the 18-month study period. Energy drinks, coffees and teas had the most exposure with 1·08 billion exposure hours from profiles and 83 million exposure hours from titles. Restaurants/food delivery services and sugar-sweetened beverages were the most frequently mentioned products in chat rooms with 1·24 million messages and 1·10 million messages, respectively.Conclusions:This study is the first to demonstrate the extent by which food and beverage brands garner millions of hours of exposure on Twitch. Future studies should evaluate the impact that this level of exposure to nutrient-poor, energy-dense products may have on behavioural and health outcomes.

Household chaos, characterized by high levels of confusion, disorganization and hurriedness in the home, is increasingly recognized as an important risk factor for adverse child outcomes. Early research on household chaos and child well-being was largely within the field of developmental psychology, where greater levels of household chaos has been associated with greater behavioral, attention and learning problems in young children. The potential influence of household chaos on child health behaviors is more recently gaining attention within public health. A recent study by Marsh et al., entitled, the Relationship between Household Chaos and Child, Parent, and Family Outcomes: A Systematic Scoping Review, presents the findings from 112 studies that assessed the influence of household chaos on a wide range of child outcomes. Findings highlight the various adverse child health outcomes across multiple domains that may be negatively affected by greater levels of household chaos including a few that reflect child health behaviors such as sleep, diet and weight gain. The review additionally presents findings from mediation and moderation analyses. This commentary highlights key aspects of the Marsh et al. review and outlines the implications of the work within health behavior research. This commentary further identifies child screen media use as a critically understudied area when considering the interplay between household chaos and child well-being.

Objectives Tobacco products in the US market are growing in diversity. Little is known about how youth access tobacco products given this current landscape. Methods Data were drawn from 15- to 17-year-olds from the Wave 1 youth sample of the US nationally representative Population Assessment of Tobacco and Health (PATH) Study. Past 30-day tobacco users were asked about usual sources of access to 12 different tobacco products, and if they had been refused sale because of their age. Results Among 15- to 17-year-olds, social sources (“someone offered” or “asked someone”) were the predominant usual source of access for each tobacco product. “Bought by self” was the usual source of access for users of smokeless (excluding snus, 23.2%), cigarillos (21.0%), cigarettes (13.8%), hookah (12.0%), and electronic cigarettes (10.5%). Convenience stores and/or gas stations were the most often selected retail source for all products except hookah. Among youth who attempted purchase, 24.3% were refused sale of cigarettes, 23.9% cigarillos, and 13.8% smokeless tobacco. Conclusions Most 15- to 17-year-old tobacco users obtain tobacco products through social sources; however, among those who purchased tobacco, the majority report not being refused sale because of age. At the time of survey, cigarette and cigar sales to under 18 years were prohibited in all 50 states, and electronic cigarettes sales in 47 states and two territories. 2014 Annual Synar Reports signaled increasing trends in retail violations of state and/or district laws prohibiting tobacco product sales to under 18 years. Monitoring illicit youth sales, conducting compliance check inspections, and penalizing violations remain important to reduce youth tobacco access at retail venues. Implications Access to the spectrum of tobacco products by youth in the United States remains predominantly through social sources. However, of the minority of youth tobacco users in 2014 who purchased tobacco themselves, a few reported being refused sale: Convenience stores and/or gas stations were the most common retail source for tobacco products. The strategies of monitoring illicit youth sales, conducting compliance checks, and penalizing violations remain important to reduce youth tobacco access at retail venues. Limiting sources of youth tobacco access remains an important focus to reduce the burden of tobacco on the public health.

Background Excess screen media use is a robust predictor of childhood obesity. Understanding how household factors may affect children’s screen use is needed to tailor effective intervention efforts. The preschool years are a critical time for obesity prevention, and while it is likely that greater household disorder influences preschool-aged children’s screen use, data on that relationship are absent. In this study, our goal was to quantify the relationships between household chaos and screen use in preschool-aged children. Methods A cross-sectional, online survey was administered to 385 parents of 2–5 year-olds recruited in 2017. Household chaos was measured with the Confusion, Hubbub and Order Scale (i.e., the chaos scale), a validated, parent-reported scale. The scale consists of 15 items, each scored on a 4-point Likert scale. Final scores were the sum across the 15 items and modeled as quartiles for analyses. Parents reported their children’s screen use for nine electronic media activities. Adjusted linear and Poisson regression were used to model associations between household chaos and children’s total weekly screen use, screen use within one hour of bedtime and screen use in the bedroom. Results Children averaged 31.0 (SD = 23.8) hours per week with screens, 49.6% used screens within one hour of bedtime and 41.0% used screens in their bedrooms. In adjusted regression models, greater household chaos was positively associated with weekly screen use (P = 0.03) and use of screens within one hour of bedtime (P

Foods of low nutritional quality are heavily marketed to children, and exposure to food ads shapes children's preferences and intake towards advertised foods. Whether food ad exposure independently relates to an overall lower diet quality among children remains unclear. We examined the association between ad-supported media use, a proxy for food ad exposure, and diet quality using the baseline data (2014-2015) from 535 3-5-year-olds in a community-based cohort study. Parents reported their child's dietary intake over 3 days via a diary, and diet quality was assessed with the Healthy Eating Index (HEI-2015) where higher scores reflect greater adherence to USDA dietary guidelines. Children's media exposure was measured through online parent surveys. Mean HEI score was 54.5 (SD = 9.4). In models adjusted for sociodemographic characteristics and metrics of parent diet quality, children's HEI scores were 0.5 points lower (adjusted beta = -0.5 [95% CI: 0.8, -0.1]; P 0.01) for each 1-h increment in weekly viewing of ad-supported children's TV networks. Children's use of media that may have food ads (e.g., apps, online games) also related to a lower diet quality yet to a lesser extent (adjusted beta -0.2 [-0.2, -0.1]; P 0.01). In contrast, children's ad-free media use was not associated with diet quality (P = 0.21). Findings support the premise that exposure to food advertisements via media may result in a lower quality diet among children independently of other risk factors.

