Access to and perceived unmet need for mental health services and support in a community sample of UK adolescents with and without experience of childhood adversity.

AIMS: Children and adolescents with a history of adverse childhood experiences (ACEs) are more likely than their peers to develop mental health difficulties, but not enough is known about their help-seeking behaviours and preferences. We aimed to determine whether ACEs are associated with access to and perceived unmet need for mental health services and support amongst secondary school students. METHODS: We used multi-level logistic regression with data from the 2020 OxWell Student Survey to assess whether ACEs were associated with (1) prior access to mental health support and (2) perceived unmet need for mental health services in a community sample of English secondary school students. We assessed ACEs as a cumulative score from the Center for Youth Wellness Adverse Childhood Experiences Questionnaire: Teen Self-Report version and accounted for current mental health difficulties as measured by the 25-item Revised Children's Anxiety and Depression Scale (RCADS). RESULTS: Our analysis included 2018 students across 64 schools, of whom 29.9% (598/2002) reported prior access to mental health support. Of those not reporting prior access, 34.1% (469/1377) reported a perceived unmet need for services. In the unadjusted models, cumulative ACE scores were significantly positively associated with both prior access to mental health support (odds ratio (OR) = 1.36; 95% confidence interval (CI): 1.29-1.43) and perceived unmet need for mental health services (OR = 1.47; 95% CI: 1.37-1.59), meaning that students who had experienced adversity had a greater chance of having previously accessed support as well as perceiving an unmet need for services. After adjusting for mental health difficulties and other sociodemographic variables, cumulative ACE scores were positively associated with prior access (adjusted OR (aOR) = 1.25; 95% CI: 1.17-1.34 with a significant interaction between RCADS and ACE scores, aOR = 0.88; 95% CI: 0.84-0.93) as well as perceived unmet need (aOR = 1.32; 95% CI: 1.21-1.43 with a significant interaction between RCADS and ACE scores, aOR = 0.85; 95% CI: 0.78-0.91). CONCLUSIONS: Although it is encouraging that adolescents with experience of adversity are more likely than their peers with similar levels of depression and anxiety symptoms to have accessed mental health support, there remains a concern that those who have not accessed support are more likely to perceive an as-yet unmet need for it. Mental health support must be available, accessible and acceptable to all who need it, especially for those groups that traditionally have not accessed services, including the more marginalised and vulnerable populations.

Role of socio-economic research in developing, delivering and scaling new crop varieties: the case of staple crop biofortification.

The CGIAR biofortification program, HarvestPlus, was founded with the aim of improving the quality of diets through micronutrient-dense varieties of staple food crops. Implemented in four phases - discovery, development, delivery and scaling - the program was designed to be interdisciplinary, with plant breeding R&D supported by nutrition and socio-economic research. This paper explains the need, use and usefulness of socio-economic research in each phase of the program. Ex ante and ex post benefit-cost analyses facilitated fundraising for initial biofortification R&D and implementation in each subsequent phase, as well as encouraged other public, private, and civil society and non-governmental organizations to take on and mainstream biofortification in their crop R&D, policies, and programs. Socio-economics research helped guide plant breeding by identifying priority micronutrient- crop- geography combinations for maximum impact. Health impacts of biofortification could be projected both by using empirical results obtained through randomized controlled bioefficacy trials conducted by nutritionists, and through farmer-adoption models estimating impact at scale. Farmer and consumer surveys and monitoring systems provided the underlying information for estimating farmer adoption models and helped understand input/output markets, farmer and consumer preferences, and additional opportunities and challenges -all of which informed crop breeding and delivery activities, while building the knowledge base for catalyzing the scaling of biofortification.

Sociodemographic disparities in non-diabetic hyperglycaemia and the transition to type 2 diabetes: evidence from the English Longitudinal Study of Ageing.

