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Objective:To characterise the prevalence and persistence of anaemia among Samoan children over a 2–3-year period.Design:Data were from two consecutive waves (2015 and 2017–2018) of the Ola Tuputupua’e ‘Growing up’ study. Anaemia (Hb < 11·0 or 11·5 g/dl for 2–4 and ≥ 5 years old, respectively) was considered ‘transient’ when it occurred at only one wave or ‘persistent’ if it was present at two consecutive waves. Child, maternal and household correlates of anaemia were examined using log-binomial and modified Poisson regressions.Setting:Eleven Samoan villages.Participants:Mother–child pairs (n 257) recruited in 2015 and reassessed in 2017–2018.Results:Anaemia prevalence was 33·9 % in 2015 and 28·0 % in 2017–2018; 35·6 % of cases identified in 2015 were persistent. Risk of anaemia at only one wave was lower among children who were older in 2015 (age 4 v. 2 years, adjusted relative risk (aRR) = 0·54, (95 % CI 0·35, 0·84), P = 0·007), had older mothers (≥ 40 v. 18–29 years, aRR = 0·61, (95 % CI 0·39, 0·95), P = 0·029) and had higher daily sodium intake (for every 100 mg/d, aRR = 0·97, (95 % CI 0·95, 0·99), P = 0·003) than children with no anaemia. Children whose anaemia persisted were more likely to have had a mother with anaemia (aRR = 2·13, (95 % CI 1·17, 3·89), P = 0·013) and had higher daily dietary iron intake (for every 10 mg/d, aRR = 4·69, (95 % CI 1·33, 16·49), P = 0·016) than those with no anaemia.Conclusions:Alongside broadly targeted prevention efforts, which are warranted given the moderate-high anaemia prevalence observed, specific attention should be paid to children with risk factors for persistent anaemia. Routine screening of children whose mothers have anaemia should be encouraged.

Objective: Self-monitoring technologies that help individuals track their health have proven effective in high-income countries but have not been widely tested or marketed in the Pacific islands. We conducted a pilot randomized controlled trial in Samoa to investigate the feasibility and acceptability of step-counters and digital scales. Methods: The trial enrolled 44 Samoan women (31-40 years), without previously diagnosed chronic conditions (hypertension, diabetes, etc.), who reported motivation to become more physically active. After measuring daily step counts for one week in the absence of feedback, participants were randomly assigned to one of three groups for a four-week intervention period: 1) FitBit Zip® step-counter, 2) digital BodyTrace© scale, or 3) both devices. Outcomes of interest were device use, psychosocial indicators of health, daily step counts, and body mass index, measured at baseline and post-intervention. Results: Participants who received scales used them a median of 5.5 times during the four-week intervention period. While FitBits were used a majority of days during the baseline period, there was significant decline in use during the intervention. In all groups, Health Locus of Control, Self-Efficacy for Exercise, and Weight Efficacy improved. However, while the Scale Only group reported improved health-related quality of life, the two groups that used FitBits either did not significantly change or significantly decreased in their assessments of this measure. No group demonstrated change in average daily step counts during the intervention; BMI increased among the two groups using the scales. Conclusions: Results suggest that self-monitoring technologies are acceptable in Samoa and generally improve psychosocial indicators of health. Further research is necessary to assess their effectiveness as an intervention tool and to determine how best to sustain device use over time. The significant increase in BMI over the relatively short intervention period highlights the importance of developing effective intervention approaches in this setting.

Sequencing ofCETPin Māori and Pacific peoples identified a common (MAF ∼2.4%-5.4%) population-specific missense variant (rs1597000001,CETP:c.530C>T p.Pro177Leu) that associates with higher HDL-C levels ([95% CI 0.211; 0.260]) and lower LDL-C ([95% CI -0.209; -0.058]). In a subsample of the study cohort (n = 11), heterozygous carriers of the population-specific variant had lower plasma CETP activity (P= 0.028). Our study identifies a population-specific missense variant inCETPwhich lowers CETP activity with an effect on HDL-C that is comparable to MendelianCETPloss-of-function mutations.

Obesity and diabetes have strong heritable components, yet the genetic contributions to these diseases remain largely unexplained. In humans, a missense variant in Creb3 regulatory factor (CREBRF) [rs373863828 (p.Arg457Gln); CREBRFR457Q] is strongly associated with increased odds of obesity but decreased odds of diabetes. Although virtually nothing is known about CREBRF’s mechanism of action, emerging evidence implicates it in the adaptive transcriptional response to nutritional stress downstream of TORC1. The objectives of this study were to generate a murine model with knockin of the orthologous variant in mice (CREBRFR458Q) and to test the hypothesis that this CREBRF variant promotes obesity and protects against diabetes by regulating energy and glucose homeostasis downstream of TORC1. To test this hypothesis, we performed extensive phenotypic analysis of CREBRFR458Q knockin mice at baseline and in response to acute (fasting/refeeding), chronic (low- and high-fat diet feeding), and extreme (prolonged fasting) nutritional stress as well as with pharmacological TORC1 inhibition, and aging to 52 weeks. The results demonstrate that the murine CREBRFR458Q model of the human CREBRFR457Q variant does not influence energy/glucose homeostasis in response to these interventions, with the exception of possible greater loss of fat relative to lean mass with age. Alternative preclinical models and/or studies in humans will be required to decipher the mechanisms linking this variant to human health and disease.

We describe diabetes care cascade engagement in 2010 and 2018 in adult Samoans and identify the characteristics of diabetes awareness. Participants were from a 2010 study of Samoans (n=2980, 24.5-< 65 years old), n= 500 of whom were followed-up in 2018 (32.5-72.5 years old). At follow-up individuals with a genetic variant associated with lower fasting glucose were oversampled by design. Care cascade components included diabetes prevalence (fasting glucose ≥ 126 mg/dL or diabetes medication use), self-report of doctor’s diagnosis of diabetes (awareness), diabetes medication use, and meets recommended glycemic control (fasting glucose ≤ 130 mg/dL). Percentage loss (proportion of individuals lost from each preceding stage) and unmet need of care (total prevalence - proportion of participants with controlled diabetes) were estimated. Characteristics associated with awareness were examined with logistic regression. In 2010, 469/2980 (15.7%) participants had diabetes, 242 (48.4% loss) were aware, 215 (11.1% loss) reported medication use, and 33 (84.6% loss) met glycemic control (unmet need of 92.9%). In 2018, 146 (29.2%) had diabetes; 61 (57.8% loss) were aware; 48 reported medication use (22.6% loss), and 7 (85.4% loss) met glycemic control (unmet need of 95.2%). Each year of added age (OR 1.07 [1.04-1.10] in 2010 and OR 1.06 [1.01-1.11] in 2018), and higher material lifestyle scores, a proxy for socioeconomic position, (OR 1.16 [1.02-1.33] in 2018) were associated with higher odds of diabetes awareness, and higher BMI (OR 0.93 [0.90-0.96] in 2018) and OR 0.94 [0.89-0.99] in 2018) and smoking (OR 0.49 [0.31-0.78] in 2010) with lower odds of awareness. We observed a very high level of unmet need in diabetes care and a high proportion of participants lost within the care cascade at both time points. Greater odds of disease awareness with increasing socioeconomic position in 2018 suggest that socioeconomic constraints may limit care engagement. Disclosure A. C. Rivara: None. N. Hawley: None. E. M. Russell: None. S. Viali: None. M. Reupena: None. T. K. Naseri: None. A. Pomer: None. R. L. Minster: None. D. E. Weeks: None. S. T. Mcgarvey: None. Funding National Institutes of Health (R01HL093093, R01HL140570, R01HL133040)

