Effectiveness of provider communication training for increasing human papillomavirus vaccine initiation at a safety-net health system.

Background: Strong provider recommendation can increase uptake of human papillomavirus (HPV) vaccination. Therefore, we developed and implemented a provider education intervention on communication strategies for recommending HPV vaccination with clinic-level audit and feedback (HPV: Communicating about HPV to Adults and Teens [HPV CHAT]). We aimed to evaluate the effect of HPV CHAT on HPV vaccine uptake in seven family medicine and pediatric clinics in a large urban health system (USA). Methods: We used a quasi-experimental design, where the eligible population included people aged 9-26 years with at least one encounter in June 2020-February 2023 at one of the participating community health clinics. We used interrupted time-series analysis to assess changes in the prevalence of HPV vaccine uptake. We used segmented Poisson regression with a log link function to estimate prevalence ratios (PR) and 95% confidence limits (CL) for level (immediate) and slope (over time) changes with adjustment for seasonality using Fourier transformation. Results: Our study population comprised 60,328 observations in which the median age was 17 years (interquartile range: 13-21). A majority (58%) were female and 87% were racial/ethnic minorities. Overall, we observed no sizeable effect of the intervention on HPV vaccination uptake. Nonetheless, heterogeneity was observed by age group with modest increases in individuals aged 9-12 and 13-17 years. Conclusion: Our provider feedback intervention had minimal effect on increasing prevalence of HPV vaccination in seven family medicine and pediatric clinics. Novel strategies are needed to address provider barriers related to HPV vaccination.

Evaluation of a human papillomavirus vaccination training implementation in clinical and community settings across different clinical roles.

Improving human papillomavirus (HPV) vaccination is a national priority but uptake declined following the coronavirus pandemic. A strong predictor of HPV vaccination in the USA is a strong provider recommendation. Therefore, we developed a brief, asynchronous training on HPV vaccine recommendations in clinical and community settings as part of a multisite quality improvement initiative. This paper aims to describe the implementation and initial outcomes of the training provided. A 20-minute training on HPV vaccine bundled recommendations, motivational interviewing, and brief responses to patient concerns (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was implemented at seven safety-net clinics, two practice-based research network clinics, and nine county immunization clinics. We integrated training with clinical care teams; thus, we assessed immediate training outcomes across their different clinical roles compared to pre-training. In April-May 2022, HPV CHAT training was launched. One hundred eighty-seven people participated in the training and completed the pre-/postevaluation surveys. Knowledge about the HPV vaccine guidelines improved with notable changes in correctly reporting vaccine eligibility (P < .05). A significant change in participants' confidence when addressing safety concerns and answering questions about the HPV vaccine (clinicians, 26.8% and 17.1%; nurses, 29.0% and 23.2%, and clinical staff, 18.2% and 37.7%) was observed. At post-test, more than 85% of clinicians and nurses reported their plan to routinely recommend the HPV vaccine. This quality improvement initiative demonstrated implementation feasibility of a brief HPV vaccine training that improved provider and clinical staff knowledge, confidence, and intention to routinely recommend HPV vaccination.

The human papillomavirus (HPV) vaccine is key to cancer prevention. Despite this fact, HPV vaccination is not widely accepted. Studies have shown that a strong recommendation can lead to HPV vaccination. Therefore, virtual educational training (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was developed to equip clinicians, nurses, and clinical staff with communication tools to support HPV recommendation and respond to patient concerns. HPV CHAT, a quality improvement initiative, was launched across numerous community and county clinical teams. To capture HPV CHAT training impact, pre- and post-evaluation surveys were disseminated alongside the training to capture training impact. After HPV CHAT implementation, training participants reported a positive impact on confidence and knowledge items; these findings were observed across all clinical roles in varying degrees. Overall, this quality improvement initiative successfully improved communication skill self-efficacy and knowledge across different clinical roles. This paper discusses training implementation strategies and the changes in knowledge and confidence after participating in the training.

Medication Management Strategies by Community-Dwelling Older Adults: A Multisite Qualitative Analysis.

OBJECTIVES: Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood. METHODS: We conducted semistructured interviews with community-dwelling older adults 65 years and older who took 5 or more prescription medications to explore medication safety strategies they use. We also compared 2 organizations' medication safety guidelines for areas of concordance and discordance. RESULTS: A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the 2 government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers. CONCLUSIONS: Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults' perspectives when developing medication safety guidelines.

