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Aims: Type 2 diabetes mellitus (T2DM) rates continue to increase across women of reproductive age in the United States. The Ohio Type 2 Diabetes Learning Collaborative aimed to improve education and screening for T2DM among women aged 18-44years at high risk for developing T2DM., Methods: Fifteen primary care practices across Ohio participated in a 12-month quality improvement (QI) collaborative, which included monthly calls to share best practices, one-on-one QI coaching, and Plan-Do-Study-Act cycles. Monthly, practices submitted data on three outcome measures on preventive education and three measures on clinical screening for T2DM., Results: Increases across each of the three preventive education rates (range of percent increase: 53.6% - 60.0%) and each of the three screening rates for T2DM (15.0% - 19.4%) were observed. Specifically, screening rates for high-risk women with two or more risk factors for T2DM (excluding gestational diabetes mellitus (GDM)) increased by 16.8% (60.5%-77.3%) while rates for T2DM among women with a history of GDM increased by 15.0% (75.0 - 90.0)., Conclusions: A quality improvement collaborative increased preventive education and screening rates for women at high-risk for T2DM in primary care settings., (Copyright © 2019 Primary Care Diabetes Europe. All rights reserved.)

Purpose: The purpose of this qualitative study was to examine perceived barriers to adoption of lifestyle changes for type 2 diabetes prevention among a diverse group of low-income women with a history of gestational diabetes mellitus (GDM)., Methods: A secondary data analysis of 10 semistructured focus group discussions was conducted. Participants were low-income African American, Hispanic, and Appalachian women ages 18 to 45 years who were diagnosed with GDM in the past 10 years. A qualitative content analysis was conducted to identify key themes that emerged within and between groups., Results: Four key themes emerged on the role of knowledge, affordability, accessibility, and social support in type 2 diabetes prevention. Women discussed a lack of awareness of the benefits of breastfeeding and type 2 diabetes prevention, inaccessibility of resources in their local communities to help them engage in lifestyle change, and the desire for more culturally relevant education on healthful food options and proper portion sizes., Discussion: Study findings suggests that to improve effectiveness of type 2 diabetes prevention efforts among low-income women with GDM history, health care providers and public health practitioners should avoid using "one-size-fits-all" approaches to lifestyle change and instead use tailored interventions that address the cultural and environmental factors that impact women's ability to engage in recommended behavior change.

Background: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, 4 state health departments (Georgia, Louisiana, Michigan, and Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates., Objective: To estimate the validity of the pregnancy checkbox on the death certificate, and to describe characteristics associated with errors using 2016 data from a 4-state quality assurance pilot., Materials and Methods: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within 1 year preceding death or by pregnancy checkbox status. Death certificates that indicated that the decedent was pregnant within 1 year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type., Results: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. A total of 97 women (21%) were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (P < .001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (P = .04). The association between decedent age category and false-positive status followed a dose-response relationship (P < .001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positive, compared with non-Hispanic white women (prevalence ratio, 1.41; 95% confidence interval, 1.01, 1.96). The sensitivity of the pregnancy checkbox among these 4 states in 2016 was 62% and the positive predictive value was 68%., Conclusion: We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes., (Published by Elsevier Inc.)

Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

Diabetes during pregnancy increases the risk for adverse maternal and infant health outcomes. Type 1 or type 2 diabetes diagnosed before pregnancy (preexisting diabetes) increases infants' risk for congenital anomalies, stillbirth, and being large for gestational age (1). Diabetes that develops and is diagnosed during the second half of pregnancy (gestational diabetes) increases infants' risk for being large for gestational age (1) and might increase the risk for childhood obesity (2); for mothers, gestational diabetes increases the risk for future type 2 diabetes (3). In the United States, prevalence of both preexisting and gestational diabetes increased from 2000 to 2010 (4,5). Recent state-specific trends have not been reported; therefore, CDC analyzed 2012-2016 National Vital Statistics System (NVSS) birth data. In 2016, the crude national prevalence of preexisting diabetes among women with live births was 0.9%, and prevalence of gestational diabetes was 6.0%. Among 40 jurisdictions with continuously available data from 2012 through 2016, the age- and race/ethnicity-standardized prevalence of preexisting diabetes was stable at 0.8% and increased slightly from 5.2% to 5.6% for gestational diabetes. Preconception care and lifestyle interventions before, during, and after pregnancy might provide opportunities to control, prevent, or mitigate health risks associated with diabetes during pregnancy., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objectives: In 2012, theCenters for Disease Control and Prevention initiated a national anti-smoking campaign, Tips from Former Smokers ( Tips ). As a result of the campaign, quit attempts among smokers increased in the general population by 3.7 percentage points. In the current study, we assessed the effects of Tips on smoking cessation in pregnant women., Methods: We used 2009-2013 certificates of live births in three US states: Indiana, Kentucky and Ohio. Smoking cessation by the third trimester of pregnancy was examined among women who smoked in the 3 months prepregnancy. Campaign exposure was defined as overlap between the airing of Tips 2012 (March 19-June 10) and the prepregnancy and pregnancy periods. Women who delivered before Tips 2012 were not exposed. Adjusted logistic regression was used to determine whether exposure to Tips was independently associated with smoking cessation., Results: Cessation rates were stable during 2009-2011 but increased at the time Tips 2012 aired and remained elevated. Overall, 32.9% of unexposed and 34.7% of exposed smokers quit by the third trimester (p<0.001). Exposure to Tips 2012 was associated with increased cessation (adjusted OR: 1.07, 95% CI 1.05 to 1.10)., Conclusions: Exposure to a national anti-smoking campaign for a general audience was associated with smoking cessation in pregnant women., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: We assessed whether smoking cessation improved among pregnant smokers who attended Women, Infants and Children (WIC) Supplemental Nutrition Program clinics trained to implement a brief smoking cessation counseling intervention, the 5As: ask, advise, assess, assist, arrange., Methods: In Ohio, staff in 38 WIC clinics were trained to deliver the 5As from 2006 through 2010. Using 2005-2011 Pregnancy Nutrition Surveillance System data, we performed conditional logistic regression, stratified on clinic, to estimate the relationship between women's exposure to the 5As and the odds of self-reported quitting during pregnancy. Reporting bias for quitting was assessed by examining whether differences in infants' birth weight by quit status differed by clinic training status., Results: Of 71,526 pregnant smokers at WIC enrollment, 23% quit. Odds of quitting were higher among women who attended a clinic after versus before clinic staff was trained (adjusted odds ratio, 1.16; 95% confidence interval, 1.04-1.29). The adjusted mean infant birth weight was, on average, 96 g higher among women who reported quitting (P<0.0001), regardless of clinic training status., Conclusions: Training all Ohio WIC clinics to deliver the 5As may promote quitting among pregnant smokers, and thus is an important strategy to improve maternal and child health outcomes., (Published by Elsevier Inc.)

Objectives: In 2006, the state of Ohio initiated the implementation of a brief smoking cessation intervention (5As: Ask, Advise, Assess, Assist, and Arrange) in select public health clinics that serve low-income pregnant and post-partum women. Funds later became available to expand the program statewide by 2015. However, close to half of the clinics initially trained stopped implementation of the 5As. To help guide the proposed statewide expansion plan for implementation of the 5As, this study assessed barriers and facilitators related to 5As implementation among clinics that had ever received training., Methods: A mixed-methods approach was used, comprising semi-structured interviews with clinic program directors (n = 21) and a survey of clinic staff members (n = 120), to assess implementation-related barriers, facilitators, training needs, and staff confidence in delivering the 5As., Results: Semi-structured interviews of program directors elucidated implementation barriers including time constraints, low self-efficacy in engaging resistant clients, and paperwork-related documentation challenges. Facilitators included availability of community referral resources, and integration of cessation interventions into the clinic workflow. Program directors believed they would benefit from more hands-on training in delivering the 5As. The survey results showed that a majority of staff felt confident advising (61%) or referring clients for tobacco dependence treatment (74%), but fewer felt confident about discussing treatment options with clients (29%) or providing support to clients who had relapsed (30%)., Conclusions: Time constraints and documentation issues were major barriers to implementing the 5As. Simplified documentation processes and training enhancements, coupled with systems change, may enhance delivery of evidence-based smoking cessation interventions.