Background Birth weight has a U-shaped relation with chronic disease. Diet quality during pregnancy may impact fetal growth and infant birth weight, yet findings are inconclusive. Objective We examined the relation between maternal diet quality during pregnancy and infant birth size among women enrolled in a prospective birth cohort. Methods Women 18-45 y old with a singleton pregnancy were recruited at 24-28 wk of gestation from prenatal clinics in New Hampshire. Women completed a validated food frequency questionnaire at enrollment. Diet quality was computed as adherence to the Alternative Healthy Eating Index. Infant birth outcomes (sex, head circumference, weight, and length) were extracted from medical records. Weight-for-length z scores, low birth weight, macrosomia, and size for gestational age [small for gestational age (SGA) or large for gestational age (LGA)] were computed. Multivariable regression models fit each outcome on quartiles of diet quality, adjusted for covariates. Models were computed overall and stratified by smoking status. Results Analyses included 862 women and infants with complete data. Lower diet quality was associated with lower maternal education, being a smoker, prepregnancy obesity status, and lack of exercise during pregnancy. Overall, 3.4% of infants were born with a low birth weight, 12.1% with macrosomia, 4.6% were SGA, and 8.7% were LGA. In an adjusted model, increased diet quality appeared linearly associated with a reduced likelihood of SGA (P-trend = 0.03), although each quartile comparison did not reach statistical significance. Specifically, ORs for SGA were 0.89 (95% CI: 0.37, 2.15), 0.73 (95% CI: 0.28, 1.89), and 0.35 (95% CI: 0.11, 1.08) for each increasing quartile of diet quality compared to the lowest quartile. Similar trends for SGA were observed among non-smokers (n = 756; P-trend = 0.07). Also among non-smokers, increased diet quality was associated with lower infant birth weight (P-trend = 0.03) and a suggested reduction in macrosomia (P-trend = 0.07). Conclusions Increased diet quality during pregnancy was related to a reduced risk of SGA in this cohort of pregnant women from New Hampshire. Additional studies are needed to elucidate the relation between maternal diet quality and macrosomia.

Polymorphisms in the Fat Mass and Obesity Associated (FTO) gene are robustly associated with overweight and obesity among children, although the underlying mechanisms are poorly understood. We tested if appetitive traits partially mediated the association between FTO genotype and increased BMI among a sample of US preadolescents. Data were from 178 unrelated 9–10 year olds who participated in an experimental study between 2013 and 2015. Children’s DNA was isolated from buccal swabs, and the rs9939609 SNP in the FTO gene was genotyped. Children’s age- and sex-adjusted BMI z-scores were computed using height and weight measured at the laboratory. Parents completed the Child Eating Behavior Questionnaire that includes three validated scales of habitual appetitive traits related to drive and regulation: satiety responsiveness, enjoyment of food and food responsiveness. Structural equation modeling was used to assess if those traits mediated the relationship between FTO and BMI z-score. The sample of children was 48.9% male and 91.0% non-Hispanic white. FTO distribution was in Hardy Weinberg equilibrium, and 16.3% of participants were homozygous for the high-risk allele. Mean BMI z-score was greatest among those with the high-risk genotype (ANOVA P

Background Fast food is cross-sectionally associated with having overweight and obesity in young children. Objectives To examine whether fast food intake independently contributes to the development of overweight and obesity among preschool-age children. Methods Prospective cohort of 3- to 5-year-old children (n = 541) followed for 1 year. Children's height and weight were objectively measured at baseline and study end. Parents reported their child's fast food intake frequency in the past week from 11 chain fast food restaurants in six online follow-up surveys, completed approximately 8 weeks apart. Poisson regression with robust standard errors modelled the risk of a child increasing in weight status (ie, transitioning from a having a healthy weight to having overweight or from having overweight to having obesity) over the study period in relation to their average weekly fast food intake, adjusted for sociodemographics, child obesogenic behaviours, and parent weight status. Results At baseline, 18.1% of children had overweight and 9.8% had obesity; 8.1% of children transitioned to a greater weight status over the 1-year period. Mean fast food intake frequency among consumers was 2.1 (SD: 1.4) times per week. The risk of increasing in weight status increased linearly with each additional time fast food was consumed in an average week over the study year (RR: 1.38; 95% CI, 1.13-1.67; P Conclusions Greater fast food intake over 1 year was associated with increasing weight status during that time in this preschool-age cohort.

Background Conditioned eating in response to external food cues may contribute to obesity risk in young children. Objectives To develop a brief, parent-reported scale to measure external food cue responsiveness for preschool-age children. Methods Focus groups with parents of preschool-age children were conducted to create an initial pool of items reflecting children's behavioral responses to external food cues. Items were included in a nationally-distributed online survey of parents of preschool-age children (n = 456). Factor analysis was used to reduce the initial item pool, the scale's psychometric properties were assessed, and scores were correlated with reported snacking behaviors. Results Nine items met inclusion criteria in the final scale, which had high internal consistency (alpha = 0.86). Final scores were the mean across the nine items. External food cue responsiveness was greater among children with, versus without, usual TV advertisement exposure. Furthermore, greater external food cue responsiveness mediated the relationship between children's usual TV advertisement exposure and snacking during TV viewing. Findings remained statistically significant when adjusted for food responsiveness as measured with the Child Eating Behavior Questionnaire. Conclusions Findings provide preliminary evidence that external food cue responsiveness is measurable by parental report in preschool-age children.

ObjectivesThis scoping review aims to facilitate psychometric developments in the field of digital media usage and well-being in young people by (1) identifying core concepts in the area of “screen time” and digital media use in children, adolescents, and young adults, (2) synthesising existing research paradigms and measurement tools that quantify these dimensions, and (3) highlighting important areas of need to guide future measure development.DesignA scoping review of 140 sources (126 database, 14 grey literature) published between 2014 and 2019 yielded 162 measurement tools across a range of domains, users, and cultures. Database sources from Ovid MEDLINE, PsycINFO and Scopus were extracted, in addition to grey literature obtained from knowledge experts and organisations relevant to digital media use in children. To be included, the source had to: (1) be an empirical investigation or present original research, (2) investigate a sample/target population that included children or young persons between the ages of 0 and 25 years of age, and (3) include at least one assessment method for measuring digital media use. Reviews, editorials, letters, comments and animal model studies were all excluded.MeasuresBasic information, level of risk of bias, study setting, paradigm, data type, digital media type, device, usage characteristics, applications or websites, sample characteristics, recruitment methods, measurement tool information, reliability and validity.ResultsSignificant variability in nomenclature surrounding problematic use and criteria for identifying clinical impairment was discovered. Moreover, there was a paucity of measures in key domains, including tools for young children, whole families, disadvantaged groups, and for certain patterns and types of usage.ConclusionThis knowledge synthesis exercise highlights the need for the widespread development and implementation of comprehensive, multi-method, multilevel, and multi-informant measurement suites.

