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Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT.To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening.All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants' outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4-12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses.A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Purpose: The purpose of this study is to characterize mothers’ experiences within a mother/infant dyad postpartum primary care program (Dyad) following gestational diabetes mellitus (GDM) to inform improvements in the delivery of care. Methods: A qualitative pilot study of women (n = 10) enrolled in a mother/infant Dyad program was conducted in a primary care practice at a large, urban academic medical center. Respondents were asked a series of open-ended questions about their experience with GDM, the Dyad program, and health behaviors. Interviews were audio-recorded, transcribed verbatim, and analyzed using ground theory with NVivo 12 Plus software. Results: Three key themes emerged: (1) Dyad program experience, (2) implementation of health behavior changes, and (3) acknowledgment of future GDM and type 2 diabetes mellitus (T2DM) health risks. Respondents felt that the program conveniently served mother and infant health care needs in a single appointment. Respondents also valued support from primary care providers when implementing health behavior changes. The Dyad program provided an opportunity for respondents to understand their current and future risk for developing GDM and T2DM. Conclusions: Postpartum women enrolled in the Dyad program received highly personalized primary care services. The results of our study will help integrate patient-centered strategies into models for GDM care to maintain patient engagement in postpartum clinical services.

Background Neonatal care of preterm infants may include dietary approaches such as high calorie formulas to promote physical growth. However, continuing growth-promoting strategies beyond the point of necessity, coupled with poverty and food insecurity which are more common among families of children born preterm, may increase the risk of obesity. Because children born preterm tend to have more pressing health conditions that require ongoing care, obesity may go undiagnosed by providers. Methods This retrospective cohort study included 38,849 children (31,548 term, 7301 preterm) born from 2010 to 2015, who received clinical care at a large pediatric medical center (Ohio, USA). Electronic medical record data, linked to Ohio birth certificates, were used to identify children with measured obesity (≥2 weight-for-length values ≥95th percentile before 24 months of age or BMI values ≥95th percentile at or after 24 months of age). Children were considered to have diagnosed obesity if their medical record had an obesity-related phrase or billing code recorded. Modified Poisson regression was used to compare risk of obesity undiagnosis among obese children born preterm versus at term. Results In total, 13,697 children had measured obesity, 10,273 (75%) of which were undiagnosed. Children born preterm with measured obesity were 8% more likely to be undiagnosed compared to children born at term (adjusted relative risk = 1.08 95% CI 1.05, 1.11). The risk was slightly higher for preterm children born to white women or born to women with higher educational attainment. For both groups, Primary Care and subspecialist clinics were the most common settings for undiagnosed obesity (74.9% and 16.8% of undiagnosed cases, respectively). Conclusions and relevance Preterm birth was associated with increased risk of undiagnosed obesity in early childhood. This highlights the need to enhance obesity screening in the preterm population and to further explore reasons for this disparity.

Background The purpose of this study was to examine the association between perceived social support and postpartum depression symptoms (PDS) and to understand how this association may differ for urban, suburban, rural Appalachian, and rural non-Appalachian women in Ohio. Methods Data were obtained via the 2016 Ohio Pregnancy Assessment Survey (n = 3382), a representative sample of postpartum women in Ohio. We conducted bivariate analyses to assess the associations between self-perceived social support and PDS, and covariates. Univariate and multivariate logistic regressions were conducted using a modified Poisson distribution to estimate the association between social support and PDS, adjusting for sociodemographic characteristics. We also examined geographical context as an independent predictor of PDS and as an effect modifier for the association between social support and PDS. Results 15.6% of survey respondents experienced PDS. Women with low levels of social support had slightly higher prevalence (aPR: 1.4, 95% CI: 1.0-2.1) of PDS compared to women with high social support. Geographic context was an independent predictor of PDS; women in rural Appalachia had significantly lower prevalence (aPR: 0.5, 95% CI: 0.2-0.9) of PDS compared to women in urban areas. We did not find that geographical context modified the relationship between social support and PDS (Wald P = .5). Conclusions Low social support was associated with increased PDS but did not reach statistical significance. Women living in rural Appalachia had a lower prevalence of PDS. Future studies should explore the reasons for lower rates of PDS in rural Appalachia.

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: Ohio First Steps for Healthy Babies (First Steps) is a free, voluntary statewide designation program coadministered by the Ohio Department of Health and the Ohio Hospital Association that promotes breastfeeding-supportive maternity practices aligned with the Baby-Friendly Hospital Initiative (BFHI).Materials and Methods: We examined Ohio birthing hospitals’ participation in First Steps, and changes in breastfeed-ing rates at hospital discharge, over the first 12 quarters of the program (July 15, 2015, to July 14, 2018) for all 110 licensed Ohio birthing hospitals. The 81 (73.6%) that achieved at least 1 step over the study period (designated as First Steps hospitals) were compared to the 29 non-First Steps hospitals, and the 17 that began participation at First Steps startup (July 15, 2015) were identified for additional analysis. Changes in breastfeeding rates were examined using a mixed effects multivariate regression model.Results: Breastfeeding increased significantly over the program period from 73.8% to 76.7% (mean 0.19% per quarter, p = .0002), but without a significant difference in breastfeeding rates between First Steps and non-First Steps hospitals. However, in a pre- and post-program analysis for the 17 hospitals that began participation at First Steps startup (excluding an additional 6 hospitals with BFHI designation), number of quarters in the program, number of steps completed, and number of births in 2015 were significantly associated with breastfeeding rates. Hospitals that completed at least 2 steps every 5 quarters in the First Steps program increased breastfeeding when compared to those not participating in the program.Conclusion: These encouraging results provide a formal evaluation of a best practices BFHI-modelled statewide program.