Obesity and diabetes have strong heritable components, yet the genetic contributions to these diseases remain largely unexplained. In humans, a missense variant in Creb3 regulatory factor (CREBRF) [rs373863828 (p.Arg457Gln); CREBRFR457Q] is strongly associated with increased odds of obesity but decreased odds of diabetes. Although virtually nothing is known about CREBRF’s mechanism of action, emerging evidence implicates it in the adaptive transcriptional response to nutritional stress downstream of TORC1. The objectives of this study were to generate a murine model with knockin of the orthologous variant in mice (CREBRFR458Q) and to test the hypothesis that this CREBRF variant promotes obesity and protects against diabetes by regulating energy and glucose homeostasis downstream of TORC1. To test this hypothesis, we performed extensive phenotypic analysis of CREBRFR458Q knockin mice at baseline and in response to acute (fasting/refeeding), chronic (low- and high-fat diet feeding), and extreme (prolonged fasting) nutritional stress as well as with pharmacological TORC1 inhibition. The results demonstrate that the murine CREBRFR458Q model of the human CREBRFR457Q variant does not influence energy/glucose homeostasis in response to these interventions. Alternative preclinical models and/or studies in humans will be required to decipher the mechanisms linking this variant to human health and disease.

ObjectiveThe minor allele of rs373863828 in CREBRF is associated with higher BMI, lower fasting glucose, and lower odds of type 2 diabetes. We examined the associations between BMI and rs373863828 on type 2 diabetes and fasting glucose with a large sample of adult Polynesians from Samoa, American Samoa and Aotearoa New Zealand and estimated direct and indirect (via BMI) effects of rs373863828 on type 2 diabetes and fasting glucose.Research Design and MethodsWe regressed type 2 diabetes and fasting glucose on BMI and rs373863828 stratified by obesity, regressed type 2 diabetes and fasting glucose on BMI stratified by rs373863828 genotype, and assessed the effects of rs373863828 on type 2 diabetes and fasting glucose with path analysis.ResultsAssociation of BMI with fasting glucose was greater in those without obesity than in those with obesity. We did not observe evidence of differences by genotype. In the path analysis, the minor allele has direct negative and indirect positive effects on type 2 diabetes risk and fasting glucose, with the indirect effect mediated through a direct positive effect on BMI.ConclusionsThere may be a stronger effect of BMI on fasting glucose in Polynesians without obesity than in those with obesity. Carrying the rs373863828 minor allele does not decouple higher BMI from odds of type 2 diabetes. Given the current cost of genotyping compared to the accessibility of measuring BMI, including rs373863828 as a clinical predictor of type 2 diabetes may not be indicated.

ObjectiveThe minor allele of rs373863828, a missense variant in CREBRF, is associated with higher BMI but lower odds of type 2 diabetes in Pacific Islanders.MethodsTo test if this protective effect operates through metabolically favorable body fat distribution, we examined the association of the minor A allele with body composition, measured using dual-energy x-ray absorptiometry (DXA), in a cross-sectional study of n=421 Samoan adults.ResultsWe replicated our earlier finding that this allele was associated with higher weight and BMI, although it was statistically significant only in women. There was no significant association of genotype with percent body fat, visceral adiposity or fat distribution, although in women, the A allele was associated with greater total fat mass (p=0.02), android (p=0.009) and trunk fat (p=0.01). In both sexes, age- and height-adjusted average lean mass was significantly greater per copy of the A allele: 2.16 kg/copy in women and 1.73 kg/copy in men.ConclusionsThese data do not support a primary role of fat distribution in mediating the association between rs373863828 genotype and type 2 diabetes risk. We suggest an alternative hypothesis: those with the A allele may more efficiently regulate blood glucose because of their greater absolute lean mass.

PRECIS Evaluation of nonmydriatic fundus photographs captured with a low-cost, smartphone-based camera facilitated remote screening of patients for enlarged optic nerve cup-to-disc ratio in the Independent Nation of Samoa, an underserved setting with one full-time ophthalmologist in the entire country. PURPOSE To investigate factors that impact inter-rater agreement of glaucoma suspect optic disc status using a low-cost, handheld nonmydriatic fundus camera. METHODS Color fundus photographs were obtained using the PanOptic iExaminer attached to an iPhone 6S by a lay examiner on 206 participants in the Independent Nation of Samoa. Images were remotely graded by an ophthalmologist and optometrist, and images from participants identified as at-risk for glaucoma were escalated to a glaucoma subspecialist for review. Fundus photo brightness, contrast, and focus were measured using the cup, rim, and temporal regions of the disc. Stereoscopic image pairs were subsequently generated from a subset of individual nonmydriatic photographs. RESULTS Features suggestive of glaucoma based on optic disc cupping were identified in 16.0% (33/206) of participants. There was moderately strong agreement between graders (90.3%) with κ=0.53 [95% confidence interval (CI)=0.33-0.73]. The intraclass correlation coefficients for the cup-to-disc ratio (CDR) and its difference were 0.84 (95% CI=0.81-0.87) and 0.68 (95% CI=0.59-0.75). Of the 33 participants identified, 94% had clinical risk criteria for potential glaucoma when reviewed by a subspecialist. Color fundus photograph cup brightness was significantly associated with cup-to-disc (CDR) grade, R2=0.36 (P

Objective: Samoa needs to intensify the response to the growing non‐communicable disease burden. This study aimed to assess bottlenecks in the care continuum and identify possible solutions. Methods: The mixed‐methods study used the cascade framework as an analysis tool and hypertension as a tracer condition for chronic non‐communicable diseases. Household survey data were integrated with medical record data of hypertension patients and results from focus group discussions with patients and healthcare providers. Results: Hypertension prevalence was 38.1% but only 4.7% of hypertensive individuals had controlled blood pressure. There were large gaps in the care continuum especially at screening and referral due to multiple socio‐cultural, economic and service delivery constraints. Conclusions: In Samoa, care for chronic non‐communicable diseases is not effectively addressing patient needs. This calls for better health communication, demand creation, treatment support, nutritional interventions and health service redesign, with a focus on primary healthcare and effective patient and community engagement. Implications for public health: The proposed actions can improve the reach, accessibility, quality and effectiveness of Samoa's chronic care services. Health system redesign is necessary to ensure continuity of care and more effective primary prevention. The findings are useful for other countries in the region facing similar challenges.