BACKGROUND/OBJECTIVE Exposure to food advertisements may cue overeating among children, especially among those genetically predisposed to respond to food cues. We aimed to assess how television food advertisements affect eating in the absence of hunger among children in a randomized trial. We hypothesized that the Fat Mass and Obesity Associated Gene (FTO) rs9939609 single nucleotide polymorphism would modify the effect of food advertisements. SUBJECTS/METHODS In this randomized experiment, 200 children aged 9–10 years old were served a standardized lunch and then shown a 34-minute television show embedded with either food or toy advertisements. Children were provided with snack food to consume ad libitum while watching the show and we measured caloric intake. Children were genotyped for rs9939609 and analyses were conducted in the overall sample and stratified by genotype. A formal test for interaction of the food ad effect on consumption by rs9939609 was conducted. RESULTS 172 unrelated participants were included in this analysis. Children consumed on average 453 (SD=185) kCals during lunch and 482 (SD=274) kCals during the experimental exposure. Children who viewed food advertisements consumed an average of 48 kCals (95% CI: 10, 85; P=0.01) more of a recently advertised food than those who viewed toy advertisements. There was a statistically significant interaction between genotype and food advertisement condition (P for interaction = 0.02), where the difference in consumption of a recently advertised food related to food advertisement exposure increased linearly with each additional FTO risk allele, even after controlling for BMI percentile. CONCLUSIONS Food advertisement exposure was associated with greater caloric consumption of a recently advertised food, and this effect was modified by an FTO genotype. Future research is needed to understand the neurological mechanism underlying these associations.

Objective Attentional bias to food cues may be a risk factor for childhood obesity, yet there are few paradigms to measure such biases in young children. Therefore, the present work introduces an eye-tracking visual search task to measure attentional bias in young children. Methods: Fifty-one 3-6-year-olds played a game to find a target cartoon character among food (experimental condition) or toy (control condition) distractors. Children completed the experimental and toy conditions on two separate visits in randomized order. Behavioral (response latencies) and eye-tracking measures (time to first fixation, initial gaze duration duration, cumulative gaze duration ) of attention to food and toy cues were computed. Regressions were used to test for attentional bias to food versus toy cues, and whether attentional bias to food cues was related to current BMI z-score. Results: Children spent more cumulative time looking at food versus toy distractors and took longer to locate the target when searching through food versus toy distractors. The faster children fixated on their first food versus toy distractor was associated with higher BMI z-scores. Conclusions: Using a game-based paradigm employing eye-tracking, we found a behavioral attentional bias to food vs. toy distractors in young children. Further, attentional bias to food cues was associated with current BMI z-score.

Background The gut microbiome has an important role in infant health and immune development and may be affected by early-life exposures. Maternal diet may influence the infant gut microbiome through vertical transfer of maternal microbes to infants during vaginal delivery and breastfeeding. We aimed to examine the association of maternal diet during pregnancy with the infant gut microbiome 6 weeks post-delivery in mother-infant dyads enrolled in the New Hampshire Birth Cohort Study. Infant stool samples were collected from 145 infants, and maternal prenatal diet was assessed using a food frequency questionnaire. We used targeted sequencing of the 16S rRNA V4-V5 hypervariable region to characterize infant gut microbiota. To account for differences in baseline and trajectories of infant gut microbial profiles, we stratified analyses by delivery mode. Results We identified three infant gut microbiome clusters, characterized by increased abundance of Bifidobacterium, Streptococcus and Clostridium, and Bacteroides, respectively, overall and in the vaginally delivered infant stratum. In the analyses stratified to infants born vaginally and adjusted for other potential confounders, maternal fruit intake was associated with infant gut microbial community structure (PERMANOVA, p

Introduction Child-directed TV advertising is believed to influence children's diets, yet prospective studies in naturalistic settings are absent. This study examined if child-directed TV advertisement exposure for ten brands of high-sugar breakfast cereals was associated with children's intake of those brands prospectively. Methods Observational study of 624 preschool-age children and their parents conducted in New Hampshire, 2014–2015. Over 1 year, parents completed a baseline and six online follow-up surveys, one every 8 weeks. Children's exposure to high-sugar breakfast cereal TV advertisements was based on the network-specific TV programs children watched in the 7 days prior to each follow-up assessment, and parents reported children's intake of each advertised high-sugar breakfast cereal brand during that same 7-day period. Data were analyzed in 2017–2018. Results In the fully adjusted Poisson regression model accounting for repeated measures and brand-specific effects, children with high-sugar breakfast cereal advertisement exposure in the past 7 days (i.e., recent exposure; RR=1.34, 95% CI=1.04, 1.72), at any assessment in the past (RR=1.23, 95% CI=1.06, 1.42), or recent and past exposure (RR=1.37, 95% CI=1.15, 1.63) combined had an increased risk of brand-specific high-sugar breakfast cereal intake. Absolute risk difference of children's high-sugar breakfast cereal intake because of high-sugar breakfast cereal TV advertisement exposure varied by brand. Conclusions This naturalistic study demonstrates that child-directed high-sugar breakfast cereal TV advertising was prospectively associated with brand-specific high-sugar breakfast cereal intake among preschoolers. Findings indicate that child-directed advertising influences begin earlier and last longer than previously demonstrated, highlighting limitations of current industry guidelines regarding the marketing of high-sugar foods to children under age 6 years.

BACKGROUND: Nutritionally poor foods are heavily advertised to children on television. Whether those same products are also advertised to parents on television has not been systematically examined. METHODS: This study is a content analysis of advertisements for children’s packaged foods and beverages aired over US network, cable, and syndicated television for 1 year (2012 to 2013). The target audience of each advertisement was defined as children or parents based on advertisement content, where parent-directed advertisements included emotional appeals related to family bonding and love. Advertisement characteristics and patterns of airtime were compared across target audience, and the proportion of total airtime devoted to advertisements targeting parents was computed. RESULTS: Fifty-one children’s food or beverage products were advertised over the study year, 25 (49%) of which were advertised directly to parents. Parent-directed advertisements more often featured nutrition and health messaging and an active lifestyle than child-directed advertisements, whereas child-directed advertisements more frequently highlighted fun and product taste. Over all products, 42.4% of total airtime was devoted to advertisements that targeted parents. The products with the most amount of airtime over the study year were ready-to-eat cereals, sugar-sweetened beverages, and children’s yogurt, and the proportion of total advertisement airtime for those products devoted to parents was 24.4%, 72.8%, and 25.8%, respectively. DISCUSSION: Television advertisements for children’s packaged foods and beverages frequently targeted parents with emotional appeals and messaging related to nutrition and health. Findings are of concern if exposure to such advertisements among parents may shape their beliefs about the appropriateness of nutritionally questionable children’s foods and beverages.