Background: Increasing the proportion of infants who are breastfed and extending breastfeeding duration are high-priority U.S. goals. Evaluation of progress is based on federal survey data, but federal survey questions do not reflect contemporary feeding practices. Materials and Methods: Our objective was to evaluate the Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) in estimating breast milk feeding and milk expression practices and compare to estimates from simultaneously administered federal survey questions. We surveyed women with child(ren) younger than the age of 6 years attending a large children's hospital for urgent or primary care. We estimated the proportions who participated in various breast milk feeding and milk expression practices and the durations of each and examined agreement between the surveys. We compared respondents with high versus low disagreement using log-binomial regression. Results: Of 225 respondents, 51% had less than a Bachelor's degree, and 44% identified as a race other than white. Similar proportions on each survey reported ever having breastfed or fed breast milk (84%). Proportions still breastfeeding or feeding breast milk at 6 and 12 months differed slightly by survey. Dyads (9%) who fed at the breast and fed expressed milk for nonidentical periods had estimates for the duration of breastfeeding or feeding breast milk that were lower per the federal survey. Respondents who answered the federal survey before the BaByMERS were more likely to provide discrepant responses (risk ratio = 3.40, 95% confidence interval: 1.18–9.80). Conclusions: This study offers further validation of brief interviewer-administered questions to collect quality data recalled about infant feeding and lactation for research purposes.

The association between body mass index (BMI, which is calculated as weight in kilograms divided by height in meters squared) and severe maternal morbidity (SMM) and/or mortality is uncertain, judging from the current evidence.To examine the association between prepregnancy BMI and SMM and/or mortality through 1 year post partum and to identify both the direct and indirect implications of maternal obesity for SMM and/or mortality by examining hypertensive disorders and pregestational diabetes as potential mediators.This population-based cohort study was conducted from March to October 2021 using the vital records and linked Medicaid claims data in the state of Ohio from January 1, 2012, through December 31, 2017. The cohort comprised pregnant Medicaid beneficiaries who delivered at 20 weeks' gestation or later and had prepregnancy BMI information.The primary exposure was maternal prepregnancy BMI, which was categorized as follows: underweight (18.5), healthy weight (18.5-24.9), overweight (25.0-29.9), class 1 obesity (30.0-34.9), class 2 obesity (35.0-39.9), and class 3 obesity (≥40.0).The primary outcome was a composite of SMM (defined using Centers for Disease Control and Prevention criteria) and/or maternal mortality between 20 weeks' gestation and 1 year post partum. Additional periods were assessed, including 20 weeks' gestation through delivery hospitalization and 20 weeks' gestation through 42 days post partum. Generalized estimating equation models were used to estimate adjusted relative risks (aRRs) for the primary outcome according to BMI category. Maternal hypertensive diseases and pregestational diabetes were assessed as potential meditators.In a cohort of 347 497 pregnancies among 276 691 Medicaid beneficiaries (median [IQR] maternal age at delivery, 25 [21-29] years; 210 470 non-Hispanic White individuals [60.6%]), the prevalence of maternal obesity was 30.5% (n = 106 031). Composite SMM and/or mortality outcome occurred in 5.3% of pregnancies (n = 18 398). Overweight (aRR, 1.07; 95% CI, 1.03-1.11) and obesity (class 1: aRR, 1.19 [95% CI, 1.14-1.24]; class 2: aRR, 1.37 [95% CI, 1.30-1.44]; class 3: aRR, 1.71 [95% CI, 1.63-1.80]) were associated with an elevated risk of SMM and/or mortality during pregnancy to 1 year post partum compared with healthy BMI. Similar findings were observed when the follow-up period was shortened to 42 days post partum or the delivery hospitalization. Hypertension mediated 65.1% (95% CI, 64.6%-65.6%) of the association between obesity and the primary outcome.Results of this study showed that maternal prepregnancy obesity was associated with an elevated risk of SMM and/or mortality. Hypertensive disorders appeared to mediate this association, suggesting that improved prevention and management of hypertensive disorders in pregnancy may reduce morbidity and mortality in individuals with obesity.

Objective To assess how often maternal transport preceded pregnancy-related deaths and describe contributing factors and recommendations related to maternal transport. Study design We used Ohio maternal mortality review committee (MMRC) data from 2010 to 2016. We defined two transport types among pregnancy-related deaths: field to hospital and hospital to hospital. We examined deaths determined by the MMRC to be potentially preventable by transfer to a higher level of care and described contributing factors and recommendations. Result Among 136 pregnancy-related deaths, 56 (41.2%) were transported. Among 15 deaths identified as potentially preventable by transfer to a higher level of care, 5 were transported between hospitals. Contributing factors for 14 deaths included inadequate response by Emergency Medical Services and lack of transport to a higher level of care. Conclusion Our results suggest opportunities for examining modification and adherence to existing protocols. Improving risk-appropriate maternal care systems is important for preventing pregnancy-related deaths.

To assess how often maternal transport preceded pregnancy-related deaths and describe contributing factors and recommendations related to maternal transport.We used Ohio maternal mortality review committee (MMRC) data from 2010 to 2016. We defined two transport types among pregnancy-related deaths: field to hospital and hospital to hospital. We examined deaths determined by the MMRC to be potentially preventable by transfer to a higher level of care and described contributing factors and recommendations.Among 136 pregnancy-related deaths, 56 (41.2%) were transported. Among 15 deaths identified as potentially preventable by transfer to a higher level of care, 5 were transported between hospitals. Contributing factors for 14 deaths included inadequate response by Emergency Medical Services and lack of transport to a higher level of care.Our results suggest opportunities for examining modification and adherence to existing protocols. Improving risk-appropriate maternal care systems is important for preventing pregnancy-related deaths.

