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It is well appreciated that malnutrition in early life has an adverse impact on the overall health of adults. In this review, we address the impact of malnutrition, social disadvantages, and poverty on the lives of children. An integrated response to these difficulties associated in the lives of children, families and the communities in which they live - the "Medical Home" - is suggested as a means to promote health for all ages. The four types of malnutrition delineated by the World Health Organization are discussed, as are differences between "socioeconomic status" and "social gradient." The latter construct is more meaningful from a health care standpoint as differences within each of the socioeconomic groupings are greater than differences between them. Poverty affects food choices with a profound impact on nutritional status. This review suggests how providing a "Medical Home" can improve dietary habits, improve overall nutrition and prevent disease. [ABSTRACT FROM AUTHOR]

BACKGROUND AND PURPOSE. Little information relating to cholesterol levels and screening for hypercholesterolemia in inner-city children exists. For this study, given the disrupted family backgrounds of many of our patients and the unreliability of family histories, our hypothesis was that in comparison with other samples, family history of coronary heart disease would be a poor screening tool for the identification of children with elevations in total serum cholesterol (TSC). SUBJECTS AND METHODS. During 15 months, more than 400 pediatric outpatients, 2 through 14 years old, were screened for a family history of atherosclerotic disease. These children were attending a clinic serving a disadvantaged black and Hispanic population at Kings County Hospital Center. Nonfasting TSC levels were measured in 300 children. Positive risk for coronary heart disease was determined by the presence of a family history of coronary heart disease (defined as angina, stroke, or myocardial infarction in any parent or grandparent) at less than 55 years age. RESULTS. The mean TSC level was 4.27 mmol/L SD +/- 0.85) (165.0 mg/dL [SD +/- 32.8]). The 29.4% of this population with a history suggestive of high risk for hypercholesterolemia had a mean TSC of 4.48 mmol/L (SD +/- 0.971) (173.2 mg/dL [SD +/- 37.5]), and those with no risk history had a mean TSC of 4.18 mmol/L (SD +/- 0.750) (161.4 mg/dL [SD +/- 29.9]) (P < .005). Use of family history of coronary artery disease as a screening tool had a sensitivity of 39.3%, a specificity of 74.5%, and a positive predictive value of 39.8% for detection of moderate hypercholesterolemia (TSC > or = 4.66 mmol/L [180 mg/dL]). CONCLUSIONS. This population's mean TSC level did not differ (P > .10) from those obtained in multiple large studies of average North American populations, and the predictive value and sensitivity of family history as a screening tool was comparable, although the prevalence of a positive family history was greater. The findings may be due to a greater prevalence of coronary artery disease at a young age in these families. In this population, a positive risk history is an important indicator for further evaluation of these children. [ABSTRACT FROM AUTHOR]

In 1934, the Federal Housing Authority precluded mortgage loans to residents of neighborhoods with non-White families or where housing was deteriorated; these were declared "hazardous" and labeled red on maps. In 1962 three redlined north Brooklyn neighborhoods had 41 children, all Black and Puerto Rican, with lead levels >60ug/dL. A review of public polices in the U.S. from 1898 to the present revealed that lead poisoning followed an income gradient with multiple disproportionate effects on non-White children in redlined neighborhoods. The poisonings diminished when federal and local regulations prevented lead exposure. While redlining had profound influences on both likelihood and severity of lead poisoning and its consequences, it was a mediator of effects. The principal causes were federal policies failing to prevent environmental contamination and local governments failing to prevent exposure.