Background: Eating in the Absence of Hunger (EAH), or consuming highly palatable foods when satiated, is one behavioral pathway that may lead to childhood obesity. EAH is an objective, laboratory-based measure. A more comprehensive understanding of potential determinants of EAH could inform childhood obesity programs outside of a laboratory setting. Objective: Systematic review of EAH experiments to identify individual, familial, and societal-level correlates of EAH among children 12 years of age or younger. Design: 1487 studies were retrieved from five electronic databases (Medline [PubMed], Web of Science, Cochrane Library, CINAHL, PsycINFO). Eligible studies were those that measured EAH as initially operationalized in a laboratory setting enrolling children ≤12 years or reporting age-specific results for children ≤12 years. Only articles written in English were included. Results: 12 cross-sectional, six prospective, and one behavioral-intervention studies were included in the review. EAH was observable among boys and girls; absolute levels of EAH increased with age; and maternal feeding styles were associated with EAH among girls. The most consistent evidence supported increased levels of EAH among overweight and obese versus normal weight children, both cross-sectionally and prospectively. Two studies supported a genetic component to EAH. Conclusions: Studies enrolling independent samples support a positive association between weight status and EAH among children; studies addressing causality are needed. Other various individual, genetic, and familiar characteristics were associated with EAH, yet studies among more heterogeneous sample populations are needed to confirm findings. Studies addressing societal-level factors related to EAH were absent.

IntroductionFlavour capsule cigarettes are a recent product worldwide, and little is known about the epidemiology of their use. We used data from a nationally representative survey to understand the sociodemographic characteristics of flavour capsule cigarette smokers and reasons for flavour capsule use.MethodsData were from the nationally representative, U.S. Population Assessment of Tobacco and Health survey (2013–2014). Analyses included 7181 adults, aged 18–44 years, who were current or former established (≥100 lifetime cigarettes) cigarette smokers. Participants reported their usual brand of cigarettes which were classified as non-menthol, menthol or flavour capsule. Analyses assessed differences in participant demographics, smoking patterns and reasons for use by product type among those aged 18–24 years. Analyses were weighted to account for the survey design.ResultsFlavour capsule cigarettes were the usual cigarettes among 9.4% of smokers aged 18–24 years and 6.0%, 3.7% and ConclusionsFlavour capsule cigarettes use is highest in young adults, particularly Hispanics. Young adult predominance, lower level of addiction symptoms and emphasis on pack design by flavour capsule users suggest that these products may be positioned as starter products.

IntroductionResearch on the relationship between digital media exposure and child development is complex, inconsistent and fraught with debate. A highlighted area of inadequacy surrounds the methodological limitations of measuring digital media use for both researchers and clinicians, alike. This protocol aims to (1) identify core concepts in the area of screen time and digital media use in children and adolescents (2) map existing research paradigms and screening/measurement tools that serve to underpin and operationalise core concepts and (3) provide an initial step in integrating these findings into a consolidated screening toolkit. It is expected this enterprise will help advance research and clinical evaluation in fields concerned with digital media use, namely medicine, child development and the social sciences.Methods and analysisThe planned scoping review will search relevant electronic databases, including Ovid MEDLINE, PsycINFO and Scopus, in addition to grey literature. All empirical investigations and presentation of original research will be considered, and measurement/screening tools for digital media usage in children and adolescents will be identified and reported on. Two reviewers will pilot test the screening criteria, and data extraction forms prior to independently screening all relevant literature and extracting the data. A three-stage synthesis process will be used to map the existent measurement and screening tools for digital media usage in children and adolescents.Ethics and disseminationThere are no ethical considerations for this scoping review. Plans for dissemination include publication in a top-tier, open-access journal, public presentations and conference proceedings. Presentation of the full scoping review has been accepted to the American Academy of Child & Adolescent Psychiatry 66th Annual Meeting.

Evidence is mixed regarding sugar-sweetened beverage (SSB) intake and adiposity among adults, perhaps because of reporting bias.The objective of this study is to determine the impact of reporting bias on any associations between increased SSB intake and overweight/obesity.Beverage intake and overweight/obese status (body mass index ≥ 25 kg m(-2)) were examined among adults from a dietary assessment and doubly labeled water study (n=250). Four web-based, 24-h recalls assessed dietary intake. SSB intake was categorized as no intake, 1-99 kcals per day and99 kcals per day. Logistic regression models adjusted for total caloric intake, age, race, education and diet quality compared SSB intake with overweight/obese status. To investigate dietary self-reporting bias, analyses were replicated in a subset of 'true reporters': those with self-reported total caloric intake within 25% of total energy expenditure per doubly labeled water assessments (n=108).One-half of participants were overweight/obese; more overweight/obese participants consumed SSB than normal-weight participants (69% vs 47%; P0.001). Intake of other beverages did not differ by adiposity. Less number of White participants (48%) consumed SSB compared with African-American participants (68%; P=0.002). Compared with no intake, SSB intake up to the median intake doubled the risk of being overweight/obese (odds ratio: 2.1, 95% confidence interval: 1.0-4.3; P=0.046) and SSB intake over the median more than doubled the risk (odds ratio: 2.6, 95% confidence interval: 1.2-6.0; P=0.018). When limited to true reporters, SSB intake significantly increased the risk of being overweight/obese by nearly fourfold.Underreporting of SSB intake may be attenuating true associations of SSB intake and the risk of being overweight/obese.

Background The timing of energy intake is a modifiable behaviour that may influence energy regulation and the risk of obesity. We examined the associations of energy intake in the morning, midday and evening with body mass index (BMI) (n = 239). Methods Cross-sectional analyses were performed using data from the University of California, Los Angeles Energetics Study. Energy intake was assessed using three 24-h dietary recalls and stratified by time-of-day: morning (00.00 h to 11.00 h), midday (11.00 h to 17.00 h) and evening (17.00 h to 00.00 h). Sensitivity analysis was conducted among ‘true-reporters’, whose self-reported energy intake was ±25% of total energy expenditure measured by doubly-labelled water (n = 99). Logistic regression models were performed adjusting for age, sex, race, education, total daily energy intake and physical activity. Results Energy intake in the morning was not associated with BMI. Participants who consumed ≥33% (versus