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.

BACKGROUND: Our aim was to understand actions by primary care teams to improve medication safety. METHODS: This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach. RESULTS: Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate. CONCLUSIONS: Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services.

A Cross-Sectional Study Comparing Traumatic Alopecia Among B-Boys and B-Girls to Other Dance Styles and Its Impact on Dance Performance and Health.

INTRODUCTION: Breaking, often mislabeled as breakdancing in the media, is a dance style originating from the Bronx of New York in the early 1970s. A unique condition in this population is a form of alopecia known as "headspin hole," or "breakdancer overuse syndrome" of the scalp. This form of hair loss may show a variety of patterns based on the activities of the dancer. The purpose of this study was to investigate the relationship between alopecia and breaking, the level of concern dancers have regarding hair loss, barriers to medical treatment, and how it affects their dancing. METHODS: This was a cross-sectional study using an online survey. The survey addressed participants' demographics, hair, dancing styles, training, and health history. Questions about the effects of hair loss on the participants were also asked. RESULTS: This study found that there was a significant difference in hair loss among breakers compared to non-breakers. This was not seen after controlling for age and sex. However, the concern for hair loss was significant even after controlling for these variables. Similarly, hair loss was significantly associated with the frequency of headspins. Despite these concerns, breakers were less likely to seek medical attention. CONCLUSIONS: This study showed that there are significant disparities in hair loss between breaking and other dance styles. Hair loss due to breaking has been shown to have significant effects on an individual's concerns, which may be compounded by the fact that this population is less likely to seek out medical care and have significantly greater substance use compared to the other dancers surveyed. Further research is necessary to investigate interventions to prevent and treat hair loss in this population and the means to decrease the gap in health care in the dance population.

A Multisite Qualitative Analysis of Perceived Roles in Medication Safety: Older Adults' Perspectives.

Older adults and caregivers play an essential role in medication safety; however, self-perception of their and health professionals' roles in medication safety is not well-understood. The objective of our study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Semi-structured qualitative interviews were held with 28 community-dwelling older adults over 65 years who took five or more prescription medications daily. Results suggest that older adults' self-perceptions of their role in medication safety varied widely. Older adults perceived that self-learning about their medications and securing them are critical to avoiding medication-related harm. Primary care providers were perceived as coordinators between older adults and specialists. Older adults expected pharmacists to inform them of any changes in the characteristics of medications to ensure medications were taken correctly. Our findings provide an in-depth analysis of older adults' perceptions and expectations of their providers' specific roles in medication safety. Educating providers and pharmacists about the role expectations of this population with complex needs can ultimately improve medication safety.

Implementation-effectiveness trial of systematic family health history based risk assessment and impact on clinical disease prevention and surveillance activities.

BACKGROUND: Systematically assessing disease risk can improve population health by identifying those eligible for enhanced prevention/screening strategies. This study aims to determine the clinical impact of a systematic risk assessment in diverse primary care populations. METHODS: Hybrid implementation-effectiveness trial of a family health history-based health risk assessment (HRA) tied to risk-based guideline recommendations enrolling from 2014-2017 with 12 months of post-intervention survey data and 24 months of electronic medical record (EMR) data capture. SETTING: 19 primary care clinics at four geographically and culturally diverse U.S. healthcare systems. PARTICIPANTS: any English or Spanish-speaking adult with an upcoming appointment at an enrolling clinic. METHODS: A personal and family health history based HRA with integrated guideline-based clinical decision support (CDS) was completed by each participant prior to their appointment. Risk reports were provided to patients and providers to discuss at their clinical encounter. OUTCOMES: provider and patient discussion and provider uptake (i.e. ordering) and patient uptake (i.e. recommendation completion) of CDS recommendations. MEASURES: patient and provider surveys and EMR data. RESULTS: One thousand eight hundred twenty nine participants (mean age 56.2 [SD13.9], 69.6% female) completed the HRA and had EMR data available for analysis. 762 (41.6%) received a recommendation (29.7% for genetic counseling (GC); 15.2% for enhanced breast/colon cancer screening). Those with recommendations frequently discussed disease risk with their provider (8.7%-38.2% varied by recommendation, p-values ≤ 0.004). In the GC subgroup, provider discussions increased referrals to counseling (44.4% with vs. 5.9% without, P < 0.001). Recommendation uptake was highest for colon cancer screening (provider = 67.9%; patient = 86.8%) and lowest for breast cancer chemoprevention (0%). CONCLUSIONS: Systematic health risk assessment revealed that almost half the population were at increased disease risk based on guidelines. Risk identification resulted in shared discussions between participants and providers but variable clinical action uptake depending upon the recommendation. Understanding the barriers and facilitators to uptake by both patients and providers will be essential for optimizing HRA tools and achieving their promise of improving population health. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01956773 , registered 10/8/2013.