AIM: To explore whether there are social inequalities in non-diabetic hyperglycaemia (NDH) and in transitions to type 2 diabetes mellitus and NDH low-risk status in England. METHODS: Some 9143 men and women aged over 50 years were analysed from waves 2, 4, 6 and 8 (2004-2016) of the English Longitudinal Study of Ageing (ELSA). Participants were categorized as: NDH 'low-risk' [HbA1c < 42 mmol/mol (< 6.0%)], NDH [HbA1c 42-47 mmol/mol (6.0-6.4%)] and type 2 diabetes [HbA1c > 47 mmol/mol (> 6.4%)]. Logistic regression models estimated the association between sociodemographic characteristics and NDH, and the transitions from NDH to diagnosed or undiagnosed type 2 diabetes and low-risk status in future waves. RESULTS: NDH was more prevalent in older participants, those reporting a disability, those living in deprived areas and in more disadvantaged social classes. Older participants with NDH were less likely to progress to undiagnosed type 2 diabetes [odds ratio (OR) 0.27, 95% confidence interval (CI) 0.08, 0.96]. NDH individuals with limiting long-standing illness (OR 1.72, 95% CI 1.16, 2.53), who were economically inactive (OR 1.60, 95% CI 1.02, 2.51) or from disadvantaged social classes (OR 1.63, 95% CI 1.02, 2.61) were more likely to progress to type 2 diabetes. Socially disadvantaged individuals were less likely (OR 0.64, 95% CI 0.41, 0.98) to progress to NDH low-risk status. CONCLUSIONS: There were socio-economic differences in NDH prevalence, transition to type 2 diabetes and transition to NDH low-risk status. Disparities in transitions included the greater likelihood of disadvantaged social groups with NDH developing type 2 diabetes and greater likelihood of advantaged social groups with NDH becoming low-risk. These socio-economic differences should be taken into account when targeting prevention initiatives.

Improving nutrition through biofortification: A review of evidence from HarvestPlus, 2003 through 2016.

Biofortification is a feasible and cost-effective means of delivering micronutrients to populations that may have limited access to diverse diets and other micronutrient interventions. Since 2003, HarvestPlus and its partners have demonstrated that this agriculture-based method of addressing micronutrient deficiency through plant breeding works. More than 20 million people in farm households in developing countries are now growing and consuming biofortified crops. This review summarizes key evidence and discusses delivery experiences, as well as farmer and consumer adoption. Given the strength of the evidence, attention should now shift to an action-oriented agenda for scaling biofortification to improve nutrition globally. To reach one billion people by 2030, there are three key challenges: 1) mainstreaming biofortified traits into public plant breeding programs; 2) building consumer demand; and 3) integrating biofortification into public and private policies, programs, and investments. While many building blocks are in place, institutional leadership is needed to continue to drive towards this ambitious goal.

Food prices, household income, and resource allocation: socioeconomic perspectives on their effects on dietary quality and nutritional status.

BACKGROUND: The recent rise in agricultural commodity prices has been dramatic, and food prices are likely to follow an upward trend, at least in the medium-term. Moreover, the recent financial crisis has also lowered incomes and increased food prices. Not only does this reduce dietary quality, but expenditures for health, sanitation, and education will decline, all of which will have a detrimental effect on health and nutrition outcomes. OBJECTIVE: To provide some perspectives on the role of major socioeconomic factors in driving health and nutrition outcomes. METHODS: We use demand elasticity parameters estimated from household-level survey data to simulate an increase in food prices, which is then mapped into energy and nutrient intakes. Furthermore, we also use household-level data to analyze the implications of unequal intrahousehold distribution of food for the nutritional status of adult women and female children. RESULTS: A 50% increase in food prices results in a decrease in energy intake of 5% to 15% and in a decrease in iron intake of 10% to 30%, depending on the strength of the induced income effect. In a country like the Philippines, this would be equivalent to an increase of 25 percentage points in the proportion of women not meeting their requirements for iron intake. CONCLUSIONS: Increasing food prices will make fighting micronutrient malnutrition in developing countries more difficult. In societies where preference is given to males in the intrahousehold distribution of nonstaple foods, this objective will be even more challenging.

Biofortification: a new tool to reduce micronutrient malnutrition.

BACKGROUND: The density of minerals and vitamins in food staples eaten widely by the poor may be increased either through conventional plant breeding or through the use of transgenic techniques, a process known as biofortification. OBJECTIVE: HarvestPlus seeks to develop and distribute varieties of food staples (rice, wheat, maize, cassava, pearl millet, beans, and sweet potato) that are high in iron, zinc, and provitamin A through an interdisciplinary, global alliance of scientific institutions and implementing agencies in developing and developed countries. METHODS: In broad terms, three things must happen for biofortification to be successful. First, the breeding must be successful--high nutrient density must be combined with high yields and high profitability. Second, efficacy must be demonstrated--the micronutrient status of human subjects must be shown to improve when they are consuming the biofortified varieties as normally eaten. Thus, sufficient nutrients must be retained in processing and cooking and these nutrients must be sufficiently bioavailable. Third, the biofortified crops must be adopted by farmers and consumed by those suffering from micronutrient malnutrition in significant numbers. RESULTS: Biofortified crops offer a rural-based intervention that, by design, initially reaches these more remote populations, which comprise a majority of the undernourished in many countries, and then penetrates to urban populations as production surpluses are marketed. In this way, biofortification complements fortification and supplementation programs, which work best in centralized urban areas and then reach into rural areas with good infrastructure. CONCLUSIONS: Initial investments in agricultural research at a central location can generate high recurrent benefits at low cost as adapted, biofortified varieties become available in country after country across time at low recurrent costs.

Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach.

OBJECTIVE: Pregnancy in women with pulmonary hypertension (PH) is reported to carry a maternal mortality rate of 30-56%. We report our experience of the management of pregnancies using a strategy of early introduction of targeted pulmonary vascular therapy and early planned delivery under regional anaesthesia. DESIGN: Retrospective observational study. SETTING: Specialist quaternary referral pulmonary vascular unit. POPULATION: Nine women with PH who chose to proceed with ten pregnancies. METHODS: A retrospective review of the management of all women who chose to continue with their pregnancy in our unit during 2002-2009. MAIN OUTCOME MEASURES: Maternal and fetal survival. RESULTS: All women commenced nebulised targeted therapy at 8-34 weeks of gestation. Four women required additional treatment or conversion to intravenous prostanoid therapy. All women were delivered between 26 and 37 weeks of gestation. Delivery was by planned caesarean section in nine cases. All women received regional anaesthesia and were monitored during the peripartum period in a critical care setting. There was no maternal mortality during pregnancy and all infants were free from congenital abnormalities. One woman died 4 weeks after delivery following patient-initiated discontinuation of therapy. All remaining women and infants were alive after a median of 3.2 years (range, 0.8-6.5 years) of follow-up. CONCLUSION: Although the risk of mortality in pregnant women with PH remains significant, we describe improved outcomes in fully counselled women who chose to continue with pregnancy and were managed with a tailored multiprofessional approach involving early introduction of targeted therapy, early planned delivery and regional anaesthetic techniques.

Review of perinatal management of arthrogryposis at a large UK teaching hospital serving a multiethnic population.

OBJECTIVE: To review the prevalence and perinatal management of cases of arthrogryposis delivering at our hospital over a 6-year period. METHODS: This was a retrospective review of cases of arthrogryposis managed at a UK teaching hospital. Cases were identified from the regional congenital anomalies register and departmental databases. Case notes were reviewed and analysed. RESULTS: From 2002 to 2007, there were 27 cases of arthrogryposis. Sixteen (59.3%) were Caucasians, 7(25.9%) Asians and 4(14.8%) Afro-Caribbean; 17(63%) were nulliparous. In eight (29.6%) cases, there was a family history of congenital anomalies. Three had previously affected siblings and in three cases the parents were affected with arthrogryposis. Five (18.5%) were from consanguineous families. Eighteen (66.7%) cases were diagnosed prenatally at a mean gestational age of 21 weeks. Twelve (57%) were delivered by caesarean section. There were 18 live births. Sixteen (59%) cases were reviewed by clinical geneticist. Following detailed review and investigation including post-mortems, 20 (74%) of our cases had a formal diagnosis or likely cause identified. CONCLUSIONS: Suspected cases of arthrogryposis require multi-disciplinary management to optimise the possibility of making a diagnosis and providing parents with accurate information to enable them to make informed choices regarding the pregnancy and providing information regarding likelihood of recurrence.

Biofortification of staple food crops.

Deficiencies of vitamin A, iron, and zinc affect over one-half of the world's population. Progress has been made to control micronutrient deficiencies through supplementation and food fortification, but new approaches are needed, especially to reach the rural poor. Biofortification (enriching the nutrition contribution of staple crops through plant breeding) is one option. Scientific evidence shows this is technically feasible without compromising agronomic productivity. Predictive cost-benefit analyses also support biofortification as being important in the armamentarium for controlling micronutrient deficiencies. The challenge is to get producers and consumers to accept biofortified crops and increase their intake of the target nutrients. With the advent of good seed systems, the development of markets and products, and demand creation, this can be achieved.

The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension.