BACKGROUND: Preschoolers in the United States are heavily exposed to unhealthy food advertisements. Whether such exposure promotes cued eating has not been documented in this age group. METHODS: Randomized experiment among 60 children, aged 2 to 5 years, recruited in 2015–2016 from New Hampshire and Vermont. Children completed the experiment at a behavioral laboratory. Children were provided with a healthy snack to consume upon arrival then randomized to view a 14-minute TV program embedded with advertisements for either a food or a department store. Children were provided 2 snack foods to consume ad libitum while viewing the TV program; 1 of those snacks was the food advertised. Eating in the absence of hunger (EAH) was operationalized as the kilocalories of snack foods consumed. t tests were used to compare EAH by advertisement condition; linear regression models assessed effect modification by the child’s age, sex, BMI percentile, and parental feeding restriction. RESULTS: Mean age was 4.1 (SD 0.9) years, 55% of children were male, 80% were non-Hispanic white, and 20% were overweight or obese. There were no differences in child or socioeconomic characteristics by advertisement condition. Child BMI was not related to EAH. Mean kilocalories consumed during the EAH phase was greater among children exposed to the food advertisements (126.8, SD: 58.5) versus those exposed to the nonfood advertisements (97.3, SD: 52.3; P = .04), an effect driven by greater consumption of the advertised food (P < .01). There was no evidence of effect modification. CONCLUSIONS: Findings suggest that food advertisement exposure may encourage obesogenic-eating behaviors among the very young.

Low circulating concentrations of vitamin D metabolites have been associated with increased risk for several diseases and clinical conditions. Large observational studies and surveys have shown that obesity is independently associated with lower serum 25-hydroxyvitamin D (25(OH)D) concentration. Few studies have examined the effect of weight loss on serum 25(OH)D concentration. The purpose of this study was to prospectively examine the effect of weight loss on serum 25(OH)D concentration. Data were collected from 383 overweight or obese women who participated in a 2-year clinical trial of a weight-loss program, in which 51% (N = 195) lost at least 5% of baseline weight by 24 months, 18% (N = 67) lost 5–10%, and 33% (N = 128) lost >10%. Women who did not lose weight at 24 months had an increase in serum 25(OH)D of 1.9 (9.7) ng/ml (mean (SD)); 25(OH)D increased by 2.7 (9.1) ng/ml for those who lost 5–10% of baseline weight; and 25(OH)D increased by 5.0 (9.2) ng/ml for those who lost >10% of baseline weight (P = 0.014). At baseline, 51% (N = 197) of participants met or exceeded the recommended serum concentration of 20 ng/ml. By study end, 64% (N = 230) of overweight or obese women met this goal, as well as 83% (N = 20) of those whose weight loss achieved a normal BMI. These findings suggest that weight loss, presumably associated with a reduction in body fat, is associated with increased serum 25(OH)D concentration in overweight or obese women.

Purpose Hot flashes (HF) affect a large proportion of breast cancer (BC) survivors and can negatively affect their quality of life. Treatments other than estrogen replacement to alleviate HF are needed. Body weight is related to hot flashes, but little is known about the effect of weight change on HF. Patients and Methods We used data from 3,088 women previously treated for early-stage BC who were enrolled onto the Women's Healthy Eating and Living study to examine the association between weight change after a breast cancer diagnosis and the odds of reporting HF. Results Overall, 36.1% of participants reported moderate to severe HF at study entry. At 2 years postdiagnosis, 69.2% of women remained within 10%, 4.8% lost at least 10%, and 26.0% gained at least 10% of their prediagnosis weight. Those who gained at least 10% of their prediagnosis weight had a greater risk of reporting HF than women who remained weight stable in that same period (odds ratio [OR], 1.33; 95% CI, 1.11 to 1.60; P = .003). Weight loss of at least 10% of prediagnosis weight was associated with a nonsignificant reduced risk (OR, 0.72; 95% CI, 0.47 to 1.08; P = .118) of reporting HF. However, the trend of weight change (weight loss and weight gain) on HF was significant both when examined categorically (P = .03) and continuously (P < .001). Conclusion Prevention of weight gain after a BC diagnosis—a modifiable behavior—may offer a viable intervention for relief of HF. Effects of intentional weight loss in BC survivors requires further study.

Background: We examined if the reduced risk of breast cancer events seen among women without baseline hot flash symptoms in the Women's Healthy Eating and Living (WHEL) dietary intervention trial was related to changes in sex hormone concentrations. Methods: Baseline and year one concentrations of total and bioavailable estradiol, and testosterone and sex hormone-binding globulin (SHBG) were compared by intervention arm among 447 postmenopausal women without hot flashes. Cox proportional hazard models tested interaction terms between study arm and baseline hormone concentrations adjusted for study site, antiestrogen use, positive nodes, tumor size, oophorectomy status, and hormone replacement therapy use. Results: Sex hormone concentrations did not differ by study arm at baseline nor at year one. Twenty-two (9.8%) events occurred in the intervention arm versus 42 (18.9%) in the comparison arm (P = 0.009). Baseline bioavailable testosterone was significantly, positively associated with additional events (HR 1.69, 95% CI: 1.00–2.84; P = 0.049). There were significant interactions between the intervention and total (P = 0.015), and bioavailable (P = 0.050) testosterone: the intervention was more protective among participants with higher baseline total (HR 0.3, 95% CI: 0.2–0.7) or bioavailable (HR 0.4, 95% CI: 0.2–0.7) testosterone than for participants with lower baseline total (HR 0.8, 95% CI: 0.4–1.5) or bioavailable (HR 0.8, 95% CI: 0.4–1.5) testosterone. No significant effects were seen for estradiol or SHBG. Conclusions: The WHEL dietary intervention may have modified other risk factors of recurrence correlated with testosterone. Impact: Sex hormones should be considered as part of a larger biological system related to the risk of breast cancer recurrence. Cancer Epidemiol Biomarkers Prev; 20(5); 939–45. ©2011 AACR.

Given the increasing numbers of long-term survivors of breast cancer, research specific to prevention of recurrence, new breast cancer events, and mortality is of considerable public health importance. The objective of this report is to present a review of the published epidemiologic research on lifestyle and breast cancer outcomes among women with a history of breast cancer. This review focused on physical activity, diet, and adiposity; and the primary outcomes were additional breast cancer events and mortality. The most consistent finding from observational studies was that adiposity was associated with a 30% increased risk of mortality. Although the observational data were not as consistent (or abundant), physical activity appeared to be associated with a 30% decreased risk of mortality. These data do not indicate that alcoholic drinks are a risk factor. Based only on the observational studies, total dietary fat appeared to be a risk factor, fiber was protective, and information on micronutrients and specific foods was sparse. However, the null results of 2 dietary intervention trials in survivors suggests that lowering fat intake or increasing consumption of fruits, vegetables, and fiber will not lead to improved prognosis in breast cancer survivors. Given that a high proportion of breast cancer patients appear to be both sedentary and obese/overweight, clinical trials are needed to investigate whether the combination of increased physical activity and reduced adiposity can improve breast cancer prognosis.