With shifting demographics and declining response rates, state and national health surveys are considering mixed mode approaches. Most states field the Pregnancy Risk Assessment Monitoring System (PRAMS) surveillance project, but few have studied the effect of encouraging online responses. Like PRAMS, the 2016 Ohio Pregnancy Assessment Survey interviewed new mothers 2–4 months after delivery (n = 3382). Fielding included a traditional mailed paper questionnaire with telephone follow-up protocol and two experiments: a rotating web invitation added a web survey link at different points during the mail protocol, and a push-to-web protocol asked women to complete the survey online before mailing a questionnaire. This analysis examined the responses rates and tested for unweighted demographic differences using Pearson’s chi-square. The unweighted response rate was highest with the traditional contact protocol (30.0%) and slightly lower among the rotating web invite (27.4%) and the push-to-web (25.5%) groups. Nearly two-thirds (64%) of push-to-web protocol respondents completed the survey online, with 70% of those web surveys submitted before the first paper questionnaire was mailed. Women who responded to the web versus mail surveys were similar on most characteristics, although in both experimental groups, women who completed the web version were more likely to be college educated. Among the push-to-web group, 60% of web and 36% of mail respondents had a 4-year college degree (p

Objective To examine how expressed milk feeding diverges from feeding at the breast in its association with neurodevelopment and behavior. We hypothesized that longer and exclusive feeding at the breast only (ie, no formula, no feeding expressed milk) would be associated with the optimal cognitive developmental, executive function, and eating behaviors and that expressed milk feeding would be associated with less-optimal outcomes. Study design The Moms2Moms cohort (Ohio, US) reported infant feeding practices at 12 months postpartum and children’s global cognitive ability, executive function, and eating behaviors at 6 years. Linear and log-binomial regression models estimated associations with durations of feeding at the breast, expressed milk, human milk (modes combined), and formula. Results Among 285 participants, each month of exclusive feeding at the breast only was associated with a decreased risk of clinically meaningful executive function (working memory) deficit (adjusted relative risk [RR] 0.78, 95% CI 0.63-0.96) but was unassociated with inhibition (adjusted RR 0.92, 95% CI 0.85-1.01). Feeding expressed milk was not clearly related to executive function outcomes. No associations with global cognitive ability were observed. Weak associations were observed with eating behaviors for some feeding practices. Conclusions Feeding at the breast may offer advantages to some aspects of executive function that expressed milk may not. Large, prospective studies exploring mechanisms could further distinguish the effect of feeding mode from that of nutrients.

Introduction An important yet understudied component of postpartum type 2 diabetes risk reduction among high risk women is experiences with the healthcare system. Our objective was to describe the healthcare experiences of a diverse, low-income sample of women with prior GDM, including their suggestions for improving care. Methods Focus groups were conducted among African American, Hispanic, and Appalachian women who were diagnosed with GDM within the past 10 years. Participants were recruited from community and medical resources. Twelve focus groups were conducted, four within each race-ethnic group. Results Three broad themes were identified around barriers to GDM care, management, and follow-up: (1) communication issues; (2) personal and environmental barriers; and (3) type and quality of healthcare. Many women felt communication with their provider could be improved, including more education on the severity of GDM, streamlining information to be less overwhelming, and providing additional support through referrals to community resources. Although women expressed interest in receiving more actionable advice for managing GDM during pregnancy and for preventing type 2 diabetes postpartum, few women reported changing behaviors. Barriers to behavior change were related to cost, transportation, and competing demands. Several opportunities for improved care were elucidated. Discussion Our findings suggest that across all racial and ethnic representations in our sample, low-income women with GDM experience similar communication, personal, and environmental barriers related to the healthcare they receive for their GDM. Considering the increased exposure to the health care system during a GDM-affected pregnancy, there are opportunities to address barriers among women with GDM across different race-ethnic groups.

To compare preterm birth rates and gestational length in four race-nativity groups including Somali Americans.Using a retrospective cohort study design of Ohio birth certificates, we analyzed all singleton births between 2000 and 2015 from four groups of women categorized as U.S.-born, non-Hispanic white (USBW), U.S.-born, non-Hispanic black (USBB), African-born black (ABB, primarily of West African birth country), and Somalia-born (SB). An algorithm trained on maternal names was used to confirm Somali ethnicity. Gestational length was analyzed as completed weeks or aggregated by clinically relevant periods. Risk of spontaneous and health care provider-initiated preterm birth was calculated in a competing risk model.Births to women in the designated groups accounted for 1,960,693 births (USBW n=1,638,219; USBB n=303,028; ABB n=10,966, and SB n=8,480). Women in the SB group had a lower preterm birth rate (5.9%) compared with women in the USBB (13.0%), ABB (8.4%), and USBW (7.9%) groups (P.001). Women in the SB group had a higher frequency of postterm pregnancy (5.8% vs less than 1%, P.001 for all groups). The lower rate of preterm birth in the SB group was unrelated to differences in parity or smoking or whether preterm birth was spontaneous or health care provider-initiated. The lower rate of preterm birth and tendency for prolonged gestation was attenuated in ethnic Somali women born outside Somalia.We report a positive disparity in preterm birth and a tendency for prolonged gestation for ethnic Somali women in Ohio. Etiologic studies in multiethnic cohorts aimed to uncover the sociobiological determinants of gestational length may lead to practical approaches to reduce prematurity in the general population.

Objective This research examined the association between perceived everyday racial discrimination, as a psychosocial stressor, and perinatal sleep quality. Design Cross-sectional (N = 640) and longitudinal associations (N = 133) between everyday experiences of discrimination and sleep quality were examined using a pregnancy and postpartum data registry. Participants We studied a sample of 640 unique women from the Perinatal Research Repository (PRR), a longitudinal study of mothers, fathers, and babies recruited from Nationwide Children's Hospital and The Ohio State University in Columbus, Ohio. Measurements Discrimination and sleep quality were assessed using the Experiences of Discrimination Scale and the Pittsburgh Sleep Quality Index, respectively. Results Overall, everyday discrimination was associated with poorer global sleep quality and all but three sleep sub-measures of the PSQI cross-sectionally, but not longitudinally. When stratified, the adverse effects of everyday discrimination varied by race and perinatal time period. Increases in everyday discrimination were independently associated with poorer sleep initiation, poorer sleep maintenance and poorer daytime dysfunction. Conclusions Findings suggest that the immediate stressors of everyday racial discrimination were independently associated with poorer sleep quality among pregnant women cross-sectionally. Poorer sleep quality has been associated with numerous adverse perinatal outcomes and this association may be important in understanding racial discrimination as a risk factor. Our failure to identify a longitudinal association makes the direction of causation uncertain, however. Further longitudinal studies are necessary to clarify the association, given the potential importance of poor sleep quality in the pathogenesis of pregnancy complications.