BackgroundThe growing burden of non-communicable diseases (NCDs) threatens low-income countries. Self-care practices are crucial for successful management of NCDs to prevent complications. We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.MethodsBetween April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted 19 in-depth interviews exploring treatment practices and response to symptoms. We used content analysis to identify emergent themes.ResultsThree themes emerged in patients’ descriptions of their self-care practices. First, patients preferred conventional medicines as their first line of resort, but often used traditional medicines. In particular, patients used traditional medicines to mitigate the negative impacts of inconsistent access to conventional medicines and to supplement those medicines. Second, patients adopted a wide range of vernacular practices to supplement treatments and unavailable diagnostic tests, including tasting their urine to gauge blood-sugar level. Finally, patients sought social support for self-care activities, relying on networks of family members and peers for instrumental and emotional support. Patients saw their children as the most reliable source of support, especially money for medicines, transport and home necessities.InterpretationPatients valued conventional medicines but also engaged in varied self-care practices. They depended upon networks of social support from family and peers to maintain self-care. Interventions to improve self-care may be more effective if they improve access to medicines and engage or enhance patients’ social support networks.

Background The prevalence of hypertension and diabetes are expected to increase in sub-Saharan Africa over the next decade. Some studies have documented that lifestyle factors and lack of awareness are directly influencing the control of these diseases. Yet, few studies have attempted to understand the barriers to control of these conditions in rural settings. The main objective of this study was to understand the challenges to hypertension and diabetes care in rural Uganda. Methods We conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals (HCPs), and 12 community health workers (known as village health team members [VHTs]) in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach. Results The results replicated several findings from other settings, and identified some previously undocumented challenges including patients’ knowledge gaps regarding the preventable aspects of HTN and DM, patients’ mistrust in the Ugandan health care system rather than in individual HCPs, and skepticism from both HCPs and patients regarding a potential role for VHTs in HTN and DM management. Conclusions In order to improve hypertension and diabetes management in this setting, we recommend taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members.

Background Organophosphate esters (OPEs)—used as flame retardants and plasticizers—are associated with adverse pregnancy outcomes such as reduced fecundity and live births and increased preterm delivery. OPEs may interfere with growth and metabolism via endocrine-disruption, but few studies have investigated endocrine-related outcomes. The objective of this pilot study (n = 56 mother-infant pairs) was to evaluate associations of OPEs with gestational weight gain (GWG), gestational age at delivery, infant anthropometry, and infant feeding behaviors. Methods We quantified OPE metabolites (bis-2-chloroethyl phosphate [BCEP], bis (1,3-dichloro-2-propyl) phosphate [BDCPP], diphenyl phosphate [DPHP]) in pooled maternal spot urine collected throughout pregnancy (~ 12, 28, and 35 weeks’ gestation). We obtained maternal sociodemographic characteristics from questionnaires administered at enrollment and perinatal characteristics from medical record abstraction. Trained research assistants measured infant weight, length, head and abdominal circumferences, and skinfold thicknesses at birth and 6 weeks postpartum. Mothers reported infant feeding behavior via the Baby Eating Behavior Questionnaire (BEBQ). Using multiple linear regression, we assessed associations of log2-transformed maternal urinary OPE metabolites with GWG, gestational age at delivery, infant anthropometry at birth, weekly growth rate, and BEBQ scores at 6 weeks postpartum. We used linear mixed effects (LME) models to analyze overall infant anthropometry during the first 6 weeks of life. Additionally, we considered effect modification by infant sex. Results We observed weak positive associations between all OPE metabolites and GWG. In LME models, BDCPP was associated with increased infant length (β = 0.44 cm, 95%CI = 0.01, 0.87) and weight in males (β = 0.14 kg, 95%CI = 0.03, 0.24). BDCPP was also associated with increased food responsiveness (β = 0.23, 95%CI = 0.06, 0.40). DPHP was inversely associated with infant abdominal circumference (β = − 0.50 cm, 95%CI = − 0.86, − 0.14) and female weight (β = − 0.19 kg, 95%CI = − 0.36, − 0.02), but positively associated with weekly growth in iliac skinfold thickness (β = 0.10 mm/wk., 95%CI = 0.02, 0.19). Further, DPHP was weakly associated with increased feeding speed. BCEP was associated with greater infant thigh skinfold thickness (β = 0.34 mm, 95%CI = 0.16, 0.52) and subscapular skinfold thickness in males (β = 0.14 mm, 95%CI = 0.002, 0.28). Conclusions Collectively, these findings suggest that select OPEs may affect infant anthropometry and feeding behavior, with the most compelling evidence for BDCPP and DPHP.

ObjectiveThe study aims were to (i) identify determinants of Nutrition Facts Panel (NFP) use and (ii) describe the association between NFP use and dietary intake among Latinos with type 2 diabetes.DesignBaseline cross-sectional data from a clinical trial were used to assess the association between NFP use and dietary intake. Diet was measured using two methods: (i) a diet quality score (the Healthy Eating Index-2010) derived from a single 24 h recall and (ii) dietary pattern (exploratory factor analyses) from an FFQ. Multivariable logistic and non-parametric quantile regressions were conducted, as appropriate.SettingsHartford County, Connecticut, USA.SubjectsLatino adults (n 203), ≥21 years of age, with diagnosed type 2 diabetes, glycosylated Hb≥7 %, and without medical conditions limiting physical activity.ResultsParticipants’ education level, diabetes-related knowledge and English speaking were positively associated with NFP use. At the higher percentiles of diet quality score, NFP use was significantly associated with higher diet quality. Similarly, NFP users were more likely to consume a ‘healthy’ dietary pattern (P=0·003) and less likely to consume a ‘fried snack’ pattern (P=0·048) compared with NFP non-users.ConclusionsThe association between reported NFP use and diet quality was positive and significantly stronger among participants who reported consuming a healthier diet. While NFP use was associated with a healthier dietary pattern, not using NFP was associated with a less-healthy, fried snack pattern. Longitudinal studies are needed to understand whether improving NFP use could be an effective intervention to improve diet quality among Latinos with type 2 diabetes.

Pacific Islanders face many health disparities, including higher rates of cardiovascular disease, cancer, obesity, and diabetes compared to other racial and ethnic groups. Specifically, the Marshallese population suffers disproportionately from type 2 diabetes, with rates 400% higher than the general US population. As part of an ongoing community-based participatory research (CBPR) partnership, 148 participants were recruited for a study examining genetic variants to better understand diabetes. Participants provided a saliva specimen in an Oragene® DNA self-collection kit. Each participant provided approximately 2 mL volume of saliva and was asked qualitative questions about their experience. The study yielded a recruitment rate of 95.5%. Among the 148 persons who participated, 143 (96.6%) agreed to be contacted for future studies; 142 (95.9%) agreed to have their samples used for future IRB-approved studies; and 144 (97.3%) gave permission for the researchers to link information from this study to other studies in which they had participated. Qualitative responses showed that the majority of participants were willing to participate because of their desire to contribute to the health of their community and to understand the genetic influence related to diabetes. This study demonstrates willingness to participate in genetic research among Marshallese living in Arkansas. Willingness was likely enhanced because the feasibility study was part of a larger CBPR effort. This study is important to community stakeholders who have voiced a desire to collaboratively conduct genetic research related to diabetes, perinatal outcomes, and cancer.