Introduction Prevalence of walking and cycling for transport is low and varies greatly across countries. Few studies have examined neighborhood perceptions related to walking and cycling for transport in different countries. Therefore, it is challenging to prioritize appropriate built-environment interventions. Objectives The aim of this study was to examine the strength and shape of the relationship between adults’ neighborhood perceptions and walking and cycling for transport across diverse environments. Methods As part of the International Physical activity and Environment Network (IPEN) adult project, self-reported data were taken from 13,745 adults (18–65 years) living in physically and socially diverse neighborhoods in 17 cities across 12 countries. Neighborhood perceptions were measured using the Neighborhood Environment Walkability Scale, and walking and cycling for transport were measured using the International Physical Activity Questionnaire–Long Form. Generalized additive mixed models were used to model walking or cycling for transport during the last seven days with neighborhood perceptions. Interactions by city were explored. Results Walking-for-transport outcomes were significantly associated with perceived residential density, land use mix–access, street connectivity, aesthetics, and safety. Any cycling for transport was significantly related to perceived land use mix–access, street connectivity, infrastructure, aesthetics, safety, and perceived distance to destinations. Between-city differences existed for some attributes in relation to walking or cycling for transport. Conclusions Many perceived environmental attributes supported both cycling and walking; however, highly walkable environments may not support cycling for transport. People appear to walk for transport despite safety concerns. These findings can guide the implementation of global health strategies. Citation Kerr J, Emond JA, Badland H, Reis R, Sarmiento O, Carlson J, Sallis JF, Cerin E, Cain K, Conway T, Schofield G, Macfarlane DJ, Christiansen LB, Van Dyck D, Davey R, Aguinaga-Ontoso I, Salvo D, Sugiyama T, Owen N, Mitáš J, Natarajan L. 2016. Perceived neighborhood environmental attributes associated with walking and cycling for transport among adult residents of 17 cities in 12 countries: the IPEN study. Environ Health Perspect 124:290–298; http://dx.doi.org/10.1289/ehp.1409466

Achieving long-term adherence to a dietary pattern is a challenge in many studies investigating the relationship between diet and disease. The Women’s Healthy Eating and Living Study was a multi-institutional randomized trial in 3088 women at risk for breast cancer recurrence. At baseline, the average participant followed a healthy dietary pattern of 7 vegetable and fruit servings, 21 g/d of fiber, and 28.7% energy from fat, although fat intake increased over the enrollment period. Using primarily telephone counseling, the intervention group was encouraged to substantially increase intakes of vegetables, fruits, and fiber while decreasing fat intake. Sets of 24-h dietary recalls were completed on 90% of eligible participants at 1 y and 86% at 4 y. Using a conservative imputation analysis, at 1 y, the intervention group consumed 38% more vegetable servings (100% when including juice) than the comparison group, 20% more fruit, 38% more fiber, 50% more legumes, and 30% more whole grain foods, with a 20% lower intake of energy from fat. At 4 y, the between-group differences were 65% for vegetables (including juice), 25% fruit, 30% fiber, 40% legumes, 30% whole grain foods, and 13% lower intake of energy from fat. The intervention effect on fat intake was similar for early vs. late enrollees. Plasma carotenoid concentrations on a random 28% sample validated self-reported vegetable and fruit intake, with a between-group difference of 66% at 1 y and over 40% at 4 y. This large change will allow testing of hypotheses on the role of dietary change in preventing additional breast cancer events.

Background: Studies suggest that arsenic exposure influences birth outcomes; however, findings are mixed. Objective: We assessed in utero arsenic exposure in relation to birth outcomes and whether maternal prepregnancy weight and infant sex modified the associations. Methods: Among 706 mother–infant pairs exposed to low levels of arsenic through drinking water and diet, we assessed in utero arsenic exposure using maternal second-trimester urinary arsenic, maternal prepregnancy weight through self-report, and birth outcomes from medical records. Results: Median (interquartile range) of total urinary arsenic [tAs; inorganic arsenic (iAs) + monomethylarsonic acid (MMA) + dimethylarsinic acid (DMA)] was 3.4 μg/L (1.7–6.0). In adjusted linear models, each doubling of tAs was associated with a 0.10-cm decrease (95% CI: –0.19, –0.01) in head circumference. Results were similar for MMA and DMA. Ln(tAs) and ln(DMA) were positively associated with birth length in infant males only; among males, each doubling of tAs was associated with a 0.28-cm increase (95% CI: 0.09, 0.46) in birth length (pinteraction = 0.04). Results were similar for DMA. Additionally, arsenic exposure was inversely related to ponderal index, and associations differed by maternal weight. Each ln(tAs) doubling of tAs was associated with a 0.55-kg/m3 lower (95% CI: –0.82, –0.28, p < 0.001) ponderal index for infants of overweight/obese, but not normal-weight, mothers (pinteraction < 0.01). Finally, there was a significant interaction between maternal weight status, infant sex, and arsenic exposure on birth weight (pinteraction = 0.03). In girls born of overweight/obese mothers, each doubling of tAs was associated with a 62.9-g decrease (95% CI: –111.6, –14.2) in birth weight, though the association was null in the other strata. Conclusions: Low-level arsenic exposure may affect fetal growth, and the associations may be modified by maternal weight status and infant sex. Citation: Gilbert-Diamond D, Emond JA, Baker ER, Korrick SA, Karagas MR. 2016. Relation between in utero arsenic exposure and birth outcomes in a cohort of mothers and their newborns from New Hampshire. Environ Health Perspect 124:1299–1307; http://dx.doi.org/10.1289/ehp.1510065

To assess the associations between children's exposure to television (TV) networks that aired child-directed advertisements for children's fast food meals with the collection of fast food meal toy premiums and frequency of family visits to those restaurants.One hundred parents of children 3-7 years old were recruited from a rural pediatrics clinic during 2011; families receiving Medicaid were oversampled. Parents reported the child's TV viewing habits and family visit frequency to the fast food restaurants participating in child-directed TV marketing at the time, and their child's requests for visits to and the collecting of toy premiums from those restaurants. Logistic regression models assessed adjusted associations between a child's TV viewing with more frequent restaurant visits (≥monthly in this population). Structural equation modeling assessed if child requests or toy collecting mediated that association.Thirty-seven percent of parents reported ≥monthly visits to the select fast food restaurants. Among children, 54% requested visits to and 29% collected toys from those restaurants. Greater child commercial TV viewing was significantly associated with more frequent family visits to those fast food restaurants (aOR 2.84 for each 1-unit increase in the child's commercial TV viewing scale, P .001); toy collecting partially mediated that positive association.Higher exposure among children to commercial TV networks that aired child-directed ads for children's fast food meals was associated with more frequent family visits to those fast food restaurants. Child desire for toy premiums may be a mediating factor.