Background In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce. Objective To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed. Methods The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon's and logistic regression (p Results Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups. Conclusion Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.

Purpose This study examined weight loss behavior and the prevalence of hyperglycemia unawareness (unknown high blood glucose) after gestational diabetes mellitus (GDM), within a nationally, representative sample. This study also examined social-demographic, psychosocial, provider communication, and health care access/utilization factors as predictors of A1C and health-protective behavior after GDM. Methods A secondary analysis of 2007-2014 National Health and Nutrition Examination Surveys (NHANES) data was conducted, including 205 women, aged 20 to 44 years, with a history of GDM, whose last live birth was in the past 10 years, excluding pregnant women and those with diabetes. Weighted bivariate, stepwise linear, and binary logistic regression analyses were conducted to examine correlates of A1C, weight change, weight loss attempt and behavior, diabetes screening, and physical activity. Results Hyperglycemia unawareness was associated with increased A1C and weight gain in the past year. Personal weight loss goal and perception of overweight increased the odds of weight loss attempt. Depressive symptoms were associated with weight gain over the past year. A third of the sample failed to have their glucose tested in the past 3 years. Two-thirds were never told about their personal risk for diabetes, but provider communication increased the odds of meeting weekly activity recommendations and glucose screening. Hispanic women and non-Hispanic black women were less likely to have had glucose screening than non-Hispanic white women. Conclusion Diabetes educators should address gaps in provider communication, while supporting psychosocial needs and reducing disparities to encourage health-protective behavior after GDM. The American Association of Diabetes Educators, 7 Self-Care Behaviors (AADE-7TM) provides an excellent framework for interventions to support health-protective behavior after GDM.

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 18–44 years 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.

Background: Detailed data on lactation practices by gestational diabetes mellitus (GDM) history are lacking, precluding potential explanations and targets for interventions to improve lactation intensity and duration and, ultimately, long-term maternal and child health. Objective: This study aimed to examine breastfeeding practices through 12 months postpartum by GDM history. Methods: Women who delivered a singleton, liveborn infant at The Ohio State University Wexner Medical Center (Columbus, OH), in 2011 completed a postal questionnaire to assess lactation and infant feeding practices and difficulties. Bivariate and multivariate associations between GDM history and lactation and infant feeding practices were examined. Results: The sample included 432 women (62% response rate), including 7.9% who had GDM during the index pregnancy. Women with GDM initiated breastfeeding (at-the-breast or pumping) as often as women without any diabetes but were more likely to report introduction of formula within the first 2 days of life (79.4% vs 53.8%, P < .01; adjusted odds ratio: 3.48; 95% confidence interval, 1.47-8.26). Women with GDM initiated pumping 4 days earlier than women without diabetes ( P < .05), which was confirmed in adjusted analyses. There was no difference in the proportion of women reporting breastfeeding difficulty (odds ratio: 2.08; 95% confidence interval, 0.78-5.52). However, there was a trend toward women with GDM reporting more formula feeding and less at-the-breast feeding as strategies to address difficulty compared with women without diabetes. Conclusion: Additional research is needed to understand why women with GDM engage in different early lactation and infant feeding practices, and how best to promote and sustain breastfeeding among these women.

OBJECTIVES: To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). METHODS: We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. RESULTS: Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. CONCLUSIONS FOR PRACTICE: QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.

Background Determining whether initiation of preterm birth was spontaneous, or through labour induction or caesarean without labour or membrane rupture is critical in surveillance and aetiological research on preterm birth, although this information is not explicitly included on the US Birth Certificate. Algorithms combining several fields from birth certificates have been developed to infer the initiating event, but none has been validated against manual review of original obstetric records. Our objective was to develop a birth certificate-based algorithm to determine initiation of preterm birth and validate it by manual review of original records. Methods We developed an algorithm from the 2003 US Standard Birth Certificate to determine spontaneous vs. indicated preterm birth. The algorithm was first tested on obstetrical records from 80 preterm (

BACKGROUND Asymptomatic infants born to women with pregestational diabetes mellitus (PGDM) are usually admitted to the well baby nursery (WBN) while those who are symptomatic or in need of specialized care are admitted to the neonatal intensive care unit (NICU). OBJECTIVE To determine if changes in the NICU admission rate of asymptomatic infants born to women with PGDM during two different epochs affected breastfeeding (BF) initiation rates. DESIGN/METHODS Retrospective cohort investigation of 386 women with PGDM and their infants who delivered in 2008-11 (epoch 1) and 457 who delivered in 2013-16 (epoch 2) at a single institution. RESULTS NICU admissions: Comparison between epoch 1 and epoch 2 showed a decrease in the number of admissions from 243 (63%) to 175 (38%) *(chi square *p < 0.05). Respiratory distress (39 and 43%) and prematurity (28 and 23%) as admission diagnoses remained unchanged. Admissions for prevention of hypoglycemia declined (32% to 21%)*. At discharge from the NICU, exclusive BF (12 to 19%)* and any BF increased (41 to 55%)* while formula feeding (FF) decreased (59 to 45%)*. Admission to the NICU remained a strong predictor of BF initiation failure (a OR 0.6, 95% , CI 0.4-0.9, p 0.005).WBN admissions: Comparison between epoch 1 and epoch 2 showed an increase in the number of admissions from 143 (37%) to 282 (62%)*. The incidence of hypoglycemia (31% and 38%) and its correction with oral feedings (76% and 71%) remained unchanged. At discharge from the WBN, exclusive BF (15 to 27%)* and any BF (52 to 62%)* increased while FF decreased (48 to 38%)*. CONCLUSIONS A decrease in the number of NICU admissions of asymptomatic infants born to women with PGDM is associated with improvements in BF initiation rates.