Background: Regular nutrition label use may have important long-term health implications. To our knowledge, the role of nutrition label use in protecting against the development of chronic diseases was unexplored prospectively before this study. Objective: We tested the association between nutrition label use and risk of a future diabetes diagnosis in a multiethnic US cohort. Design: Data from the ongoing National Longitudinal Survey of Youth–1979 (NLSY79) were analyzed. From 2002 (baseline) to 5 follow-up time points (2004–2012), 7150 diabetes-free, multiethnic young adults were prospectively followed for a diagnosis of incident diabetes. Nutrition label use, diabetes diagnosis, time to diabetes diagnosis, and all covariates were self-reported. Results: Between January 2002 and September 2013, 430 participants (6.0%) were diagnosed with diabetes. A weighted, multivariable, extended Cox regression was conducted, which suggested that in nutrition label users, the HR of diabetes diagnosis risk decreased significantly with time (P-nutrition label use × time interaction < 0.05) compared with risk in nutrition label nonusers. Conclusions: There is an association between nutrition label use and diabetes risk in the longer term. However, additional longitudinal research with a robust dietary intake assessment is needed to test this hypothesis.

Objective To understand how body size preferences changed in Samoa between 1995 and 2017 to 2019. Methods Data were from adults aged from 31 to 59 years, who participated in two separate cross-sectional studies of obesity and cardiometabolic risk conducted in Samoa in 1995 and 2017 to 2019. Participants nominated line drawings representing their current size, ideal size, the most attractive and healthiest size, and the lower/upper limits of "normal" size. Results In both sexes, body size preferences and perceived current average body size have increased, yet preference for bodies smaller than one's perceived current size has persisted. Furthermore, the range of body sizes that people considered "normal" has narrowed, suggesting decreased tolerance for extremes of body size. Conclusions These findings may have implications for mental and physical health outcomes, inform development of future health initiatives, and contribute to a deeper understanding of how body norms and weight-related public health efforts interface.

ObjectiveYoung children are particularly vulnerable to malnutrition as nutrition transition progresses. The present study aimed to document the prevalence, coexistence and correlates of nutritional status (stunting, overweight/obesity and anaemia) in Samoan children aged 24–59 months.DesignA cross-sectional community-based survey. Height and weight were used to determine prevalence of stunting (height-for-age Z-score Z-score >+2) based on WHO growth standards. Anaemia was determined using an AimStrip Hemoglobin test system (Hb SettingTen villages on the Samoan island of Upolu.SubjectsMother–child pairs (n 305) recruited using convenience sampling.ResultsModerate or severe stunting was apparent in 20·3 % of children, 16·1 % were overweight/obese and 34·1 % were anaemic. Among the overweight/obese children, 28·6 % were also stunted and 42·9 % anaemic, indicating dual burden of malnutrition. Stunting was significantly less likely among girls (OR=0·41; 95 % CI 0·21, 0·79, PP=0·032). The odds of anaemia decreased with age and anaemia was more likely in children with an anaemic mother (OR=2·20; 95 % CI 1·22, 3·98, P=0·007). No child, maternal or household characteristic was associated with more than one of the nutritional status outcomes, highlighting the need for condition-specific interventions in this age group.ConclusionsThe observed prevalences of stunting, overweight/obesity and anaemia suggest that it is critical to invest in nutrition and develop health programmes targeting early childhood growth and development in Samoa.

SummaryBackground Paediatric observational studies demonstrate associations between sleep, television viewing and potential changes in daytime activity levels. Objective(s) To determine whether experimental changes in sleep lead to changes in children's sedentary and physical activities. Methods Using a within-subject counterbalanced design, 37 children 8–11 years old completed a 3-week study. Children slept their typical amount during a baseline week and were then randomized to increase or decrease mean time in bed by 1.5 h/night for 1 week; the alternate schedule was completed the final week. Children wore actigraphs on their non-dominant wrist and completed 3-d physical activity recalls each week. Results Children reported watching more television (p

Background The prevalence of obesity and diabetes in Samoa, like many other Pacific Island nations, has reached epidemic proportions. Although the etiology of these conditions can be largely attributed to the rapidly changing economic and nutritional environment, a recently identified genetic variant, rs373863828 (CREB 3 regulatory factor, CREBRF: c.1370G>A p.[R457Q]) is associated with increased odds of obesity, but paradoxically, decreased odds of diabetes. Objective The overarching goal of the Soifua Manuia (Good Health) study was to precisely characterize the association of the CREBRF variant with metabolic (body composition and glucose homeostasis) and behavioral traits (dietary intake, physical activity, sleep, and weight control behaviors) that influence energy homeostasis in 500 adults. Methods A cohort of adult Samoans who participated in a genome-wide association study of adiposity in Samoa in 2010 was followed up, based on the presence or absence of the CREBRF variant, between August 2017 and March 2019. Over a period of 7-10 days, each participant completed the main study protocol, which consisted of anthropometric measurements (weight, height, circumferences, and skinfolds), body composition assessment (bioelectrical impedance and dual-energy x-ray absorptiometry), point-of-care glycated hemoglobin measurement, a fasting blood draw and oral glucose tolerance test, urine collection, blood pressure measurement, hand grip strength measurement, objective physical activity and sleep apnea monitoring, and questionnaire measures (eg, health interview, cigarette and alcohol use, food frequency questionnaire, socioeconomic position, stress, social support, food and water insecurity, sleep, body image, and dietary preferences). In January 2019, a subsample of the study participants (n=118) completed a buttock fat biopsy procedure to collect subcutaneous adipose tissue samples. Results Enrollment of 519 participants was completed in March 2019. Data analyses are ongoing, with results expected in 2020 and 2021. Conclusions While the genetic variant rs373863828, in CREBRF, has the largest known effect size of any identified common obesity gene, very little is currently understood about the mechanisms by which it confers increased odds of obesity but paradoxically lowered odds of type 2 diabetes. The results of this study will provide insights into how the gene functions on a whole-body level, which could provide novel targets to prevent or treat obesity, diabetes, and associated metabolic disorders. This study represents the human arm of a comprehensive and integrated approach involving humans as well as preclinical models that will provide novel insights into metabolic disease. International Registered Report Identifier (IRRID) RR1-10.2196/17329

Background In 2020, non-communicable diseases (NCDs) currently account for 40% of deaths in east Africa and are expected to surpass communicable diseases as the leading causes of death in sub-Saharan Africa by 2030. However, there remain many gaps in the provision of high quality, patient-centred NCD service delivery in low-income countries such as Uganda, especially in rural settings. We developed a discrete choice experiment (DCE) to understand how patients with common NCDs, such as hypertension and diabetes, make health-care-seeking decisions. A DCE is a quantitative tool that measures the weight of different factors that affect a decision. Participants are presented with two hypothetical scenarios to choose between. Here we report on the formative, qualitative phase of DCE development. Methods For this DCE, choice sets consist of two health facilities described in terms of various attributes (factors) that affect decision-making. To develop a locally relevant DCE, we conducted formative qualitative research consisting of 18 in-depth interviews with patients seeking care for hypertension or diabetes, or both, at three health facilities in rural Nakaseke District, Uganda. We purposively selected participants so that each disease and facility were represented. Interviews explored how participants choose which facility to visit and challenges that she or he faces in accessing care or medicines, or both. A team of three researchers coded the interviews using a directed approach to reveal 11 potential attributes on which patients make decisions. After review of the data and analysis with local and international content experts, we narrowed this list to six attributes to be included in the DCE. Findings The six selected attributes included: provision of education; availability of medicines; transport to the facility; costs associated with treatment; interactions with health-care providers; and presence of peer support groups. Attribute levels encompassed the range of experiences for each attribute as emerged from qualitative analysis. We then developed a full profile, fractional factorial DCE with three surveys. Interpretation The process of developing this NCD-focused DCE relied on reference to the literature, primary qualitative data collection, and expert consensus to create a tool that would yield actionable data to improve NCD health service delivery in rural Uganda. Little is known about how rural patients in low-income and middle-income countries navigate the health-care system, nor is there much description of how to develop DCEs to investigate patient preferences in these countries. This work will guide public health officials in developing NCD service delivery options and inform investigators on DCE development. Funding Yale Institute of Global Health Hecht Global Health Faculty Network Award Downs International Health Student Travel Fellowship