To examine whether weight gain after diagnosis of breast cancer affects the risk of breast cancer recurrence. Patients included 3215 women diagnosed with early stage breast cancer (Stage I > 1 cm., II, and IIIA) who were enrolled either in an observational cohort of breast cancer survivors or were part of the comparison group of a dietary intervention trial to prevent breast cancer recurrence. We computed weight change from 1 year prior to diagnosis to study enrollment. Delayed entry Cox proportional hazards models were used to evaluate associations of categories of weight change with time to recurrence, controlling for known prognostic factors. Neither moderate (5-10%) nor large (> 10%) weight gain (HR 0.8, 95% CI, 0.6-1.1; HR 0.9, 95% CI, 0.7-1.2, respectively) after breast cancer diagnosis was associated with an increased risk of breast cancer recurrence in the early years post-diagnosis (median time of 73.7 months from diagnosis). Our research provides evidence that weight gain commonly seen in the first several years following a breast cancer diagnosis does not increase a woman's risk for breast cancer recurrence in the first 5-7 years post-diagnosis. However, this research does not address the effects of weight gain on overall survival or on the risk of other new cancers, other prognostic outcomes of concern to the breast cancer survivor.

Study objective The epidemiology of emergency department (ED) visits for epistaxis is unknown. We use national data to fill this gap and test hypotheses that epistaxis visits are more common with increasing age and in winter. Methods We identify ED visit with epistaxis from 10 years of the National Hospital Ambulatory Medical Care Survey. We calculate visit rates by age and other demographic characteristics and assess mode of arrival and disposition. Results are presented with 95% confidence intervals (CIs). Results From 1992 to 2001, epistaxis occurred at 4,503,000 ED visits, or 0.46% (95% CI 0.41% to 0.51%) of all visits. Per 1,000 population, 1.7 (95% CI 1.5 to 1.9) ED visits for epistaxis occurred annually. The age-related frequency was bimodal, with peaks among those younger than 10 years (4.0 per 1,000 visits) and aged 70 to 79 years (12.0 per 1,000 visits). Most cases (83%; 95% CI 80% to 86%) were atraumatic. Traumatic cases were younger than atraumatic cases (mean age 31 versus 49 years). From December to February, atraumatic epistaxis occurred in 0.50% (95% CI 0.40% to 0.60%) of all visits versus 0.34% (95% CI 0.30% to 0.39%) during nonwinter months. Fifteen percent (95% CI 12% to 18%) of cases arrived by ambulance, and 6% (95% CI 5% to 7%) of patients were hospitalized. Conclusion Epistaxis accounts for about 1 in 200 ED visits in the United States. Although there is an early age peak (age >10 years), the frequency increases from age 20 years onward, with the highest rates in the elderly. Epistaxis visits are more common in the winter. Future efforts to decrease epistaxis visits might focus on education of the elderly and parents of young children about nasal mucosa care and basic approaches to home management.

Objective: To describe the epidemiology of US emergency department (ED) visits for bronchiolitis, including the characteristics of children presenting to the ED and the variability in bronchiolitis care in the ED. Methods: Data were obtained from the 1992 to 2000 National Hospital Ambulatory Medical Care Survey. Cases had International Classification of Diseases, Ninth Revision, Clinical Modification code 466 and were younger than 2 years. National estimates were obtained using assigned patient visit weights; 95% confidence intervals were calculated using the relative standard error of the estimate; analysis used χ2 and logistic regression. Results: From 1992 to 2000, bronchiolitis accounted for approximately 1,868,000 ED visits for children younger than 2 years. Among this same age group, the overall rate was 26 (95% confidence interval 22-31) per 1000 US population and 31 (95% confidence interval 26-36) per 1000 ED visits. These rates were stable over the 9-year period. Comparing children with bronchiolitis to those presenting with other problems, children with bronchiolitis were more likely boys (61% vs. 53%; P = 0.01) and Hispanic (27% vs. 20%; P = 0.008). Therapeutic interventions varied and 19% were admitted to the hospital. The multivariate predictor for receiving systemic steroids was urgent/emergent status at triage (odds ratio 4.0, 1.9-8.4). Multivariate predictors for admission were Hispanic ethnicity (odds ratio 2.3, 1.1-5.0) and urgent/emergent status at triage (odds ratio 3.7, 2.0-6.9). Conclusions: ED visit rates for bronchiolitis among children younger than 2 years were stable between 1992 and 2000. The observed ED practice variation demonstrates that children are receiving medications for which there is little supporting evidence. Boys and Hispanics are at-risk groups for presentation to the ED, and Hispanics are more likely to be hospitalized.

Objectives. We evaluated emergency department (ED)–based outreach for the State Children’s Health Insurance Program (SCHIP). Methods. We conducted a multicenter trial among uninsured children (≤ 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days. Results. We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P Conclusions. Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.

Background Hip fracture is a significant injury for older persons. Little has been reported about emergency department (ED) care of these patients. Objective To characterize the management of older patients treated in the ED for hip fracture with specific attention to the use of analgesia. Methods This study analysed data from the National Hospital Ambulatory Medical Care Survey ( approximately 400 hospitals report each year) for the years 1992-2000. We included records of patients who were at least 50 years old and had a diagnosis of hip fracture (International Classification of Disease, 9th revision, clinical modification 820-820.9) in any of the three fields allowed for recording diagnosis. Results There were 1,935,000 ED visits ( approximately 215,000 a year), predominantly among older white women. The rate in those over 80 years old was 25 times that of the youngest group. Fifty-six per cent of patients received analgesia (44% narcotics). There were no ethnic or racial distinctions in the use of analgesia. Conclusions The ED visit presents a largely untapped opportunity for focused efforts in fall and hip fracture prevention, especially in countries with comprehensive geriatric services and well integrated healthcare delivery systems. Despite the high likelihood of pain, the administration of analgesics appears to be low and may be a worthy focus for practice improvement.