Acknowledgements: Laura Dattner, John Krai and Linda Oppenheim provided assistance in obtaining archival material and manuscript review. Edwin Rosenthal's decedents, Robert, Eleanore Jane and Edwin Rosenthal II, provided information about their distinguished grandfather's life and commitments. Linda Oppenheim, Michael Angelo, Jessica Lydon, and Sofie Serada, archivists at Princeton University, Thomas Jefferson University, Temple University, and the College of Physicians of Philadelphia provided access to material on Edwin Rosenthal and medical care in Philadelphia at the turn of the 20th century. We thanks Laura Dattner, John Krai and Linda Oppenheim for their manuscript review., Background: The Souls of Black Folks, W. E. B. Du Bois' compelling narrative from 1903, includes a description of the death of his only son, Burghardt. His death was caused by diphtheria and occurred in Atlanta, GA in the year 1899. Mortality from diphtheria had fallen precipitously in the mid-1890s, but neither city of Atlanta nor Philadelphia, from which the family had recently moved, had made the diphtheria antitoxin available for general use., Objectives: To identify factors affecting availability diphtheria treatment in the two cities the Du Bois family lived in and to address implications for immunization policies today., Methods: We reviewed data and observations from medical texts and articles from the turn of the 20th century, health department records, archives of newspapers and Du Bois' writings., Results: Mortality from diphtheria dropped precipitously at the end of the 19th century with the introduction of laryngecostomy and a diphtheria antitoxin. However these measures required action by health departments and was dependent on the availability of physicians and medical facilities. Lack of Public Health Departments put all southerners at risk for infectious illnesses. With respect to diphtheria, there was neither an available supply of antitoxin nor physician care available. Philadelphia may have been too mired in corruption to provide antitoxin. Burghardt lived in close proximity to a facility where antitoxin was available, data suggests he would have received appropriate treatment there and was likely to have survived. Similar phenomena-disinterest and dysfunction-affect provision of immunization for children today. Currently, availability of immunization is affected by ethnicity, income levels and immigration status., (© 2015 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Foods dense in micronutrients are generally more expensive than those with higher energy content. These cost-differentials may put low-income families at risk of diminished micronutrient intake., Objectives: We sought to determine differences in the cost for iron, folate, and choline in foods available for purchase in a low-income community when assessed for energy content and serving size., Methods: Sixty-nine foods listed in the menu plans provided by the United States Department of Agriculture (USDA) for low-income families were considered, in 10 domains. The cost and micronutrient content for-energy and per-serving of these foods were determined for the three micronutrients. Exact Kruskal-Wallis tests were used for comparisons of energy costs; Spearman rho tests for comparisons of micronutrient content. Ninety families were interviewed in a pediatric clinic to assess the impact of food cost on food selection., Results: Significant differences between domains were shown for energy density with both cost-for-energy (p < 0.001) and cost-per-serving (p < 0.05) comparisons. All three micronutrient contents were significantly correlated with cost-for-energy (p < 0.01). Both iron and choline contents were significantly correlated with cost-per-serving (p < 0.05). Of the 90 families, 38 (42 %) worried about food costs; 40 (44 %) had chosen foods of high caloric density in response to that fear, and 29 of 40 families experiencing both worry and making such food selection., Conclusion: Adjustments to USDA meal plans using cost-for-energy analysis showed differentials for both energy and micronutrients. These differentials were reduced using cost-per-serving analysis, but were not eliminated. A substantial proportion of low-income families are vulnerable to micronutrient deficiencies.

Background. While rapid early weight gain are common in children who become obese later in life, so is growth faltering in the first 3 months of life. Objective. We seek to determine what relationship weight gain in the first six months of age, separated into two 3-month periods, have with the BMI of children ages 4 to 6 years in an inner-city community. Subjects. A convenience sample cohort of 154 children attending an inner-city clinic. Methods. Consecutive charts were reviewed retrospectively. Age, gender, birth weight and weight change in the first and second 3 months of life were introduced as fixed factors using mixed linear models with BMI in years 4 to 6 as the dependent variable. Results. Weight change quartile in the first 3 months of life did not predict of BMI in years 4 to 6; however, weight changes quartiles during months 4 to 6 were significant predictors for subsequent overweight. Conclusion. The data presented herein suggest that, for this specific population, weight gain can be promoted when it is most essential. It is necessary, however, to identify intermediary variables that could affect outcomes in this and other communities.

Twenty-seven pediatric residents were assessed for knowledge, attitudes, and behaviors regarding rights of immigrant families. A program documenting immigrant rights was reinforced in the clinic with posters and individual consultations on immigrant children's needs. This brief program was effective in instructing residents on health and nutritional services for immigrant patients.