Background The prevalence of non-communicable diseases (NCDs) is increasing in rural sub-Saharan Africa. Implementation and adaptation of recommended self-care practices is crucial for successful management of NCDs to prevent complications. However, little is known about self-care practices in patients living in rural sub-Saharan Africa. In this study, we aimed to understand patients' adherence to self-care practices for hypertension, diabetes, or both, in rural Uganda and their reasons for non-adherence. Methods We conducted a mixed-methods study in adult patients previously diagnosed with diabetes or hypertension, or both, who attended outpatient NCD clinics at three health facilities in Nakaseke district. We concurrently collected quantitative data from a random sample of patients using pretested, structured questionnaires and held focus group discussions and in-depth interviews with a purposive sample of patients. Descriptive statistics were calculated for the quantitative data. Qualitative analysis was conducted using a thematic approach. Findings Between April and August, 2019, we administered questionnaires and carried out six focus group discussions and 19 in-depth interviews with 385 participants. Mean age was 54·0 years (SD 14·57) and most respondents, 257 (66·8%), were female. Of the 385 participants, 39·2% (151) had diabetes; 36·9% (142) had hypertension, and 23·9% (92) had both conditions. Most respondents reported daily adherence to medication for hypertension (79·5% [186/234]) and diabetes (84·8% [206/243]). Few participants (15·6% [60/385]) reported daily vigorous physical activity, but 63·1% (243/385) reported moderate physical activity at least once per week. Most respondents reported adherence to recommendations for dietary changes (75·6% [291/385]), non-smoking (98·7% [380/385]), alcohol abstinence (90·1% [347/385]), and weight management (75·6% [291/385]). From the interviews and discussions, patients reported that they tried to adhere to recommended medications but were limited by the inability to obtain them. Most patients reported irregular self-monitoring and many reported confusion about recommended practices due to mixed messages, mainly from their peers. Respondents also reported use of herbal remedies, soaking swollen feet in salt water, and coping with stress through prolonged sleep, social isolation, and alcohol use. Interpretation Varied self-care practices exist among rural Ugandan NCD patients. Patients inconsistently engage in recommended practices because of uncertain access to medicines, structural barriers, and inconsistent messaging. Locally adapted educational self-care programmes and consistent access to medicines could help improve self-care in these patients. As low-income countries like Uganda continue to advance their NCD policies, specific attention should be focused on strategies to ensure equitable access to essential NCD medicines. Additionally, the unique circumstances of people living in rural settings should be taken into account when developing programmes for management of NCDs. Funding Yale Institute of Global Health Hecht Global Health Faculty Network Award

To determine associations among objectively-measured nocturnal sleep time, bedtime and obesogenic behaviors, including dietary intake, timing of intake, and physical activity, in a diverse sample of school-aged children who presented for behavioral treatment to enhance sleep duration.Eighty-seven children (8-11 y, 66.7% female, zBMI: 0.86 ± 1.0) who self-reported sleeping9.5 h/night were studied for one week using wrist actigraphy to estimate sleep; hip-worn accelerometers to measure physical activity; and 24 h dietary recalls to capture dietary intake and meal timing. Pearson and Spearman's rho correlations and linear regressions controlling for age, gender and race were used for statistical analyses.Mean bedtime was 10:31 PM (±58.2 min) and mean nocturnal sleep time was 7.7 h (±37.5 min). Although later bedtime was associated with shorter sleep time (r = -0.61, p 0.001), the two variables were differentially related to obesity risk factors. Later bedtime, but not sleep time, correlated with greater daily fat intake, later first meal of the day, and greater after-dinner intake (all p 0.05). Nocturnal sleep time, but not bedtime, correlated with zBMI (p = 0.04). Both sleep time and later bedtime were associated with a later last meal of the day (all p 0.05). Findings remained consistent after controlling for demographic factors. In short-sleeping school-aged children, bedtime may be more predictive of dietary obesity risk factors whereas sleep duration may be more predictive of zBMI. Results suggest that health providers should consider both bedtime and sleep duration for reducing obesity risk in children.Enhancing Sleep Duration: Effects on Children's Eating and Activity Behaviors, NCT03186508, https://clinicaltrials.gov/ct2/show/NCT03186508.

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers’ beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers’ beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social–cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers’ perceived discrimination from maternal health care providers.

Background Exposure to preeclampsia or gestational hypertension is associated with higher offspring systolic blood pressure ( SBP ), but less is known about associations with other cardiometabolic risk markers. Methods and Results We studied 1097 children from the Project Viva cohort born 1999‐2002. Exposures were preeclampsia or gestational hypertension and mean maternal SBP in each trimester from prenatal records. Outcomes were research measures in midchildhood (mean 8.0 years) of SBP , overall adiposity, and a global cardiometabolic risk score comprising measures of SBP , waist circumference, glycemia, and lipids. We conducted linear regression analyses adjusted for maternal characteristics and offspring sex and age. In adjusted models, maternal preeclampsia or gestational hypertension (n=98, 9.1%) versus normal blood pressure was associated with slightly higher offspring SBP z‐score (0.15 units; 95% confidence interval [CI] −0.03, 0.32) but otherwise predicted better cardiometabolic health markers including metabolic risk z‐score (−0.23 units; −95% CI 0.44, −0.03) and several of its components as well as lower body mass index z‐score (−0.27 units; 95% CI −0.48, −0.06) and lower fat mass index (−0.91 kg/m 2 ; 95% CI −1.35, −0.47). Similarly, higher mean third‐trimester maternal SBP was associated with higher offspring SBP z‐score (0.09 units per 10 mm Hg; 95% CI 0.02, 0.16) and lower overall and central adiposity but not with biomarkers of metabolic risk. Results for second‐trimester SBP were generally similar. First‐trimester blood pressure was associated with higher offspring blood pressure but not with other outcomes. Conclusions Higher maternal late‐pregnancy SBP and hypertensive disorders of pregnancy were associated with higher offspring SBP but otherwise better cardiometabolic health.

Background Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management. Methods We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data. Results VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services. Conclusions Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.