Major U.S. federal maternal and child health surveys collect an infant feeding history for children under 6 years of age using survey questions that have changed little over decades. Yet, infant feeding and lactation practices have changed with the increasing popularity of milk expression (pumping).Cognitive interviews were conducted to test the 9-item Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) with a diverse sample of 15 U.S. mothers of children 1-5 years of age. A 42-item coding scheme was applied to identify interviewer and respondent problems in fielding and answering the questions. Problems were examined in relation to demographics and infant feeding and lactation history.The extent of problems was modest. Of 42 possible problem codes, only 9 were identified as actual problems for one or more respondents on one or more questions. The most common problems involved uncertainty about the timing of when one started expressing milk, making a mental shift to realize that maternal milk expression and the child's consumption of that milk could be distinct concepts, and difficulty with certain terms or phrases. Problems tended to arise among mothers with more complex infant feeding or lactation histories, who also tended to be those with higher levels of education.BaByMERS is a promising, brief tool for collecting a recalled infant feeding or lactation history among mothers with young children. Future research can evaluate additional characteristics of the tool to further confirm its utility for large epidemiological studies of maternal and child health.

Background: Exclusive breastfeeding is recommended in the first 6 months of life, especially for infants born to women with a history of gestational diabetes mellitus (GDM). Yet, women with a history of GDM face challenges with exclusive breastfeeding in the early postpartum period, a critical period for setting up longer term breastfeeding success. Minimal research has been published on associated risk factors for not exclusively breastfeeding. Objective: The purpose of this study was to examine the association between GDM and exclusive breastfeeding at hospital discharge. Methods: We conducted a cross-sectional analysis including 2038 women who participated in the population-based Infant Feeding Practices Study II between May 2005 and June 2007. Results: Gestational diabetes mellitus prevalence was 5.8%. The crude prevalence of exclusive breastfeeding at hospital discharge was 62.2% among women with GDM compared to 75.4% of women without GDM ( P < .01). After adjusting for sociodemographic, behavioral, and anthropometric factors, the odds of exclusive breastfeeding were lower among women with GDM compared to women without diabetes (odds ratio = 0.59; 95% confidence interval, 0.39-0.92). Furthermore, women who had gestational weight gain (GWG) below the Institute of Medicine guidelines had lower odds of exclusive breastfeeding compared to women who had normal GWG (odds ratio = 0.62; 95% confidence interval, 0.45-0.85). Conclusion: Women with GDM history and women with inadequate GWG may need additional education to promote exclusive breastfeeding during maternal hospital stay. It is important for health care providers to assess both factors when providing education on exclusive breastfeeding and to support these women’s breastfeeding efforts in the early postpartum period to maximize potential for longer term breastfeeding success.

Purpose. To determine when women receive pregnancy-related preventive health messages and to examine differences in receipt timing by maternal characteristics. Design. The cross-sectional secondary analyses used data from the Pregnancy Risk Assessment Monitoring System (PRAMS). Setting. The study used PRAMS responses from Maryland, Michigan, New Jersey, Ohio. Subjects. Study participants were women with a recent live birth. Measures. Health messages included mental health, safe medications, smoking, alcohol, and illegal drugs. The timing of message receipt was categorized as early (preconceptionally and prenatally) or late (prenatally only/never). Analysis. Weighted χ2 tests and multivariable logistic regression were used for analysis. Results. Among n = 3446, women with unintended pregnancies received all messages, except safe medications, significantly more early vs. late compared with women intending pregnancies (all p < .01). In multivariable analyses, there were no significant associations between timing of receipt and pregnancy intention, parity, preconception insurance status, or adequacy of prenatal care for any of the health messages. Hispanic women had increased odds of receiving the messages early compared with non-Hispanic white women, as did high school graduates vs. women with more education and women with lower household incomes vs. women with higher incomes. Conclusions. Women who may be perceived to be at higher risk of adverse pregnancy outcomes and/or engaging in high-risk behavior (minorities, lower education, lower income) appear to be getting messages early more often than do other women; messages are not reaching all women equally.

Objective To examine trends in breastfeeding initiation, continuation, and exclusivity by prepregnancy weight from 2004 to 2011 and the associations between these outcomes and prepregnancy weight. Methods Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System, a survey of women with a recent live birth from 34 states and New York City, were used. Trends in breastfeeding initiation, continuation, and exclusivity at 12 weeks postpartum were evaluated by prepregnancy BMI. Logistic regression was used to identify the association between prepregnancy BMI and the breastfeeding outcomes. Results Among 244,196 women, with increasing BMI, a decreasing number of women initiated, continued, and breastfed exclusively. From 2004 to 2011, the rates of breastfeeding initiation increased significantly for women of all weight classes (P

Background While breastfeeding in the United States is on the rise, trends among infants admitted to the Neonatal Intensive Care Unit (NICU) are less known. The objective of this study was to examine trends in breastfeeding initiation among NICU-admitted infants in Ohio from 2006 to 2012 and to determine differences in breastfeeding initiation trends by gestational age. Methods Using Ohio Vital Statistics birth certificate data, the Cochran–Armitage test for trend was used to determine significant trends in breastfeeding by gestational age. Logistic regression was used to examine the association between breastfeeding initiation and gestational age by year. Results From 2006 to 2012, 48,758 infants born in Ohio were admitted to the NICU, representing 5.6 percent of all newborns. Breastfeeding among NICU-admitted infants increased from 53.3 percent in 2006 to 63.8 percent in 2012 (p

More than 85% of contemporary lactating women in the United States express their milk at least sometimes. Some produce milk exclusively through pumping. We characterized women who pumped but never fed at the breast and compared their infant feeding practices with those of women who fed at the breast with or without pumping.Study participants were those delivered at Ohio State University Wexner Medical Center in 2011 and completed a questionnaire at 12 months postpartum (n = 478). We used bivariate and multivariate approaches (survival analysis) to compare women who pumped but never fed at the breast with women who fed at the breast with or without pumping.Women (n = 33, 6.9%) who pumped but never fed at the breast comprised a diverse group but were more likely to have delivered preterm and were of lower socioeconomic status on average. They initiated pumping and formula feeding earlier (median = day 1 after delivery) and were more likely to report difficulty making enough milk compared with women who fed at the breast with or without pumping. They had much shorter total duration of milk production (adjusted hazard ratio = 3.3, 95% confidence interval: 2.1, 5.2) after controlling for clinical and sociodemographic confounders.Pumping without feeding at the breast is associated with shorter milk feeding duration and earlier introduction of formula compared with feeding at the breast with or without pumping. Establishing feeding at the breast, rather than exclusive pumping, may be important for achieving human milk feeding goals.