Objective: To report a case of Mauriac syndrome in a young child with poorly controlled type 1 diabetes mellitus., Methods: We describe the typical features of Mauriac syndrome and review the clinical, laboratory, and ultrasound findings and follow-up results in our current patient., Results: Hepatomegaly, growth impairment, and cushingoid features characterize Mauriac syndrome. Most frequently, it is seen in adolescents and young adults with a history of poor glycemic control. In our current patient, a 3-year-old boy with type 1 diabetes mellitus of 2 years' duration, Mauriac syndrome developed in the context of a disrupted social environment. His liver enzyme derangement, hepatomegaly, and growth improved once euglycemia was achieved., Conclusion: Although Mauriac syndrome is currently uncommon, close monitoring of children with type 1 diabetes is important to maintain optimal glycemic control and prevent such an occurrence.

Undernutrition--protein energy malnutrition or specific nutrient deficiencies--has been an inherent characteristic of impoverished populations throughout the world. Over-nutrition, obesity and nutrition imbalance is a current concern among those with rising though still insufficient incomes. We review data to suggest that the prevalence of these forms of malnutrition in populations is highly influenced by the rate of appearance of discretionary income. In developed countries, discretionary (alternatively "disposable") income refers to funds available after obligate payments (rent, heat, and the cost of getting to work) and payment for necessities (food and clothing). For families living at or below poverty, the last dollar earned is spent on these obligations. Undernutrition is common. By contrast, likelihood for obesity or imbalance increases with rising income when that last dollar is earned without certainty that it is available for discretionary spending. In the United States, neither under- nor over-nutrition is likely when new income is free and clear of debt or obligation. This occurs at approximately three times the poverty level. While income poverty and food insecurity affect risk for malnutrition rather than outcome, nutrition education programs that address issues of income and food support increase likelihood for adherence to recommendations.

Introduction: Current lead screening guidelines recommend monitoring lead levels in children under 3 years of age. There are, however, a number of children between the ages of 3 and 6 years who have elevated blood lead levels. Whether these lead elevations are new or chronic has not been examined., Objective: To determine the proportion of children with lead levels greater than or equal to 10 microg/dL after their third birthday when all prior testing had been normal., Methods: Retrospective study based on 39000 venous lead tests obtained between 1993 and 1998. From this group, 2046 children were located who had blood lead levels of less than 10 microg/dL before 36 months and who had a follow-up lead level after 36 months. All lead assays were done by the City of New York laboratories, which had an intrasample variability of 13%., Results: Sixty-six (3.2%) of the 2046 children showed an elevation in blood lead for the first time after their third birthday. The abnormal values ranged from 10 to 25 microg/dL. The majority (72%) of the screen-positive children, however, had lead levels of 10 to 12 microg/dL, and 63.3% of screen-positive children with repeat tests had lead levels that reverted to below 10 microg/dL., Conclusions: The data indicate that some new cases of lead level elevations did occur after 3 years of age in this 'high-risk' community; however, the current study provides evidence that universal screening for lead poisoning beyond 3 years of age is not warranted in this community as it is not likely to pick up clinically important exposure.

Objectives: To describe the activities of existing nutrition education consortia and their efforts to support nutrition education in medical schools and residency programs., Methods: In an effort to improve nutrition education at member schools, regional consortia have: organized conferences and courses for faculty, fellows, residents, and students, developed curricula, fostered networking among faculty with shared interests, provided awards for excellence in teaching and research to faculty and students, collaborated with dieticians and non-physician faculty, prepared protocols for evaluation including formal tests, feedback techniques and preparation of Observed Structured Clinical Evaluation (OSCE). The structure and activities of two existing regional centers are described., Measures of Outcome: Goals and objectives for nutrition education have been established, but there remains a significant need for improvements in outcome measures., Results: Regional networks have been active in supporting nutrition education in those medical schools which have participated, and they have made contributions to the literature on nutrition education for medical students. A specific advantage of the regional center concept is the ability to pool the resources of many schools, each with a limited number of faculty interested and knowledgeable in nutrition., Conclusion: The activities of the two Regional Centers suggest that medical school nutrition education programs can gather strength beyond that available at any single institution by forming a regional network. Collaboration of regional networks might offer a means to significantly improve medical student nutrition education. Future efforts, however, require closer attention to the need for evaluation of effectiveness.