Background In Brazil, 88% of births among women with private insurance are caesarean sections, even though a caesarean rate above 15% is associated with greater maternal and child morbidity and mortality. Aiming to reduce unnecessary caesarean sections in the private sector, in July 2015 the Brazilian government enacted Resolucao Normativa 368, a regulation requiring the use of partograms, pre-natal cards to document pregnancies, and consent forms for elective caesareans, and recommending that obstetricians provide women with an informational letter about birth. Aims This study aimed to describe Brazilian women’s experiences deciding their mode of birth and obstetricians’ roles in this decision-making process after Resolucao Normativa 368’s enactment. Methods Interviews were conducted with obstetricians (n = 8) and women who had recently given birth (n = 19) in Pelotas, Brazil, and the constant comparative method was used to identify emergent themes. Findings Resolucao Normativa 368’s provisions do not appear to affect decision-making about birth mode. Reportedly, consent forms were rarely used, and were viewed as bureaucratic formalities. Obstetricians described consistent use of pre-natal cards and partograms, but all participants were unaware of informational letters about birth. Moreover, women viewed caesarean sections as a way to avoid pain, and obstetricians felt that vaginal birth’s long duration, unpredictability, and low remuneration contribute to high caesarean section rates. Conclusions Improved enforcement of Resolucao Normativa 368, accompanied by structural changes like an on-call schedule and higher compensation for vaginal births in the private sector, could better inform patients about modes of birth and incentivise physicians to encourage vaginal birth.

The objective of this study is to describe the utilization of prenatal care in American Samoan women and to identify socio-demographic predictors of inadequate prenatal care utilization. Using data from prenatal clinic records, women (n = 692) were categorized according to the adequacy of prenatal care utilization index as having received adequate plus, adequate, intermediate or inadequate prenatal care during their pregnancy. Categorical socio-demographic predictors of the timing of initiation of prenatal care (week of gestation) and the adequacy of received services were identified using one way analysis of variance and independent samples t tests. Between 2001 and 2008 85.4 % of women received inadequate prenatal care. Parity (P = 0.02), maternal unemployment (P = 0.03), and both parents being unemployed (P = 0.03) were negatively associated with the timing of prenatal care initiation. Giving birth in 2007–2008, after a prenatal care incentive scheme had been introduced in the major hospital, was associated with earlier initiation of prenatal care (20.75 vs. 25.12 weeks; P < 0.01) and improved adequacy of received services (95.04 vs. 83.8 %; P = 0.02). The poor prenatal care utilization in American Samoa is a major concern. Improving healthcare accessibility will be key in encouraging women to attend prenatal care. The significant improvements in the adequacy of prenatal care seen in 2007–2008 suggest that the prenatal care incentive program implemented in 2006 may be a very positive step toward addressing issues of prenatal care utilization in this population.

What is already known about this subject Samoan adults are recognized for their particularly high body mass index and prevalent obesity. While Polynesians are understudied in other populations infancy is a critical period in the development of obesity. Breastfeeding has been shown to attenuate obesity risk. What this study adds Samoan infants show remarkably rapid gain in weight but not length in early infancy resulting in a prevalence of overweight and obesity far higher than has been previously reported elsewhere. Breastfeeding is associated with slower weight gain in infancy suggesting that its protective benefits for obesity risk are generalizable outside of European-derived populations. BACKGROUND: Samoans are recognized for their particularly high body mass index and prevalent adult obesity but infants are understudied. OBJECTIVE: To examine the prevalence of overweight and obesity and determine the contribution of feeding mode to obesogenic growth trajectories in American Samoan infants. METHODS: Data were extracted from the well baby records of 795 (n = 417 male) Samoan infants aged 0-15 months. Mixed-effects growth models were used to produce individual weight and length curves. Further mixed-effects models were fitted with feeding mode (breastfed formula- or mixed-fed) as a single observation at age 4 (+/-2) months. Weight and length values were converted to z-scores according to the Centers for Disease Control 2000 reference. RESULTS: At 15 months 23.3% of boys and 16.7% of girls were obese (weight-for-length > 95th percentile). Feeding mode had a significant effect on weight and length trajectories. Formula-fed infants gained weight and length faster than breastfed infants. Formula-fed boys were significantly more likely to be obese at 15 months (38.6%) than breastfed boys (23.4%) chi(2) = 8.4 P < 0.01 odds ratio = 2.05 95% confidence interval (1.04 4.05). CONCLUSION: Obesity in American Samoans is not confined to adults. Obesity prevention efforts should be targeted at early life and promotion of breastfeeding may be a suitable intervention target. (c) 2013 The Authors. Pediatric Obesity (c) 2013 International Association for the Study of Obesity.

For the past three decades, global maternal and child health efforts have focused on ensuring adequate nutrition for pregnant women, access to essential medicines, skilled health providers, safe facilities for birthing, and treating conditions such as prematurity, which remains the leading cause of newborn death.1 As a result, maternal deaths have fallen by almost 45% since 1990 and the mortality of those aged under five years has more than halved.2 But, this global progress stands to be undermined by the rapidly rising prevalence of obesity and related non-communicable diseases (NCDs), such as diabetes and chronic hypertension, amongst the obstetric population.

Background Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa. Methods A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction. Result Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores. Conclusions Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers. Electronic supplementary material The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

BACKGROUND The majority of US consumers use the nutrition facts panel (NFP) or health claims for food selections. Although previous studies have consistently reported positive impacts of NFP use on dietary intake, evidence regarding the effect of the use of health claims, either alone or in combination with the NFP, on diet quality and health outcomes is scarce. OBJECTIVES Our primary objective was to test for associations of the use of food labels (the NFP or health claims) with overall diet quality in individuals with prediabetes. In addition, we examined the association between food label use and glycated hemoglobin (HbA1c) concentrations. DESIGN We conducted a weighted linear regression, which was appropriate for a complex sampling survey, with the use of cross-sectional data from 2654 US adults with undiagnosed prediabetes who participated in the 2005-2010 NHANES cycles. The following 4 categories of food label (NFP or health claims) use were identified: 1) both labels, 2) health claims only, 3) neither label, and 4) the NFP only. Healthy Eating Index-2010 score, which we used to assess diet quality, was calculated from two 24-h recalls. Blood samples for analyzing HbA1c concentrations (glycemic control) were collected in the mobile examination center. RESULTS The overall diet quality scores for the use of both labels [b: -2.76 (95% CI: -5.04, -0.48); P = 0.019], of health claims only [b: -3.46 (-6.64, -0.28); P = 0.033], and of neither label [b: -4.01 (-5.75, -2.28); P < 0.001] were lower than those of NFP-only users. Moreover, HbA1c concentrations of users of both labels [b: 0.09% (95% CI: 0.03%, 0.16%); P = 0.008] and health claims only [b: 0.13% (95% CI: 0.02%, 0.25%); P = 0.021] were higher than those of NFP-only users. CONCLUSIONS In participants with undiagnosed prediabetes, the use of health claims alone, of both labels, or of neither label (compared with the use of the NFP only) was associated with poorer diet quality. In addition, users of neither label and users of both labels had poorer glycemic control. Further studies are needed to understand why the use of health claims may not be health promoting in this high-risk population.

Lower levels of LINE-1 methylation in peripheral blood have been previously associated with risk of developing non-communicable conditions, the most well-explored of these being cancer, although recent research has begun to link altered LINE-1 methylation and cardiovascular disease. We examined the relationship between LINE-1 methylation and factors associated with metabolic and cardiovascular diseases through quantitative bisulfite pyrosequencing in DNA from peripheral blood samples from participants of the Samoan Family Study of Overweight and Diabetes (2002–03). The sample included 355 adult Samoans (88 men and 267 women) from both American Samoa and Samoa. In a model including all sample participants, men had significantly higher LINE-1 methylation levels than women (p = 0.04) and lower levels of LINE-1 methylation were associated with higher levels of fasting LDL (p = 0.02) and lower levels of fasting HDL (p = 0.009). The findings from this study confirm that DNA “global” hypomethylation (as measured by methylation at LINE-1 repeats) observed previously in cardiovascular disease is associated with altered levels of LDL and HDL in peripheral blood. Additionally, these findings strongly argue the need for further research, particularly including prospective studies, in order to understand the relationship between LINE-1 DNA methylation measured in blood and risk factors for cardiovascular disease.