In patients with pulmonary hypertension, pregnancy is associated with a high risk of maternal death. Such patients are counselled to avoid pregnancy, or if it occurs, are offered early interruption. Some patients, however, decide to continue with their pregnancy and others may present with symptoms for the first time whilst pregnant. Pulmonary vasodilator therapy provides a treatment option for these high-risk patients. The present study describes three patients with pulmonary arterial hypertension of various aetiologies who were treated with the prostacyclin analogue iloprost during pregnancy, and the post-partum period. Nebulised iloprost commenced as early as 8 weeks of gestation and patients were admitted to hospital between 24-36 weeks of gestation. All pregnancies were completed with a duration of between 25-36 weeks and all deliveries were by caesarean section under local anaesthetic. All patients delivered children free from congenital abnormalities, and there was no post-partum maternal or infant mortality. In conclusion, although pregnancy is strongly advised against in those with pulmonary hypertension, the current authors have achieved a successful outcome for mother and foetus with a multidisciplinary approach and targeted pulmonary vascular therapy.

Comparison of the effects of two different types of calcium supplementation on markers of bone metabolism in a postmenopausal osteopenic population with low calcium intake: a double-blind placebo-controlled trial.

OBJECTIVE: To investigate calcium supplements in postmenopausal women. Calcium supplements in postmenopausal women with a low calcium intake have been shown to prevent osteoporotic vertebral fracture, but calcium is variably absorbed and often poorly tolerated, which may limit effectiveness. METHODS: The study compared the efficacy and tolerability of 500 mg/day of calcium in the form of ossein-hydroxyapatite (OHC) versus 500 mg/day of tricalcium phosphate (TCP) and placebo in the prevention of postmenopausal bone loss. This was a prospective randomized study enrolling 153 postmenopausal osteopenic women. Serum and urine markers of bone turnover were collected at 3 and 6 months. Bone density measurement was performed at baseline and 6 months in all participants, and at 12 months in women taking OHC. RESULTS: At 3 and 6 months, both TCP and OHC decreased serum markers of bone formation significantly, compared with placebo. At 6 months, TCP and OHC decreased osteocalcin by 9.9% and 12.3%, respectively; the aminoterminal propeptide of type I procollagen (PINP) was decreased by 5.3% and 6.3%, respectively; bone-specific alkaline phosphatase was decreased by 4.3% and 6.7%, respectively, compared with baseline. The effects on bone resorption markers or on bone mineral density did not reach statistical significance, although OHC increased bone density by 0.8% at the spine at 12 months. Both forms of calcium were well tolerated and did not differ from placebo in terms of side-effects. CONCLUSIONS: While both OHC and TCP were well tolerated and significantly reduced bone turnover markers, the effect of ossein-hydroxyapatite seems slightly superior to that of tricalcium phosphate.

Improved pregnancy outcome in a patient with renal allograft nephropathy undergoing temporary hemodialysis.

We report a case of a woman with a poorly functioning renal allograft and a positive anti-cardiolipin antibody who was dialysis-independent and conceived 18 months following her transplant. She was electively maintained on hemodialysis during the pregnancy and delivered a live infant at 31 weeks gestation. Her renal function returned to prepregnancy levels post partum and she remained dialysis-independent.

Micronutrient fortification of plants through plant breeding: can it improve nutrition in man at low cost?

Can commonly-eaten food staple crops be developed that fortify their seeds with essential minerals and vitamins? Can farmers be induced to grow such varieties? If so, would this result in a marked improvement in human nutrition at a lower cost than existing nutrition interventions? An interdisciplinary international effort is underway to breed for mineral- and vitamin-dense varieties of rice, wheat, maize, beans and cassava for release to farmers in developing countries. The biofortification strategy seeks to take advantage of the consistent daily consumption of large amounts of food staples by all family members, including women and children as they are most at risk for micronutrient malnutrition. As a consequence of the predominance of food staples in the diets of the poor, this strategy implicitly targets low-income households. After the one-time investment is made to develop seeds that fortify themselves, recurrent costs are low and germplasm may be shared internationally. It is this multiplier aspect of plant breeding across time and distance that makes it so cost-effective. Once in place, the biofortified crop system is highly sustainable. Nutritionally-improved varieties will continue to be grown and consumed year after year, even if government attention and international funding for micronutrient issues fades. Biofortification provides a truly feasible means of reaching malnourished populations in relatively remote rural areas, delivering naturally-fortified foods to population groups with limited access to commercially-marketed fortified foods that are more readily available in urban areas. Biofortification and commercial fortification are, therefore, highly complementary. Breeding for higher trace mineral density in seeds will not incur a yield penalty. Mineral-packed seeds sell themselves to farmers because, as recent research has shown, these trace minerals are essential in helping plants resist disease and other environmental stresses. More seedlings survive and initial growth is more rapid. Ultimately, yields are higher, particularly in trace mineral-'deficient' soils in arid regions.