At the turn of the 20th century, studies of a family known in the literature as the Kallikaks were used to document the hereditary nature of mental retardation, poverty, and antisocial behavior. This family was said to authenticate eugenic theory, which states that heritable characteristics carried by individuals on "independent unit characters are unalterable determinants of behavior and performance. A review of the original Kallikak data, however, suggests that in utero exposure to alcohol rather than heredity contributed significantly to the transgenerational learning failure seen throughout the Kallikak pedigree. However, eugenic theory was so thoroughly accepted that the promotion and acceptance of "hereditary feeblemindedness" as the principal cause of the developmental problems in the affected offspring smothered the research efforts on in utero effects of alcohol until long after the eugenic concepts were abandoned later in the century.

Measures of height, weight, nonverbal cognitive ability (Ravens progressive matrix), visual-motor-perceptual ability (Beery-Buktenica test of Visual Motor Integration [VMI]), the imitation-of-gestures technique, and academic achievement (Stanford Early Achievement) were obtained for a sample of 82 children from a poor inner-city community. In contrast to prior reports from the United States and about other developed countries, anthropometric measures were related both to academic achievement and to these measures of neurodevelopment. They were not consistently related to measures of nonverbal cognitive ability. Regression analyses revealed that general cognitive ability contributed more variance (39%) to predictions of achievement than all other variables, including weight for age (13%) and VMI (6%). Children with reduced somatic growth were likely to do poorly in school, but the data do not show that undernutrition causes learning failure. Rather, they suggest that environmental problems affecting the development of thought processes and nutrient intake precede both growth and learning failure.

In a survey of black inner-city school children 10 to 13 years of age, a significant correlation was found for obesity index (weight/height(2)) and measurements of systolic blood pressure. Significant correlations were found for both blood pressure and obesity index of mothers and daughters. No such relationships were found for mothers and sons. There was an increased availability of sodium-rich foods found for girls as their age increased. This was not found for boys.Both obesity and a sodium-rich diet are risk factors for the development of hypertension. The present study suggests that among over-weight black girls in the preteen years, attempts should be made (1) to identify (and limit) any increase in the consumption of salty foods and (2) to limit weight gain appropriately.

While the identification of a growth-retarded or otherwise undernourished child suggests a diagnosis of child abuse or neglect, it is not certain that abused children from poor communities are less well nourished than children living in similar environments. The setting of this study--day care centers in an urban poor city--provided an opportunity to make this comparison with appropriate community-based controls. Measures of height, weight, and weight/height (Body Mass Index (BMI] were compared for 196 children, 2 to 6 years of age, 53 of whom were victims of physical abuse. The data was adjusted for age, sex, and ethnicity using logistic regression analysis to determine occurrence of wasting (weight for height less than 5th percentile) and stunting (height for age less than 5th percentile). Significantly more abused children (16.3%) showed wasting as compared to non-abused (0.7%) with abused children 16.6 times more likely to show wasting than non-abused (95% confidence limits on the Odds Ratio 1.9-145.0). While 11.6 percent of abused children showed stunting compared to 5.6 percent of non-abused, this difference was not significant when the data was adjusted for demographic factors. The BMI (15.02 kg/m2) for abused children was significantly less than that (15.9 kg/m2) for non-abused children (F = 8.11; p = 0.0049). In the present study, significant wasting as seen in acute malnutrition was found among abused children at diagnosis, suggesting that within an urban poor community the growth of children so identified does differ from the growth of children who are not abused.

Thirty-two adolescents were matched to mature controls for a study of variables known to influence the course and outcome of pregnancy. These included: ethnicity; clinic payment status; year of delivery; parity; and presence or absence of alcohol and tobacco use. The comparative factors examined included: age of menarche; gynecologic age; admission hemoglobin; prepregnant weight and height; weight gain during pregnancy; complications of pregnancy; length of gestation; birth weight; 1- and 5-minute apgar scores; and the presence or absence of congenital defects. There was no significant difference between young adolescents and matched controls in infant birth weight or apgar scores when the above confounding factors were controlled. Young gravidae, however, had significantly shorter gestations, earlier menarche, lower hemoglobin levels, and poorer weight gain during pregnancy than mature women. Multiple-regression analysis suggests that 1) pregnancy weight gain was associated with the trimester the gravida enrolled in the Supplemental Food Program for Women, Infants, and Children (WIC) (p = 0.008) and maternal stature (p = 0.012); 2) length of gestation was associated with maternal stature (p = 0.022) and prepregnant weight (p = 0.011); and 3) maternal hemoglobin was associated with birth weight (p = 0.087). Alternative interpretations are discussed.