Introduction: Gestational diabetes mellitus (GDM) is associated with a 7-fold increased lifetime risk for developing type 2 diabetes mellitus. Early diagnosis of type 2 diabetes is crucial for preventing complications. Despite recommendations for type 2 diabetes screening every 1 to 3 years for women with previous diagnoses of GDM and all women aged 45 years or older, screening prevalence is unknown. We sought to assess Ohio primary health care providers' practices and attitudes regarding assessing GDM history and risk for progression to type 2 diabetes., Methods: During 2010, we mailed surveys to 1,400 randomly selected Ohio family physicians and internal medicine physicians; we conducted analyses during 2011-2013. Overall responses were weighted to adjust for stratified sampling. Chi-square tests compared categorical variables., Results: Overall response rate was 34% (380 eligible responses). Among all respondents, 57% reported that all new female patients in their practices are routinely asked about GDM history; 62% reported screening women aged 45 years or younger with prior GDM every 1 to 3 years for glucose intolerance; and 42% reported that screening for type 2 diabetes among women with prior GDM is a high or very high priority in their practice., Conclusion: Because knowing a patient's GDM history is the critical first step in the prevention of progression to type 2 diabetes for women who had GDM, suboptimal screening for both GDM history and subsequent glucose abnormalities demonstrates missed opportunities for identifying and counseling women with increased risk for type 2 diabetes.

To identify perceived roles with regard to care for women with gestational diabetes mellitus (GDM) history and resources for improving care among women with a history of GDM from the perspective of obstetrician/gynecologists (OB/GYNs), certified nurse midwives (CNM), family practitioners, and internists. In 2010, a survey was sent to a random sample of OB/GYNs, CNM, family practitioners, and internists (n = 2,375) in Ohio to assess knowledge, attitudes, and postpartum practices regarding diabetes prevention for women with a history of GDM. A total of 904 practitioners completed the survey (46 %). Over 70 % of CNMs strongly agreed it is part of their job to help women with GDM history improve diet and increase exercise, compared with 60 % of family practitioners/internists and 55 % of OB/GYNs (p < 0.001). More OB/GYNs and CNMs identified a need for more local nutrition specialists and patient education materials, compared with family practitioners/ internists. Between 60 and 70 % of OB/GYNs and CNMs reported lifestyle modification programs and corresponding reimbursement would better support them to provide improved care. Health care providers giving care to women with GDM history have varying perceptions of their roles, however, there was agreement on resources needed to improve care.

Lower income women are at higher risk for preconception and prenatal smoking, are less likely to spontaneously quit smoking during pregnancy, and have higher prenatal relapse rates than women in higher income groups. Policies prohibiting tobacco smoking in public places are intended to reduce exposure to secondhand smoke; additionally, since these policies promote a smoke-free norm, there have been associations between smoke-free policies and reduced smoking prevalence. Given the public health burden of smoking, particularly among women who become pregnant, our objective was to assess the impact of smoke-free policies on the odds of preconception smoking among low-income women. We estimated the odds of preconception smoking among low-income women in Ohio between 2002 and 2009 using data from repeated cross-sectional samples of women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). A logistic spline regression was applied fitting a knot at the point of enforcement of the Ohio Smoke-free Workplace Act to evaluate whether this policy was associated with changes in the odds of smoking. After adjusting for individual- and environmental-level factors, the Ohio Smoke-free Workplace Act was associated with a small, but statistically significant reduction in the odds of preconception smoking in WIC participants. Comprehensive smoke-free policies prohibiting smoking in public places and workplaces may also be associated with reductions in smoking among low-income women. This type of policy or environmental change strategy may promote a tobacco-free norm and improve preconception health among a population at risk for smoking.

Background: Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening., Methods: This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010., Results: Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners., Conclusions: Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Medical homes deliver primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective. Children with special health care needs (CSHCN) require a wide range of support to maintain health, making medical home access particularly important. We sought to understand independent risk factors for lacking access. We analyzed Ohio, USA data from the National Survey of Children with Special Health Care Needs (2005-2006). Among CSHCN, 55.6% had medical home access. The proportion achieving each medical home component was highest for having a personal doctor/nurse and lowest for receiving coordinated care, family-centered care and referrals. Specific subsets of CSHCN were significantly and independently more likely to lack medical home access: Hispanic (AOR=3.08), moderate/high severity of difficulty (AOR=2.84), and any public insurance (AOR=1.60). Efforts to advance medical home access must give special attention to these CSHCN populations and improvements must be made to referral access, family-centered care, and care coordination.