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

INTRODUCTION: Over 4 billion prescriptions are dispensed each year to patients in the United States, with the number of prescriptions continuing to increase. There is a growing recognition of pharmacists' potential in improving medication safety in community settings, in collaboration with primary care providers (PCPs). However, the nature of collaboration has not been well defined, and barriers and strategies are not articulated. AREA COVERED: For this narrative review, published studies were retrieved from PubMed between January 2000 and December 2020. Search terms included "patient safety," "medication safety," "collaboration," "primary care physician," and "community pharmacy." Resulting articles were categorized as follows: defining collaboration, types of collaboration, and barriers and solutions to collaboration. EXPERT OPINION: It is important to understand the factors within a community pharmacy setting that limit or facilitate community pharmacists' participation in medication safety activities. Strategies such as medication review are a common form of collaboration. Barriers to collaboration include misconceptions regarding roles and differences in access to clinical information and community pharmacy practice variability. Future recommendations include increasing training and utilization of pharmacists/PCP teams, increasing community pharmacists' practice in emerging roles, and expanding the community pharmacist role in transitions of care from the hospital to the community.

Ambulatory Medication Safety in Primary Care: A Systematic Review.

PURPOSE: To review the literature on medication safety in primary care in the electronic health record era. METHODS: Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias. RESULTS: Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm. CONCLUSIONS: This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.

Patient Research Interest Differences by Gender and Race/Ethnicity: A North Texas Primary Care Practice-Based Research Network (NorTex) Study.

BACKGROUND: Recruiting and increasing participation of women and racial/ethnic groups remains an ongoing struggle despite the National Institutes of Health Revitalization Act mandating the inclusion of these populations. This study examined gender and racial/ethnic differences in research interest in participating in Practice-Based Research Network studies focused on cardiovascular disease (CVD), diabetes, cancer, and mental health research. METHODS: A total of 1348 participants and 18 NorTex clinics from the North Texas Primary Care Registry Project (NRP) database were included in this cross-sectional study. Participants who signed up through the registry to participate in future research projects and self-reported as non-Hispanic White, Hispanic, or non-Hispanic Black were included. Research interest in heart disease, high cholesterol, high blood pressure and heart failure were categorized as CVD; depression and anxiety were categorized as mental health; diabetes and cancer research were coded as single item dependent variables. RESULTS: Of registry participants, 72% were female, 34.5% were Black, and 24.4% were Hispanic. Of participants, 70% (n = 942) were interested in CVD research, the leading area of interest. Mental health research (56.3%, n = 755) was the second highest area of interest, while cancer had the least interest (38.4%, n = 515). After controlling for age, smoking, and having a diagnosis of the medical condition, gender did not predict interest in CVD, diabetes, cancer, or mental health research. However, race/ethnicity significantly predicted interest in diabetes and cancer research. CONCLUSION: Results indicate there are racial/ethnic differences in interest in specific research topics among our registry participants. This information may be helpful to develop successful recruitment strategies.

Development and implementation of tablet-based screening for interpersonal violence in primary care settings.

Technology Enhanced Screening and Supportive Assistance (TESSA) is program that includes a patient-facing mobile web app designed to identify primary care patients with a history of interpersonal violence (IPV). The implementation study included 1495 participants screened. Approximately one in four reported experiences with intimate partner violence (29%) or sexual assault (24%). Among those offered health advocacy services based on their victimization experiences, 31% indicated they wished to accept the assistance. We conclude that a tablet-based self-screening tool in primary care clinics is a viable way to identify and offer services to people who have experienced interpersonal violence.

Physical Aggression and Coronary Artery Calcification: A North Texas Healthy Heart Study.