OBJECTIVES: Obesity leads to deleterious effects on not only cardiovascular health but also on the reproductive health of women. We estimate the prevalence of menstrual irregularity and of polycystic ovarian syndrome (PCOS) in Samoan women, among whom obesity prevalence is extremely high. We explore the association of these reproductive health conditions with adiposity, cardiometabolic risk factors, and androgen levels. METHODS: A cross-sectional sample of Samoan women 25–39 years of age (n=470) from a larger population-based genome-wide association study (GWAS) of adiposity and cardiometabolic disease was assessed for the prevalence of oligomenorrhea/amenorrhea (OM/AM) using a self-reported questionnaire. Serum androgens and anti-Müllerian hormone (AMH) levels were assayed to determine hyperandrogenemia and presence of polycystic ovaries, respectively, using criterion values. PCOS was classified using NIH criteria of having at least two of the three conditions: menstrual irregularity, hyperandrogenism, and polycystic ovaries. We contrasted socio-demographic, reproductive health, and cardiometabolic risk factors between those with and without OM/AM and similarly for PCOS. RESULTS: The prevalence of OM/AM was 7.4% (95% CI: 5.1, 9.8), and women with OM/AM had significantly higher central adiposity. PCOS was estimated at 6.8% (95% CI: 4.5, 9.1), and those with PCOS were younger but had higher overall and central adiposity measures, higher triglycerides, and higher prevalence of insulin resistance than women without PCOS. CONCLUSIONS: The prevalence of menstrual irregularity and PCOS are less than hypothesized given the high levels of adiposity in this population. Nevertheless, Samoan women with menstrual irregularity and other features of PCOS have significantly poorer metabolic health.

Growth reference charts are the basic assessment tool of child health whether at an individual, community, or national level. The comparison of a child's height or weight with the distribution of heights or weights of a reference sample provides evidence of the normality or otherwise of the process of growth. In the UK, the most widely used growth references are the UK1990 growth references (UK90). In 2006 the World Health Organisation launched the new chart and stated that, "The new growth curves are expected to provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and to establish the breastfed infant as the normative model for growth and development." It is important to distinguish between a growth reference (e.g. UK90) and a growth standard (e.g. WHO 2006). Growth reference charts are usually based on cross-sectional data, they are for use with samples and they reflect growth "as is" rather than "as it ought to be". Growth standards are a different tool – they are based on longitudinal data in which the source sample has been selected according to some pre-defined criteria and reflect growth not "as is" but growth "as it ought to be". The Scientific Advisory Committee on Nutrition (SACN) recommended in 2007 that a modified WHO chart be adopted in the UK. These UK-WHO growth charts combined the UK90 data with the WHO data; the WHO data were used from birth to 4 years and the UK90 data from 4 years onwards. However, the WHO charts are standards not references and reflect the growth of children growing in unconstrained environments. Because they are longitudinal standards the WHO charts (particularly from birth to 2 years) should be used specifically for individuals rather than samples. They do not purport to represent the growth characteristics of the average child in a population and if used as a growth reference rather than a growth standard they will potentially provide conflicting and erroneous information. Tests of the UK-WHO chart in the UK indicate a good fit for length/height but a relatively poorer fit for weight because of slower weight gain in the WHO sample. Tests of the WHO charts from outside the UK recognise their usefulness for well-fed economically privileged children but recommend local growth charts when available. In addition, the vast majority of UK infants are not exclusively breastfed for anywhere near the recommended duration of 4 months and the duration of breastfeeding is heavily influenced by social and economic circumstances. It is, of course, the infants who live in social and economically deprived conditions, with young, poorly educated mothers who also have the greatest risk of growth faltering and for whom an accurate and appropriate growth assessment tool is of paramount importance. The choice of a growth chart clearly depends on the question being asked. Growth charts are not only tools but they are very specific tools designed to do a particular job. Their appropriate use requires training and education even though their appearance as relatively simple graphs of height or weight against age gives the impression of simplicity and a lack of sophistication. Indeed they are neither of these things. If the question relates to the growth of a child in comparison to breastfed infants living in socio-economic conditions that do not constrain growth then the WHO standard is the appropriate tool. If, on the other hand, the question relates to the growth of a child in comparison to other British children from no specific socio-economic background and with no specific feeding regime, then the UK90 will effectively answer the question. Of course, the WHO standard can be used in both situations but the probable absence of exclusive breastfeeding and perhaps the variation in socio-economic conditions within which the infant lives will necessarily alter the interpretation of the pattern of growth.

Objective To define biochemical hyperandrogenemia (HA) among a population-based sample of reproductive-aged Samoan women, taking into consideration their high BMI levels. Design and methods A secondary analysis was performed among a cross-sectional sample of Samoan women aged 25–39 years (n = 494) who were part of a larger genome-wide association study (GWAS) of adiposity. Women indicating pregnancy/lactation, hysterectomy, oophorectomy, cancer treatment, or use of contraceptive injections were excluded from the study. We analyzed the distribution of free androgen index (FAI) values to establish normative androgen data among Samoan women of reproductive age. Using the lowest tertile of body mass index (BMI), we defined HA as free androgen index (FAI) values > 95th FAI percentile in that subsample. We compared the anthropometric and metabolic characteristics of women with HA to women with normal androgen levels. Results HA was defined as FAI > 8.5. Using this definition, 14% of women were classified as hyperandrogenemic. Women with HA had significantly higher average BMI values, abdominal circumferences, fasting triglycerides, and insulin levels as well as significantly lower adiponectin levels. Conclusion This study is the first to define normative androgen values among Samoan women with a quantitative assessment of the relationship between adiposity and androgen levels. The uniquely high BMI levels in the population not only provide important clinical insight into normative androgen values among Samoan women, but they also serve as references for the clinical assessment of HA, taking into consideration BMI, in other populations.

Introduction: Initiation of breastfeeding is almost universal in American Samoa, but duration of exclusive breastfeeding is short. Increasing the duration of exclusive breastfeeding may be an efficacious strategy for childhood obesity prevention in American Samoa.Aim: To understand influences on infant feeding in American Samoa and to identify potential barriers to exclusive breastfeedingMethods: A mixed-methods, prospective study following Samoan women (n=44), their partners, and their infants from late pregnancy (average 37 weeks gestation) until eight weeks post-partum was completed in 2013. Participants reported intentions for infant feeding before birth, and practices were self-reported in questionnaires completed at 3- and 8-weeks postpartum.Results: While 79.5% of women intended to exclusively breastfeed for the first few weeks postpartum, less than 40% were exclusively breastfeeding at 3-weeks postpartum. Many women of the women who introduced formula before 3-weeks did so before hospital discharge. Barriers to exclusive breastfeeding included lack of skin-to-skin contact after delivery, delays in the initiation of breastfeeding, pain during breastfeeding, and a lack of education about infant satiety cues.Discussion: Structural rather than individual level barriers to breastfeeding were identified by American Samoan women. Existing evidence-based interventions to promote exclusive breastfeeding could be adapted for use in this setting and should begin before hospital discharge.