In a hematologic survey conducted in 1972, microcythemia in school children was found to be associated with microcythemia in other family members. The association of cultural characteristics of chronic poverty with reduced red cell volume suggested nutritional iron deficiency. A resurvey of families was made in 1975. For 39 children between the ages of 3 and 10 years at the time of both surveys, mean hemoglobin concentration (HGB) decreased from 21.0 g/dl to 10.8 g/dl. Thirteen infants, 6 months to 3 years of age in 1972, in the resurveyed families had mean HGB of 11.5 g/dl as compared to 10.4 g/dl for 9 similarly aged children newly born into the resurvey families. The rate of somatic growth was unchanged during the interval between survey. During the interval between 1972 and 1975, food costs rose nationally, and the purchase of meat products decreased both nationally and (as found in this study) locally. The data suggest that the high cost of foods rich in micronutrients may increase the prevalence of iron deficiency in an impoverished community.

This study was designed to identify differences in parental behaviors and the availability of food between undernourished and well-nourished inner-city children of early school age. Children with a constellation of measurements of height below the 25th percentile, midarm muscle circumference below the 50th percentile, and hemoglobin concentration below 11.5 g/dL were considered undernourished. These children were matched with controls having measurements above these levels. The homes of all children were investigated. Families of undernourished children were found to have significantly less variety of nutritious foods requiring preparation by an adult available in the home (P less than .01), to have greater variety of convenience foods of low nutritional value (P less than .01), and to prefer fewer vegetables (P less than .04) and dairy products (P less than .01). The Polansky Child Level of Living Scale showed that mothers of undernourished children were less likely to prepare meals regularly for their children (P less than .05) and that they were less effective in providing general parental support to their children (P less than .03).

In a large sample (N = 7116) of women who had two pregnancies within six years, the 50th percentile of weight gain between pregnancies was 2 lb (0.9 kg). Weight gain in pregnancy, week of registration, cigarette smoking, race, percent of ideal body weight, complications of pregnancy, and marital status in the first pregnancy, as well as breast-feeding in the hospital and interval between the two pregnancies, correlated significantly with interpregnancy weight change, and explained 24% of the variance (P less than .0001). Weight gain in the first pregnancy alone explained 21% of the variance in weight change between pregnancies. After adjustment for the effects of other variables on weight change, weight gains in pregnancy of 20 lb (9.1 kg) or more were statistically significant (P less than .05); the more weight a woman gained above 20 lb (9.1 kg), the more she retained by the start of her next pregnancy.

The authors performed a case-control study of 60 school children who were examined for a constellation of anomalies suggestive of fetal alcohol exposure. Nonretarded learning disabled children were 7.25 times (95%, confidence interval, 1.05 to 50.0) more likely than controls to have signs consistent with alcohol exposure in fetal life. These data suggest an expanded spectrum of fetal alcohol effects. Early recognition of minor physical anomalies could result in prompt evaluation and treatment of these children.

The growth and nutritional status of 2,056 schoolchildren from a poor community in southern New Jersey were assessed. Age-adjusted differences in growth among black, white, and Hispanic children were examined. Black youths were 2.5 centimeters (cm) taller (P less than .001) and 0.9 kilograms (kg) heavier than white youths (P less than .05). Black girls were 4.1 cm taller (P less than .001) and 2.8 kg heavier than white girls (P less than .01). Hispanic girls were 1 kg heavier (P less than .05) and 0.9 cm taller (not significant) than white girls. There was little difference in growth between Hispanic and white youths. Children were assessed with the use of the Centers for Disease Control's nutritional surveillance cutpoints; less than 5 percent of each ethnic group fell below the fifth percentile, according to the National Center for Health Statistics' weight-for-height standards. White and Hispanic youths were twice as likely as blacks to fall below the 5th percentile for stature or to be overweight (above the 95th percentile for weight-for-height). Compared with black girls, white and Hispanic girls were three to four times more likely to fall below the fifth percentile for stature. The prevalence of short stature was also higher among white girls (15.9 percent) compared with Hispanics (10.3 percent). There was little difference in the prevalence of overweight by ethnic group for girls. These data show that white children from poor communities have decreased growth and suggest that they may be at increased risk of nutritional problems.