In-hospital experiences among women with gestational diabetes mellitus (GDM) could impact breastfeeding success. We sought (1) to determine changes in the prevalence of hospital breastfeeding experiences between 2004-2008 and 2009-2011 among women with GDM and women without diabetes; (2) to determine whether GDM is associated with higher occurrence of experiencing Baby-Friendly hospital practices because of their known higher rates of breastfeeding difficulties.Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System, a survey of women with a recent live birth from 16 states and New York City, were used based on inclusion of an optional survey question about hospital breastfeeding experiences. We examined the association of in-hospital experiences with GDM within each survey phase using chi-square tests. Weighted multivariable logistic regression was used to determine the association between GDM and hospital breastfeeding experiences.Among 157,187 (8.8% GDM), there were crude differences by GDM status for at least 60% of hospital experiences despite increases in positive hospital experiences between time periods. Women with GDM were less likely to report breastfeeding in the first hour (adjusted odds ratio: 0.83, confidence interval [95% CI] 0.73-0.94), feeding only breast milk in the hospital (0.73, 0.65-0.82), and feeding on demand (0.86, 0.74-0.99) compared with women without diabetes. Women with GDM were significantly more likely to report receiving a pump (1.28, 1.07-1.53) and a formula gift pack (1.17, 1.03-1.34) compared with women without diabetes.Although women with GDM experienced improvements in-hospital breastfeeding experiences over time, disparities in breastfeeding practices remained for five in-patient (hospital) practices that included four negative practices (breastfeeding in the first hour, feeding only breast milk in the hospital, told to feed per mother's preference, receiving a formula gift pack) and one positive practice (receiving a pump).

To describe enrollment and compare demographic and clinical characteristics of neonates enrolled in the perinatal research repository (PRR) with eligible, but non-enrolled neonates.Characteristics from enrolled infants were compared with eligible, but non-enrolled infants using t-tests, Wilcoxon rank tests and χ(2) tests.Between 1 January 2010 and 31 December 2011, 622 infants admitted to the neonatal intensive care unit (NICU), born37 weeks were screened for the PRR were eligible for enrollment. Of these, 233 enrolled in the study. There were no significant differences between enrolled and non-enrolled infants with regard to race, birth weight, gestational age and Apgar scores. Enrolled patients had a significantly longer length of stay [mean (standard deviation) = 55.0 (58.9) versus 38.0 (45.8) days; p0.01]. Mortality was significantly greater in the non-enrolled group (11.7 versus 3.0%; p0.01). Both groups had a similar total number of diagnoses [mean (standard deviation) = 5.7 (3.1) versus 5.8 (3.2)]; however, among survivors enrolled infants had slightly lower prevalence of hypoxic ischemic encephalopathy (0.0 versus 2.9%; p0.01) and seizures (1.8 versus 6.4%; p0.01). There were no significant differences in enrollment by prevalence of other morbidities.These results suggest that a specimen collecting repository can enroll a sufficiently representative sample of eligible patients.

PURPOSE Although the independent effects of lactation consultants and peer counselors have been shown to improve breastfeeding outcomes, the joint effects have yet to be considered, particularly in the neonatal intensive care unit (NICU) in nondelivery hospitals. Therefore, the objective of this study was to assess the effect of lactation staff type on breastfeeding outcomes during hospital stay after the addition of peer counselors to a NICU lactation program. SUBJECTS A total of 596 mother-infant pairs admitted to Nationwide Children's Hospital, Columbus, Ohio, pre- and postlactation program expansion. DESIGN A descriptive pre-/posttest study as conducted. MAIN OUTCOME MEASURES Differences in provision of any maternal breast milk, exclusive breast milk, or direct breastfeeding during NICU stay and at discharge were evaluated pre and postprogram implementation. Logistic regression was used to determine associations between lactation staff type and each outcome during hospital stay. RESULTS Infants receiving any breast milk during NICU stay increased from baseline to postprogram year 1 (63% vs 73%; P= 0.03). Direct breastfeeding increased from baseline to postprogram year 4 (42% vs 53%; P= 0.03). Mothers seen by only peer counselors were less likely to provide any breast milk at discharge, provide exclusive breast milk during stay or discharge, to be direct breastfeeding during stay or at discharge compared with mothers seen by both peer counselors and lactation consultants. CONCLUSIONS NICU lactation programs should consider including both peer counselors and lactation consultants to improve breastfeeding outcomes during hospital stay.

Aims To determine the extent of provision of preconception care among women with prepregnancy diabetes or women who develop gestational diabetes compared with women without diabetes and to examine the association between preconception care receipt and diabetes status, adjusting for maternal characteristics. Methods Data were collected from women who completed the Pregnancy Risk Assessment Monitoring System questionnaire in 10 US states (Hawaii, Maryland, Maine, Michigan, Minnesota, New Jersey, Ohio, Tennessee, Utah and West Virginia) in the period 2009 to 2010. Weighted, self-reported receipt of preconception care by diabetes status was examined. Multivariate logistic regression was used to identify the association between preconception care receipt and diabetes status. Results Overall, 31% of women reported receiving preconception care. Women with prepregnancy diabetes (53%) reported the highest prevalence of preconception care, while women with gestational diabetes and women without diabetes reported a lower prevalence (32 and 31%, respectively). In the adjusted model, there was no difference in reported preconception care receipt between women with gestational diabetes and women without diabetes (odds ratio 1.1, 95% CI 0.9, 1.3), while women with prepregnancy diabetes were significantly more likely to report receipt of preconception care (odds ratio 2.2, 95% CI 1.5, 3.3) than women without diabetes. Conclusions Although all women of reproductive age should receive preconception care, it is vital that women with known risk factors, such as those with prepregnancy diabetes and with risk factors for gestational diabetes, are counselled before pregnancy to optimize maternal and infant health outcomes. It is encouraging that women with prepregnancy diabetes report receiving preconception care more often than women on average, but preconception care is still not reaching all women at high risk.