Substantial variation across states in the prevalence and trends in childhood overweight and obesity indicate a need for state-specific surveillance to make state comparisons to national estimates and identify high-risk populations. The purpose of this study was to examine body mass index (BMI) trends among third-grade children in Ohio between the 2004-2005 and 2009-2010 school years and examine changes in prevalence of obesity by specific demographic subgroups. Third-grade children (n=33,672) were directly weighed and measured throughout the school years by trained health care professionals. Trends in overweight/obesity (≥85th percentile of BMI by age/sex), obesity (≥95th percentile), and obesity level 2 (≥97th percentile) over five time periods (2004-2005, 2006-2007, 2007-2008, 2008-2009, 2009-2010) were modeled using logistic regression, accounting for the survey design and adjusting for sex, race/ethnicity, National School Lunch Program (NSLP) participation, and age. Differences in these BMI categories were also examined by these subgroups. BMI estimates did not demonstrate a statistically significant trend over the five time periods for overweight/obesity (34% to 36%), obesity (18% to 20%), or obesity level 2 (12% to 14%). However, increases in overweight/obesity prevalence were found in Hispanic children (37.8% vs 53.1%; P<0.01). Decreases in obesity (16.6% vs 14.1%; P=0.02) and obesity level 2 (11.3% vs 9.3%; P=0.02) were found among children not participating in NSLP and residing in suburban counties (obesity [17.3% vs 14.7%; P=0.03] and obesity level 2 [11.8% vs 9.8%; P=0.05]). Finally, decreases in overweight/obesity and obesity level 2 among boys were observed (15% vs 12.9%; P=0.02). Despite no significant overall trends in overweight/obesity, obesity, or obesity level 2 between 2004 and 2010, prevalence changed among specific subgroups. Obesity prevention efforts should be widespread and include special emphasis on groups experiencing increases or no change in prevalence., (Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Introduction: Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement., Methods: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening., Results: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care., Discussion: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies., (© 2013 by the American College of Nurse-Midwives.)

To compare preconception health indicators (PCHIs) among non-pregnant women aged 18-44 years residing in Appalachian and non-Appalachian counties in 13 U.S. states. Data from the 1997-2005 Behavioral Risk Factor Surveillance System were used to estimate the prevalence of PCHIs among women in states with ≥1 Appalachian county. Counties were classified as Appalachian (n = 36,496 women) or non-Appalachian (n = 88,312 women) and Appalachian counties were categorized according to economic status. Bivariate and multivariable logistic regression models examined differences in PCHIs among women by (1) Appalachian residence, and (2) economic classification. Appalachian women were younger, lower income, and more often white and married compared to women in non-Appalachia. Appalachian women had significantly higher odds of reporting

Measurement of height and weight in large studies may force the use of multiple measurers. The purpose of this study was to evaluate the reliability of height, weight, and body mass index (BMI) measures collected by multiple measurers in a large, statewide BMI surveillance program. A random subsample of schools (n=30) was selected from schools that participated in the 2009 to 2010 Ohio third-grade Oral Health/BMI surveillance program. Children (n=1,189) were measured by multiple volunteer health professional measurers and again by a trained researcher, who was standard across all schools. Mean differences for height, weight, and BMI percentiles were calculated for BMI category classifications. Agreement was estimated by the reliability coefficient, McNemar's test, and Kappa statistic. Sensitivity, specificity, and positive and negative predictive values were estimated using the trained researcher measures as the reference. Overall mean differences (95% confidence interval) were 0.45 (0.41-0.48) cm for height, 0.07 (-0.01-0.15) kg for weight, and 1.37 (1.20-1.53) for BMI. The correlation coefficient for all three measures was over 0.9 (P<0.01), indicating a strong positive association between measures. BMI category classifications showed substantial reliability (Kappa range: 0.94-0.96). Percentage agreement ranged from 98% to 99% for all BMI categories, as did sensitivities and specificities. Positive predictive values for all BMI categories were approximately 97%, and close to 100% for negative predictive values. Reliability for height, weight, BMI percentile, and BMI classification was very high, supporting the use of multiple trained measurers in a statewide BMI surveillance program. Similar methods can be applied to other public health and clinical settings to improve anthropometric measurement reliability., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Introduction: Data on overweight and obesity prevalence among children enable state and local officials to develop, target, fund, and evaluate policies and programs to address childhood overweight. During the 2004-2005 school year, the Ohio Department of Health (ODH) conducted surveillance of elementary school-aged children through coordination with the ODH oral health survey to create a system that would provide county and state estimates of obesity and overweight prevalence., Methods: We used a stratified, cluster-sampling survey design. Schools were considered clusters and were sampled from strata determined by their county and by their participation rate in the Free and Reduced Price Meal program. We selected public elementary schools by probability proportional to size sampling without replacement. We requested consent from the guardian or parent of each third-grade student. Trained health care professionals used state-purchased equipment to weigh students and measure their height. We removed implausible observations and calculated sex-specific, body mass index (BMI)-for-age percentiles using Centers for Disease Control and Prevention growth charts., Results: Of eligible schools, 374 agreed to height and weight screening; 41 were considered substitutes. Of 26,590 enrolled students, 17,557 (66.0%) returned consent forms, and 15,209 (57.2%) provided consent. BMI estimates were generated for 14,451 students, resulting in an overall response rate of 54.3%. The overall oral health response rate was 52.8%., Conclusion: By adding BMI screening to Ohio's third-grade oral health survey and incorporating trained volunteer screeners, the ODH successfully implemented overweight and obesity surveillance using minimal resources. Future efforts should focus on improving student response rate.