BACKGROUND: The purpose of this study was to determine the association between aspects of hostility and coronary artery calcification (CAC) scores. Specifically, analyses differentiated between subtypes of hostility and their relation to CAC. METHODS: A sample of 571 patients aged 45 or older with no history of cardiovascular disease completed assessments of demographic, psychosocial, and medical history, along with a radiological CAC determination. Logistic regression was used to determine the association between hostility and CAC. Hostility was measured using the Aggression Questionnaire, which measured total aggression and how aggression is manifested on four scales: Physical, Verbal, Anger, and Hostility Aggression. RESULTS: Regression analyses indicated that only the physical aggression parameter was related to CAC: a 5% increase in odds of CAC presence was indicated for every point increase in physical aggression. The association remained significant in adjusted analyses. Other factors associated with CAC in adjusted analyses included: age, gender, race/ethnicity, BMI, and dyslipidemia. CONCLUSIONS: Psychosocial factors, such as physical aggression, are emerging factors that need to be considered in cardiovascular risk stratification.

The Implementation of an Interpersonal Violence Screening Program in Primary Care Settings: Lessons Learned.

BACKGROUND: Interpersonal violence (IPV) is a public health issue that disproportionately affects women. IPV screening improves likelihood of survivor disclosure and access to additional support. To enhance primary care IPV screening, Technology Enhanced Screening and Supportive Assistance (TESSA) uses integrated technological systems to deliver bidirectional, evidence-informed health navigation, health management, and safety interventions. This study evaluates TESSA implementation in primary care clinics using the Consolidated Framework for Implementation Research (CFIR). METHOD: CFIR is a metatheoretical framework used for evaluating clinical intervention implementation. Salient constructs within CFIR's five domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified (23 constructs), and pertinent implementation details were examined. RESULTS: Key lessons learned included intervention characteristic constructs like intervention source (e.g., selecting tablets that can screen for items integral to the program's aims) and adaptability (e.g., ensuring tablets worked with electronic medical records for each clinic), process constructs like engaging champions (e.g., garnering buy-in from key clinic stakeholders and staff), outer setting constructs like patient needs and resources (e.g., addressing pertinent patient resource needs) and external policies and incentives (e.g., incentivizing clinics by addressing clinic needs), and inner setting constructs like leadership engagement (e.g., ensuring buy-in from organizational leaders as leadership changed frequently). CONCLUSIONS: CFIR identifies important implementation factors for programs like TESSA that screen for high-risk populations and implement in primary care settings. The TESSA program implementation permits increased IPV screening among primary health care populations, thus promoting access to resources for otherwise hard-to-reach populations.

Association between acculturation and metabolic syndrome in Hispanic adults mediated by fruits intake.

OBJECTIVES: Hispanic adults in the USA tend to have a disproportionate prevalence of metabolic syndrome (MetS) as compared to other races. DESIGN: We examined whether the association between acculturation and MetS and its components are mediated by the intake of fruit in Hispanics. SETTING: Data from the National Health and Nutrition Examination Surveys 2009-2016 were used in this study. PARTICIPANTS: A total of 2078 Hispanics aged ≥ 20 years were included in this analysis. RESULTS: The mediating role of total fruit intake was assessed using multivariable-adjusted logistic structural equation models with the bootstrapping method by estimating indirect (IE) and direct (DE) effects from acculturation to MetS. High acculturation was associated with increased odds of MetS (adjusted OR = 1·20, 95 % CI 1·04, 1·39), central obesity (OR = 1·24, 95 % CI 1·07, 1·44) and high blood pressure (OR = 1·16, 95 % CI 1·02, 1·32) among Hispanic adults. Total fruits intake partially mediated the associations of acculturation with MetS (ORIE = 1·02, 95 % CI 1·00, 1·03) and central obesity (ORIE = 1·02, 95 % CI 1·00, 1·03), whereas fully mediated the association between acculturation and high blood pressure (ORIE = 1·03, 95 % CI 1·01, 1·06). Moreover, intake of total fruits fully mediated the acculturation-MetS association among Mexican Americans (ORIE = 1·02, 95 % CI 1·00, 1·05). CONCLUSIONS: Our findings suggested that increasing fruit consumption may reduce the impact of high acculturation on MetS development in Hispanic adults. Further studies are needed to confirm these findings.

Prevalence of elevated liver enzymes and their association with type 2 diabetes risk factors in children.