Objectives: To describe the characteristics and admission patterns of patients with syncope presenting to U.S. emergency departments (EDs). Methods: The ED portion of the National Hospital Ambulatory Medical Care Survey, 1992–2000, was analyzed. Nationally representative weighted estimates for incidence and admission rates were estimated and stratified by demographic variables. Presence of cardiovascular diagnoses on ED discharge was noted. Results: Of the 865 million ED visits during the nine-year study period, an estimated 6.7 million (0.77%; 95% confidence interval [95% CI] = 0.69% to 0.85%) were related to syncope. Higher incidences of ED visits for syncope were found in elder, female, and non-Hispanic patients compared with their reference groups. The overall admission rate was 32% (95% CI = 28% to 36%). Older, male, and white patients were admitted more frequently than their counterparts. Of patients older than 80 years of age, 58% (95% CI = 49% to 67%) were admitted. Associated cardiovascular International Classification of Diseases, Ninth Revision (ICD-9), codes for ischemic, structural, and arrhythmic heart disease were noted in 10% (95% CI = 8% to 13%) of patients, and 66% (95% CI = 56% to 76%) of these patients were admitted. Conclusions: Syncope is a frequent reason for ED visits and admissions. Elders and patients with associated cardiovascular diagnoses are frequently discharged, and admission practices appear to deviate from consensus panel guidelines.

Background and Aim In the United States, the fast food companies McDonald’s and Burger King participate in marketing self-regulation programs that aim to limit emphasis on premiums and promote emphasis of healthy food choices. We determine what children recall from fast food television advertisements aired by these companies. Methods One hundred children aged 3–7 years were shown McDonald’s and Burger King children’s (MDC & BKC) and adult (MDA & BKA) meal ads, randomly drawn from ads that aired on national US television from 2010–11. Immediately after seeing the ad, children were asked to recall what they had seen and transcripts evaluated for descriptors of food, healthy food (apples or milk), and premiums/tie-ins. Results Premiums/tie-ins were common in children’s but rarely appeared in adult ads, and all children’s ads contained images of healthy foods (apples and milk). Participants were significantly less likely to recall any food after viewing the children’s vs. the adult ad (MDC 32% [95% confidence interval 23, 41] vs. MDA 68% [59, 77]) p

Objective To describe programming themes and the inclusion of adolescents in the base audience for television channels with high levels of energy drink advertising airtime. Design Secondary analysis of energy drink advertising airtime over US network and cable television channels (n = 139) from March, 2012 to February, 2013. Programming themes and the inclusion of adolescents in each channel's base audience were extracted from cable television trade reports. Main Outcome Measure Energy drink advertising airtime. Analysis Channels were ranked by airtime; programming themes and the inclusion of adolescents in the base audience were summarized for the 10 channels with the most airtime. Results Over the study year, 36,501 minutes (608 hours) were devoted to energy drink advertisements; the top 10 channels accounted for 46.5% of such airtime. Programming themes for the top 10 channels were music (n = 3), sports (n = 3), action-adventure lifestyle (n = 2), African American lifestyle (n = 1), and comedy (n = 1). MTV2 ranked first in airtime devoted to energy drink advertisements. Six of the 10 channels with the most airtime included adolescents aged 12–17 years in their base audience. Conclusions and Implications Energy drink manufacturers primarily advertise on channels that likely appeal to adolescents. Nutritionists may wish to consider energy drink media literacy when advising adolescents about energy drink consumption.

Background: The insulin-like growth factor-I (IGFI) receptor is a potential target for breast cancer treatment and may be influenced by dietary intake. Methods: Nested, case–control study of 265 postmenopausal breast cancer survivors; primary breast cancer tissue was stained to determine IGFI receptor status. Change in carbohydrate intake from baseline to year 1 of study was estimated from 24-hour dietary recalls. Breast cancer recurrence cases (91) were matched to two controls (n = 174) on disease and study characteristics and counter matched on change in carbohydrate intake. Weighted conditional logistic regression models fit the risk of recurrence on IGFI receptor status and dietary change. Results: Half of the tumors were IGFI receptor positive. Increased risk of recurrence was associated with IGFI receptor–positive status [HR 1.7; 95% confidence interval (CI), 1.2–2.5] and, separately, with a stable/increased intake of carbohydrates (HR 2.0; 95% CI, 1.3–5.0). There was a borderline significant interaction between those two variables (P = 0.11). Specifically, carbohydrate intake had no significant impact on risk of recurrence among women who were receptor negative, yet increased the risk of recurrence by more than 5-fold among women who were receptor positive (HR 5.5; 95% CI, 1.8–16.3). Conclusions: Among women whose tumor tissue is positive for the IGFI receptor, reducing carbohydrate intake after diagnosis could reduce the risk of breast cancer recurrence. These findings need replication in a larger sample. Impact: This is the first study to suggest that it may be possible to personalize dietary recommendations for breast cancer survivors based on molecular characteristics of their primary tumor tissue. Cancer Epidemiol Biomarkers Prev; 23(7); 1273–9. ©2014 AACR.

Habitual short sleep duration appears to increase the risk of obesity. The objective of this paper is to investigate the association of habitual sleep duration with objective measures of energy balance. One hundred twelve African-American and 111 non-Hispanic whites aged 21-69 y participated in a cross-sectional study of dietary assessment and biomarkers. Participants reported the mean number of hours per day spent sleeping over the past year. Short sleep duration was defined as ≤6 h/d of sleep. Energy intake (kilocalories) was objectively assessed using the 2-point doubly labeled water technique to determine total energy expenditure, which is approximately equal to energy intake. Physical activity energy expenditure (kilocalories) was estimated as total energy expenditure minus each participant's calculated basal metabolic rate and the thermogenic effect of food. Compared with participants who slept ≤6 h, individuals who slept 8 h were significantly less likely to be obese (OR: 0.33; 95% CI: 0.14, 0.79). However, this association was not linear across 6-9 h of sleep (P-trend = 0.16). There was an inverse association between sleep and energy intake (P-trend = 0.07): compared with ≤6 h/d, adults who reported ≥9 h sleep consumed 178 fewer kcal/d. There was also an inverse association between sleep and physical activity (P-trend = 0.05): compared with ≤6 h/d of sleep, adults who reported 9 h of usual sleep expended 113 fewer kcal/d in physical activity. These data indicate that, compared with longer sleep duration, adults who report habitual short sleep duration have somewhat higher physical activity energy expenditure but considerably higher energy intake. Habitual short sleep duration appears to be 1 of the facets of modern life leading to a mismatch between energy intake and physical activity.