Objectives: Thyrotoxicosis is produced by excessive quantities of thyroid hormone. Its most common causes involve inflammation of the thyroid gland. Much more rarely, thyrotoxicosis is due to exogenous intake of thyroid hormones or iodide compounds. Few outbreaks are documented. In 2003 to early 2004, doctors in Minas, Uruguay noted a sharp increase in the incidence of thyrotoxicosis in a neighbourhood, with multiple cases within families. The objective of this study was to identify the source of the outbreak., Study Design: A case-control study was conducted following surveillance and environmental inspection., Methods: Case patients were symptomatic residents of Minas with documented thyroid-stimulating hormone concentrations <0.1 microUI/ml or <0.49 microUI/ml and elevated free triiodothyronine or free thyroxine. Control subjects were frequency matched with case patients by barrio of residence and age. Case patients, control subjects and persons who prepared and purchased household food were interviewed using a standard questionnaire. Odds ratios adjusted (AOR) for age and gender were calculated by logistic regression in SUDAAN to account for neighbourhood and family clustering., Results: Fifty-nine case patients aged 9-74 years (median 39 years) were identified. Of the 56 interviewed, 52% were women and 71% resided in one barrio. Case patients were more likely than control subjects to eat minced beef at least weekly and purchase it from Butcher A [AOR 6.1; 95% confidence interval (CI) 2.61-14.46], and were more likely to eat chorizo at least weekly and purchase it from Butcher B (AOR 11.6; 95% CI 1.30-102.27). One beef supplier selling meat cuts containing thyroid gland was identified., Conclusions: The most likely cause of this outbreak of thyrotoxicosis was consumption of minced beef and chorizo contaminated with thyroid gland. Tight regulation and oversight of slaughter, processing, and sales of meat and meat products are imperative for prevention of future outbreaks.

Three New York State agencies undertook a state-wide initiative in 2001 to enhance the effectiveness of the Special Supplemental Program for Women, Infants, and Children (WIC) Farmers' Market Nutrition Program (FMNP) for both families and farmers. The program enhancements included four components intended to influence market and consumer behavior: hiring a state-wide Cornell Cooperative Extension staff member to initiate and coordinate FMNP promotion efforts; increased collaboration among state-level agencies; local-level community capacity-building; and dissemination of newly developed nutrition education resources. Because components were overlapping and potentially synergistic, the total effect was considered. To test the hypothesis that the enhancements increased Program utilization as measured by redemption rates, a time-series, quasi-experimental design was employed in which observed 2001 redemption was tested for departure from earlier trends. Linear regression showed FMNP coupon redemption rates from 1996 through 2000 decreased 2.36% annually (P = 0.002). This trend was interrupted in 2001 when actual redemption exceeded predicted redemption by >2.2% (P < 0.055). Alternate explanations for this shift were deemed improbable. These findings show that FMNP goals were advanced through a coordinated, collaborative initiative with activities at state and local levels, resulting in increased utilization of FMNP benefits by WIC participants and increased income to local farmers.