OBJECTIVES: Given their established role in hepatic function and insulin resistance for adults, early screening of type 2 diabetes mellitus (T2DM) in the pediatric population may potentially be improved by the assessment of elevated liver enzymes. METHODS: Our study enrolled 151 nondiabetic children aged 10-14 years. Patients were assessed for demographics and five risk factors for T2DM. The levels of γ-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) levels were determined in serum samples. The effects of demographics and risk factors on abnormal liver enzyme levels were assessed with univariate chi-square analyses and also with multivariate logistic regression analyses, which were controlled for gender. RESULTS: Frequencies for abnormal liver enzyme values were as follows: 13 (9%) for GGT, 5 (3%) for ALT, and 20 (13%) for ALP. Across analyses, two results were consistently statistically significant. Females were more likely to have abnormal ALP levels, and patients with BMI percentile ≥95% and with acanthosis nigricans were more likely to have abnormal GGT levels. CONCLUSIONS: Our study suggests GGT as potential marker for T2DM discovery in children. Subsequent long-term longitudinal studies would help to more clearly delineate GGT's association with T2DM. Additionally, future studies that elucidate the molecular contribution of GGT elevation to T2DM pathogenesis are needed.

Association of Magnesium Intake with Liver Fibrosis among Adults in the United States.

Liver fibrosis represents the consequences of chronic liver injury. Individuals with alcoholic or nonalcoholic liver diseases are at high risk of magnesium deficiency. This study aimed to evaluate the association between magnesium and calcium intakes and significant liver fibrosis, and whether the associations differ by alcohol drinking status. Based on the National Health and Nutrition Examination Survey (NHANES) 2017-2018, the study included 4166 participants aged >18 years who completed the transient elastography examination and had data available on magnesium intake. The median liver stiffness of 8.2 kPa was used to identify subjects with significant fibrosis (≥F2). The age-adjusted prevalence of significant fibrosis was 12.81%. Overall total magnesium intake was marginally associated with reduced odds of significant fibrosis (p trend = 0.14). The inverse association of total magnesium intake with significant fibrosis was primarily presented among those who had daily calcium intake <1200 mg. There were no clear associations for significant fibrosis with calcium intake. Findings suggest that high total magnesium alone may reduce risk of significant fibrosis. Further studies are needed to confirm these findings.

At the intersection of precision medicine and population health: an implementation-effectiveness study of family health history based systematic risk assessment in primary care.

BACKGROUND: Risk assessment is a precision medicine technique that can be used to enhance population health when applied to prevention. Several barriers limit the uptake of risk assessment in health care systems; and little is known about the potential impact that adoption of systematic risk assessment for screening and prevention in the primary care population might have. Here we present results of a first of its kind multi-institutional study of a precision medicine tool for systematic risk assessment. METHODS: We undertook an implementation-effectiveness trial of systematic risk assessment of primary care patients in 19 primary care clinics at four geographically and culturally diverse healthcare systems. All adult English or Spanish speaking patients were invited to enter personal and family health history data into MeTree, a patient-facing family health history driven risk assessment program, for 27 medical conditions. Risk assessment recommendations followed evidence-based guidelines for identifying and managing those at increased disease risk. RESULTS: One thousand eight hundred eighty-nine participants completed MeTree, entering information on N = 25,967 individuals. Mean relatives entered = 13.7 (SD 7.9), range 7-74. N = 1443 (76.4%) participants received increased risk recommendations: 597 (31.6%) for monogenic hereditary conditions, 508 (26.9%) for familial-level risk, and 1056 (56.1%) for risk of a common chronic disease. There were 6617 recommendations given across the 1443 participants. In multivariate analysis, only the total number of relatives entered was significantly associated with receiving a recommendation. CONCLUSIONS: A significant percentage of the general primary care population meet criteria for more intensive risk management. In particular 46% for monogenic hereditary and familial level disease risk. Adopting strategies to facilitate systematic risk assessment in primary care could have a significant impact on populations within the U.S. and even beyond. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01956773 , registered 10/8/2013.

Environment-wide association study on childhood obesity in the U.S.