Factors affecting long-term adherence to hormone replacement therapy after screening for osteoporosis.

OBJECTIVE: To investigate factors likely to influence adherence to hormone replacement therapy (HRT) in women known to have low bone mass. STUDY DESIGN: This was a prospective study of bone mineral density screening in 6282 women aged 50-54 years. RESULTS: Low bone mass at either the hip or spine was found in 1462 women. The principal route of HRT delivery, transdermal or oral, as well as the presence of climacteric symptoms before starting treatment, did not influence adherence. However, adherence to HRT type was significantly superior in hysterectomized women taking unopposed estradiol (median 32 months) compared with those on sequential HRT (median 28 months; p = 0.011). Overall, a 5-year adherence to HRT of 61% was achieved. CONCLUSION: Approximately 34% of women starting HRT are likely to stop in the first 2 years of use. Following this, the discontinuation rate is low. The combination of knowledge of risk for osteoporosis and regular follow-up positively influences long-term adherence to HRT.

Coliforms in the water and hemoglobin concentration are predictors of gastrointestinal morbidity of Bangladeshi children ages 1-10 years.

The presence of pathogens in the water and children's poor nutritional status are likely to increase morbidity in developing countries. Understanding the interactions between the environmental and nutritional factors is important from the standpoint of improving child health. In this study, we analyzed the effects of fecal and total coliforms in the water available at the source and that stored in the household on the spells of gastrointestinal morbidity of 99 Bangladeshi children at three time points in an 8-month period. Fecal and total coliforms in the stored water were significant predictors (P < 0.05) of morbidity that was modeled using dynamic random effects models. Moreover, children with better hemoglobin status experienced lower morbidity. An empirical model for the proximate determinants of hemoglobin concentration showed significant negative associations between children's hookworm loads and hemoglobin. While the children's intakes of bioavailable iron, iron from meat, fish, and poultry, and iron from animal sources were not significant predictors of hemoglobin status in this population, the need for broader interventions for improving child health was apparent.

Invasive testing for the karyotyping of mid-trimester intrauterine fetal death (IUFD): a pilot study.

INTRODUCTION: Aneuploidy remains a common cause of fetal loss after the first trimester. Conventional karyotyping from fetal solid tissues post-delivery unfortunately has a poor success rate particularly where the fetus is macerated. To overcome this we obtained amniocentesis and/or chorionic villus samples from mid-trimester intrauterine fetal deaths (IUFDs) prior to medical termination of pregnancy. SUBJECTS: Ten women with diagnosed IUFD between 12 and 24 weeks' gestation underwent amniocentesis and/or CVS performed after counselling. RESULTS: Successful karyotypes were obtained in all pregnancies. Five of the ten pregnancies were complicated by aneuploidy (two with trisomy 21, two with trisomy 18, and one with trisomy 13). CONCLUSION: The high rate of aneuploidy (50%) in this small cohort emphasises the need for karyotyping. A successful karyotype in all ten pregnancies demonstrates the value of offering these procedures before a termination of pregnancy. We would recommend the adoption of this approach in the management of IUFD occurring after the first trimester.

Plant breeding: a new tool for fighting micronutrient malnutrition.

The final permanent solution to micronutrient malnutrition in developing countries is a substantial improvement in dietary quality--higher consumption of pulses, fruits, vegetables, fish and animal products that the poor already desire but cannot presently afford. Meanwhile breeding staple foods that are dense in minerals and vitamins provides a low-cost, sustainable strategy for reducing levels of micronutrient malnutrition. Getting plants to do the work of fortification, referred to as "biofortification," can reach relatively remote rural populations that conventional interventions are not now reaching and can even have benefits for increased agricultural productivity. Biofortification, thus, complements conventional interventions. The symposium articles discuss several examples of ongoing research projects to develop and disseminate nutrient-dense staple food crops and issues that remain to be resolved before successful implementation can be attained.