Background In American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration. Aims (1) To examine American Samoan mothers’ feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding. Methods Eighteen semi-structured interviews were conducted with American Samoan mothers at 16–32 days postpartum. Interviews focused on mother's knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data. Findings Intention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous “back-up option” where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design. Conclusion This study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting.

Background As obesity has increased worldwide, so have levels of obesity during pregnancy and excess gestational weight gain (GWG). The aim of this paper was to describe GWG among American Samoan women and examine the association between GWG and four adverse pregnancy and infant outcomes: cesarean delivery, small- and large-for-gestational age (SGA/LGA), and infant overweight/obesity. Methods Data were extracted from prenatal care records of 632 Samoan women. Mixed-effects growth models were used to produce individual weight-for-gestational week curves from which second and third trimester weight gain was estimated. Binary logistic regression was used to examine associations between GWG and the outcomes of interest. Results Most women were overweight/obese in early pregnancy (86%) and 78% exceeded the Institute of Medicine GWG guidelines. Greater GWG in the second trimester and early pregnancy weight were independently associated with increased odds of a c-section (OR 1.40 [95% CI: 1.08, 1.83]) and OR 1.51 [95% CI: 1.17, 1.95], respectively). Risk of delivering a LGA infant increased with greater third trimester weight gain and higher early pregnancy weight, while second trimester weight gain was negatively associated with SGA. Risk of infant overweight/obesity at 12 months increased with early pregnancy weight (OR: 1.23 [95% CI: 1.01, 1.51]) and infant birthweight. Conclusions The high levels of pregnancy obesity and excessive GWG in American Samoa suggest that it is important for physicians to encourage women into prenatal care early and begin education about appropriate GWG and the potential risks of excess weight gain for both the mother and baby.

Aim To examine ethnic and sex differences in the pattern of skeletal maturity from adolescence to adulthood using a novel longitudinal analysis technique (SuperImposition by Translation And Rotation (SITAR)). Setting Johannesburg, South Africa. Participants 607 boys and girls of black as well as white ethnicity from the Birth to Twenty bone health study, assessed annually from 9 to 20 years of age. Outcome measure Bone maturity scores (Tanner–Whitehouse III radius, ulna, and short bones (TW3 RUS)) assessed longitudinally from hand-wrist radiographs were used to produce individual and mean growth curves of bone maturity and analysed by the SITAR method. Results The longitudinal analysis showed that black boys matured later by 7.0 SE 1.6 months (p

DNA methylation changes occur in animal models of calorie restriction, simulating human dieting, and in human subjects undergoing behavioral weight loss interventions. This suggests that obese (OB) individuals may possess unique epigenetic patterns that may vary with weight loss. Here, we examine whether methylation patterns in leukocytes differ in individuals who lost sufficient weight to go from OB to normal weight (NW; successful weight loss maintainers; SWLMs) vs currently OB or NW individuals. This study examined peripheral blood mononuclear cell (PBMC) methylation patterns in NW (n=16, current/lifetime BMI 18.5-24.9) and OB individuals (n=16, current body mass index (BMI)⩾30), and SWLM (n=16, current BMI 18.5-24.9, lifetime maximum BMI ⩾30, average weight loss 57.4 lbs) using an Illumina Infinium HumanMethylation450 BeadArray. No leukocyte population-adjusted epigenome-wide analyses were significant; however, potentially differentially methylated loci across the groups were observed in ryanodine receptor-1 (RYR1; P=1.54E-6), myelin protein zero-like 3 (MPZL3; P=4.70E-6) and alpha 3c tubulin (TUBA3C; P=4.78E-6). In 32 obesity-related candidate genes, differential methylation patterns were found in brain-derived neurotrophic factor (BDNF; gene-wide P=0.00018). In RYR1, TUBA3C and BDNF, SWLM differed from OB but not NW. In this preliminary investigation, leukocyte SWLM DNA methylation patterns more closely resembled NW than OB individuals in three gene regions. These results suggest that PBMC methylation is associated with weight status.

Infants with rapid weight gain in the first 1 to 2 years of life have twice the risk of obesity1 and greater central adiposity2,3 compared with infants with more gradual weight gain. Rapid infant weight gain is also associated with insulin resistance and beta-cell dysfunction4-6 in childhood and cardiovascular disease risk in adulthood.7 Furthermore, there is evidence that girls who experience rapid weight gain in infancy have an earlier age at menarche than girls with slower weight gain.8-10 Because girls with earlier menarche also tend to become obese,11-13 rapid infant weight gain may be an early sign that an individual is on a trajectory toward both accelerated maturation and obesity. However, there are no published studies linking infant weight gain to developmental advancement in boys. Skeletal age is an indicator of physical development that can be used to examine the relationship between infant weight gain and the rate of maturation in both sexes. An observed clustering of slow intrauterine growth, rapid postnatal growth, earlier menarche, and adverse metabolic outcomes has been explained using life history theory as an evolutionary trade-off between growth in size and reproductive success when poor maternal nutritional status signals the presence of a constrained growth environment.14 Under this model, accelerated development during periods of nutritional bounty may slightly increase the reproductive lifespan and thereby create positive selection. In this circumstance, it would be expected that the relationship between infant weight gain and the rate of physical and sexual maturation would be strongest in contexts in which prenatal growth is slow and post-natal growth is very rapid. However, the differing effect of rapid infant weight gain on the tempo of growth and maturation in children in more or less constrained growth environments has not been formally tested. With prospective data on infant and childhood growth and skeletal maturation in birth cohorts from the United States and Johannesburg, South Africa, this study addresses the hypothesis that rapid infant weight gain is associated with advanced childhood skeletal maturity across widely contrasting environmental circumstances, independent of birth weight, childhood body mass index (BMI), and body size (stature).

Introduction: Gestational Diabetes (GDM) is associated with myriad maternal and fetal complications. Pacific Islanders are known to be at increased risk for GDM and this is compounded by high levels of pregnancy obesity. Adequate screening for GDM is key to identify cases and act preventatively to ameliorate the associated risks. In a clinical audit, we aimed to evaluate the adequacy of GDM screening among pregnant women in American Samoa.Method: Data were extracted in a medical record review undertaken in American Samoa June-August 2009. Clinical records of 622 women were reviewed to determine: (a) whether or not the patient was screened for GDM, (b) in which week of gestation this screening occurred, and (c) what type of GDM screening the patient received. Chi-square and independent samples t-tests were used to identify differences in socio-demographic characteristics between those who were screened adequately and those who were not.Findings: Few women (16.2%) received adequate GDM screening. Many women received a first prenatal visit GDM screen in accordance with local guidelines, but very few women received a follow-up oral glucose tolerance test (OGTT) in the recommended 24-28 week testing period. There were no socio-demographic differences between those who were adequately screened and those who were not.Conclusion: Despite the presence of clear guidelines for GDM screening in American Samoa, this study highlights the critical need for improved screening in this high risk population. The causes of inadequate screening, which are currently unknown, must be identified and interventions should be targeted at both the clinician and patient to improve the adequacy of GDM screening in this setting.