BACKGROUND: Childhood obesity is a national public health issue with increasing prevalence. It has been linked to diet, lack of physical activity, and genetic susceptibility, with more recent evidence that it could also result from environmental factors. Studies linking it to environmental factors are limited, unsystematic, incomprehensive, and inconclusive. OBJECTIVE: To conduct an environment-wide association study (EWAS) to comprehensively investigate all the environmental factors available in a nationally representative sample of children to determine factors associated with childhood obesity. METHODS: We utilized the 1999-2016 National Health and Nutrition Examination Survey (NHANES) datasets and included all children/adolescents (6-17 years). Obesity was measured using body mass index and waist to height ratio. A multinomial and binary logistic regression were used adjusting for age, sex, race/ethnicity, creatinine, calorie intake, physical activity, screen time, limitation to physical activities, and socioeconomic status. We then controlled for multiple hypothesis testing and validated our findings on a different cohort of children. RESULTS: We found that metals such as beryllium (OR: 3.305 CI: 1.460-7.479) and platinum (OR: 1.346 CI: 1.107-1.636); vitamins such as gamma-tocopherol (OR: 8.297 CI: 5.683-12.114) and delta-tocopherol (OR: 1.841 CI:1.476-2.297); heterocyclic aromatic amines such as 2-Amino-9H-pyrido (2,3-b) indole (OR: 1.323 CI: 1.083-1.617) and 2-Amino-3-methyl-9H-pyriodo(2,3-b)indole (OR: 2.799 CI: 1.442-5.433); polycyclic aromatic amines such as 9- fluorene (OR: 1.509 CI: 1.230-1.851) and 4-phenanthrene (OR: 2.828 CI: 1.632-4.899); and caffeine metabolites such as 1,3,7-trimethyluric acid (OR: 1.22 CI: 1.029-1.414) and 1,3,7-trimethylxanthine (OR: 1.258 CI: 1.075-1.473) were positively and significantly associated with childhood obesity. CONCLUSION: Following the unique concept of EWAS, certain environmental factors were associated with childhood obesity. Further studies are required to confirm these associations while investigating their mechanisms of action.

Trends in Magnesium Intake among Hispanic Adults, the National Health and Nutrition Examination Survey (NHANES) 1999-2014.

This study aimed at examining trends in magnesium intake among U.S. Hispanic adults stratified by gender, Hispanic origins, age, and poverty income ratio (PIR) level. Data on 9304 Hispanic adults aged ≥20 years from eight National Health and Nutrition Examination Survey (NHANES) cycles (1999-2014) were included in this study. For each cycle, survey-weighted mean dietary and total magnesium intakes were estimated. The prevalence of dietary and total magnesium intake below the Recommended Dietary Allowance (RDA) was further estimated stratified by gender and age groups. Linear regression was used to test trend. Over the survey cycles, both dietary and total magnesium intakes were significantly increased among Hispanic adults. In the study period, magnesium intake tended to be lower in females, adults in other Hispanic-origin group, those aged ≥65 years old, and those with a PIR <1.0. The prevalence of magnesium intake inadequacy decreased among Hispanic adults; however, more than 70% of Hispanic males and females continued to have magnesium intake below the RDA in 2013-2014. From 1999/2000 to 2013/2014, despite several improvements in magnesium intake having been identified, additional findings showed insufficient intake in Hispanic males and females, suggesting the need to improve magnesium intake through diet and dietary supplementation for U.S. Hispanics.

Comparison of Dietary Micronutrient Intakes by Body Weight Status among Mexican-American and Non-Hispanic Black Women Aged 19-39 Years: An Analysis of NHANES 2003-2014.

The objective of the current study was to examine micronutrient intake from foods in women of childbearing age and to better understand potential nutritional problems varied by body weight status in minority women. A sample of women aged 19-39 years from the National Health and Nutrition Examination Surveys (NHANES) 2003-2014 was analyzed. Dietary intakes of 13 micronutrients were estimated using the National Cancer Institute method. Mexican-American and non-Hispanic Black women were categorized into normal/under-weight, overweight, or obese groups according to their body mass index (BMI). Mexican-American and non-Hispanic Black women had lower dietary intakes for vitamins A, B2, B6, B12, and D, folate, calcium, and magnesium than non-Hispanic Whites. Among Mexican-Americans, obese women had the lowest dietary intake of vitamins A, B2, C and D. Obese non-Hispanic Black women had significantly lower dietary intakes of iron and zinc than their normal/under-weight counterparts. Comparable percentages (>30%) of Mexican-American and non-Hispanic Black women had dietary intake less than the Estimated Average Requirements (EARs) for several key nutrients including vitamin A, C and D, folate, calcium and magnesium, and the percentages varied by body weight status. These results indicate micronutrient inadequacies persist among and within racial/ethnic and body weight groups.