Background Preconception care (PCC) is a form of primary prevention for promoting health, assessing risk, and intervening to modify risk factors to try to improve maternal and infant outcomes. Clinical provision of preconception care before and after the release of recommendations has not been evaluated. Our objective was to determine trends in self-reported receipt of PCC from 2004 to 2010, and factors associated with self-reported receipt of PCC. Methods Pregnancy Risk Assessment Monitoring System (PRAMS) data from 12 states were used to determine trends in PCC. Weighted multivariable logistic regression was used to identify factors associated with self-reported receipt of PCC. Results The sample consisted of n = 64,084 women, with 30.8 percent reporting receipt of PCC. PCC increased from 30.3 percent in 2004 to 32.6 percent in 2010 (p = 0.08 for trend). Women who were younger, with lower household income, or with a preterm birth were less likely to report PCC. Women with lower levels of education, who were non-Hispanic black, intending pregnancy, without previous children, or with prepregnancy government insurance were more likely to report PCC. Conclusions Only one-third of women with a recent live birth report receipt of any PCC. There is a need to increase PCC receipt, especially among populations that demonstrate lower levels.

Objective Although recent literature indicated an association between dental caries and poor academic performance, previous work relied on self-reported measures. This analysis sought to determine the association between academic performance and untreated dental caries (tooth decay) using objective measures, controlling for school-level characteristics. Methods School-level untreated caries prevalence was estimated from a 2009-2010 oral health survey of Ohio third-graders. Prevalence estimates were combined with school-level academic performance and other school characteristics obtained from the Ohio Department of Education. Linear regression models were developed as a result of bivariate testing, and final models were stratified based upon the presence of a school-based dental sealant program (SBSP). Results Preliminary bivariate analysis indicated a significant relationship between untreated caries and academic performance, which was more pronounced at schools with an SBSP. After controlling for other school characteristics, the prevalence of untreated caries was found to be a significant predictor of academic performance at schools without an SBSP (P = 0.001) but not at schools with an SBSP (P = 0.833). Conclusions The results suggest the association between untreated caries and academic performance may be affected by the presence of a school-based oral health program. Further research focused on oral health and academic performance should consider the presence and/or availability of these programs.

ObjectiveTo examine (i) the prevalence of and associations between breast-feeding initiation and continuation by maternal diabetes status and (ii) the reasons for not initiating and/or continuing breast-feeding by maternal diabetes status.DesignSecondary data analyses of a population-based cross-sectional study were conducting using data from the US Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (PRAMS), 2009–2011. Multivariable logistic regression was used to investigate the associations between breast-feeding initiation and continuation by diabetes status.SettingThirty states and New York City, USA.SubjectsMothers of recently live-born infants, selected by birth certificate sampling.ResultsAmong 72755 women, 8·8 % had gestational diabetes mellitus (GDM) and 1·7 % had pregestational diabetes mellitus (PDM). Breast-feeding initiation was similar among GDM and no diabetes mellitus (NDM) women (80·8 % v. 82·2 %, respectively, P=0·2), but continuation was lower among GDM (65·7 % v. 68·8 %, respectively, P=0·01). PDM women had lower initiation and continuation compared with NDM (78·2 %, P=0·03 and 60·4 %, PConclusionsDifferences in breast-feeding initiation and continuation prevalence by maternal diabetes status may reflect differences in prenatal education, indicating the need for increased efforts among PDM women. Additionally, non-smoking women with PDM or GDM would benefit from additional breast-feeding education.

BACKGROUD AND OBJECTIVE Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting. METHODS: We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts. RESULTS: From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined. CONCLUSIONS: By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk.

Determining whether initiation of preterm birth was spontaneous, or through labour induction or caesarean without labour or membrane rupture is critical in surveillance and aetiological research on preterm birth, although this information is not explicitly included on the US Birth Certificate. Algorithms combining several fields from birth certificates have been developed to infer the initiating event, but none has been validated against manual review of original obstetric records. Our objective was to develop a birth certificate-based algorithm to determine initiation of preterm birth and validate it by manual review of original records.We developed an algorithm from the 2003 US Standard Birth Certificate to determine spontaneous vs. indicated preterm birth. The algorithm was first tested on obstetrical records from 80 preterm (37 weeks) births in Columbus OH (2006-12) abstracted by an obstetrics research nurse and reviewed by an obstetrician-gynecologist. Onset of delivery was spontaneous if the initiating event was premature rupture of membranes (PROM) or contractions, or indicated if the initiating event was induction or caesarean without labour or PROM. The algorithm was validated in an independent sample of 100 preterm births from four hospitals.Codes for tocolysis, fetal intolerance of labour, and anaesthesia during labour did not predict labour and were dropped. The final algorithm correctly classified 73/80 cases, kappa = 0.83. In the validation, 86/100 cases were correctly classified. The kappa statistic was 0.68 (0.52, 0.83); predictive values for spontaneous and indicated onset were 85% (75%, 92%) and 89% (71%, 98%).The algorithm distinguished spontaneous from indicated preterm birth, using birth certificates, with good accuracy.

Background. Certain chronic diseases increase risk for invasive pneumococcal disease (IPD) and are indications for receipt of 23-valent pneumococcal polysaccharide vaccine (PPV23). Since the pediatric introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in 2000, incidence of IPD among adults has declined. The relative magnitude of these indirect effects among persons with and without PPV23 indications is unknown. Methods. We evaluated IPD incidence among adults with and without PPV23 indications using populationand laboratory-based data collected during 1998–2009 and estimates of the denominator populations with PPV23 indications from the National Health Interview Survey. We compared rates before and after PCV7 use by age, race, PPV23 indication, and serotype. Results. The proportion of adult IPD cases with PPV23 indications increased from 51% before to 61% after PCV7 introduction (P< .0001). PCV7-serotype IPD declined among all race, age, and PPV23 indication strata, ranging from 82% to 97%. Overall IPD rates declined in most strata, by up to 65%. However, incidence remained highest among adults with PPV23 indications compared with those without (34.9 vs 8.8 cases per 100 000 population, respectively). Apart from age ≥65 years, diabetes is now the most common indication for PPV23 (20% of all cases vs 10% of cases in 1998–1999). Conclusions. Although IPD rates have declined among adults, adults with underlying conditions remain at increased risk of IPD and comprise a larger proportion of adult IPD cases in 2009 compared with 2000. A continued increase in the prevalence of diabetes among US adults could lead to increased burden of pneumococcal disease.

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

Background Sweetened beverages of low nutritional quality might be displacing more nutritious beverages, such as 100% fruit juice and milk, from children's diets. However, previous research has not examined changes in beverage intake over time using nationally representative longitudinal data. Objective Our objective was to examine changes in sweetened beverage, milk, and juice consumption between 5th and 8th grade. Design We used a longitudinal analysis of self-reported beverage consumption. Participants/setting Data were from the Early Childhood Longitudinal Survey–Kindergarten Cohort 1998-1999 (ECLS-K), a nationally representative study of children followed from kindergarten through 8th grade. This analysis used data from Spring 2004 and 2007, when most children were in 5th and 8th grade, respectively (n=7,445). Main outcome measures Main outcome measures were changes in consumption of sweetened beverages, milk, and 100% fruit juice last week. Statistical analyses performed Survey-adjusted linear regression was used to estimate longitudinal relationships between servings of milk, sweetened beverages, and 100% fruit juice, controlling for child and family characteristics and food consumption. Results Children's milk consumption decreased between 5th and 8th grade, and these decreases were larger among children who drank sweetened beverages daily. However, after controlling for demographic characteristics, changes in children's milk consumption were not significantly related to changes in their consumption of sweetened beverages over time (β=.005; P =0.81), while changes in milk consumption were positively related to changes in juice consumption (β=.087; P Conclusions Observed decreases in average milk consumption from 5th to 8th grade were not related to changes in sweetened-beverage consumption. They were positively related to changes in fruit juice consumption, so not indicating displacement. Caloric beverages generally tended to increase or decrease in tandem, so focus must be placed on their role in children's entire diet and on balancing them with food and total beverage intake.

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 (P0.01), 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.

This review summarizes the current data on diabetes risk factors, prevalence, and prevention efforts in Asia and Asian migrant populations. Studies indicate that type 2 diabetes mellitus is a large and growing threat to public health in Asian populations. Furthermore, Asian subgroups (e.g., South Asians/Asian Indians, Chinese) have unique risk factor profiles for developing diabetes, which differ from other populations and between Asian ethnic groups. Lifestyle intervention programs are effective in preventing diabetes in Asians, as with other ethnicities. The strength of these findings is lessened by the lack of systematically collected data using objective measurements. Large epidemiologic studies of diabetes prevalence and risk factor profiles and translational trials identifying sustainable and culturally acceptable lifestyle programs for Asian subgroups are needed.

Incidence of diabetes among US foreign-born individuals is not well studied. Data were from the Multi Ethnic Study of Atherosclerosis. Cox proportional hazards regression was used to examine diabetes risk by race/ethnicity, place of birth, and duration of residence among foreign-born. Foreign-born Latinos had a higher risk of incident diabetes compared to US-born Latinos (hazard ratio (HR) 1.79 [95 % confidence interval (CI) 1.00–3.21]). Latinos born in Mexico (HR, 2.26 [95 % CI, 1.18–4.33]) had higher risk of incident diabetes compared to US-born Latinos. Foreign-born living in the US ≥20 years had a higher adjusted risk of incident diabetes compared to those in the US for

International migration is at an all-time high, with the largest numbers migrating to the US, making this an ideal setting to study migrant health. While previous studies have shown that foreign-born individuals in the US tend to be in better health than the native born with regard to several health outcomes, less is known about such advantages in terms of cardiovascular disease and diabetes, which are some of the leading causes of morbidity and mortality worldwide. In this paper, we highlight the main existing resources available for the study of cardiometabolic health among US immigrants that researchers have yet to fully utilize. Despite the limited literature on migration and cardiovascular disease and diabetes, there are several data sources that can be used to better understand the importance of location exposures and of predispositions to these diseases.

Objectives: The purpose of this review was to examine methodological similarities and differences in states that have implemented joint school-based oral health/body mass index (BMI) surveillance. Methods: Individuals in states with joint oral health/BMI surveillance were interviewed by e-mail and phone on the following: how the collaboration came about, survey methodology, rewards for participation, BMI data collection methods, data forms, BMI results, how BMI data were utilized, lessons learned, and challenges. Results: Nine states were represented in this review (Colorado, Georgia, Illinois, Maine, New Hampshire, North Dakota, Ohio, Wisconsin, and Wyoming). All states collected surveillance data among third-grade children through selecting a random, stratified sample of elementary schools. These states also used state-specific BMI protocols, including use of standardized, calibrated equipment to measure height/weight. Many states also used local support to implement the surveillance program and used external sources for statistical support. Differences among these states included types of rewards used, mode of consent, and parties involved in the collaboration. The most common uses of the BMI data include: assessing the magnitude of the problem, informing programs, allocation of resources, identification of priority areas for prevention research, support for grant applications, and program evaluation. Conclusions: Although there are some minor differences among states that have implemented joint school-based oral health/BMI surveillance, there are overarching similarities such as survey design and standardization of BMI measures. States considering implementing BMI surveillance efforts can use this review as a starting point to consider attributes such as program effectiveness and methods to improve or enhance surveillance systems already in place.