Systematic review of interventions designed to reduce screen time in children and adolescents

This descriptive systematic review describes intervention trials for children and youth that targeted screen time (ST) as a way to prevent or control obesity and measured ST, and at least one of the following: physical activity, dietary intake, and adiposity. Both “hands-on” (e.g., video games) and “hands free” (e.g., television viewing) ST were included. Published, completed intervention trials (k=12), not-yet-published, completed trials (k=6), and in-progress trials (k=11) were identified through searches of electronic databases, including trial registries and bibliographies of eligible study reports. Study characteristics of the 29 identified trials were coded and presented in evidence tables. Considerable attention was paid to the type of ST addressed, measures used, and the type of interventions. Based on the number of in-progress and not-yet-published trials, the number of completed, published reports will double in the next three years. Most of the studies were funded by federal sources. General populations, not restricted by race, gender, or weight status, were targets of most interventions with children ages 9-12 yeas as the modal age group. Most trials used randomized control trials in which the majority of control or comparison group received an intervention. The mean number of participants was 242.8 (SD=314.7) and interventions were delivered over an average of 10.5 months and consisted of approximately 16 sessions, with a total time of about eight hours. The majority of completed trials evaluate each of the four constructs, however, most studies have more than one measure to assess each construct (e.g., BMI and tricep skinfold thickness to evaluate adiposity) and rarely did studies use the same measures. This is likely why the majority of studies produced at least one significant intervention effect on each outcome that was assessed. The four major outcomes should be evaluated in all interventions attempting to reduce screen time in order to determine the mechanisms involved that may contribute to obesity. More importantly researchers should work together to determine the best measures to evaluate the four main constructs to allow studies to be compared. Another area for consensus is the definition of ST. ^

Parents' impressions of inappropriate television content for Hispanic preschool children

Rates of childhood obesity have increased three-fold in the last 20 years, and experts estimate that well over half of adolescents with a Body Mass Index at or above the 95th percentile become obese adults. These trends are even more pronounced in ethnic minority and lower income populations that are disproportionately impacted by obesity and its complications. It would be appropriate, then, to focus obesity interventions on Hispanic children. Television viewing, especially, has been shown to contribute to obesity by increasing caloric intake and decreasing physical activity. Parent involvement has proven to be a critical component in changing children’s health behaviors. In order to explore parents’ motivations for limiting their children’s television viewing, I qualitatively analyzed data from twenty-five interviews with Houston area Head Start parents. Using Grounded Theory, four main categories of concern emerged from the audio-recorded conversations: developmentally inappropriate content, the influence of television, poor health behaviors/outcomes, and general disapproval with television. Developmentally inappropriate content was the most frequently mentioned category with 119 mentions. This included violence, the most common sub-theme. In all, parents were more concerned with television content that produced proximate consequences such as modeling violent behavior or inappropriate language. Content that encouraged behaviors that led to obesity or other delayed consequences were of less concern to the parents. This suggests that future interventions aimed at encouraging Hispanic parents to reduce their children’s television viewing should draw motivation from parents’ concerns about developmentally inappropriate content, rather than focusing on deleterious health outcomes such as obesity. ^

School screening for tuberculosis in high risk areas of Texas

Screening for latent tuberculosis infection (LTBI) is an integral component of an effective tuberculosis control strategy, but one that is often relegated to the lowest priority. In a state with higher than national average rates of tuberculosis, due consideration should be given to LTBI screening. Recent large scale contact investigations in the middle school of Del Rio, Texas, raised questions about the status of school screening for LTBI. An evidence based approach was used to evaluate school screening in high risk areas of Texas. A review of the literature revealed that the current recommendations for LTBI screening in children is based on administration of a risk factor questionnaire that should be based on the four main risk factors for LTBI in children that have been identified. Six representative areas in Texas were identified for evaluation of the occurrence of contact investigations in schools for the period of 2006 to 2009 and any use of school screening programs. Of the five reporting areas that responded, only one utilized a school screening program; this reporting area had the lowest percentage of contact investigations occurring in schools. Contact investigations were most common in middle schools and least common in elementary schools. In metropolitan areas, colleges represented up to 42.9% of contact investigations. The number of contact investigations has increased from 2006 to 2008. This report represents a small sample, and further research into the frequency, distribution and risk for contact investigations in schools and the efficacy of screening programs should be done. ^

Hispanic physicians' tobacco intervention practices: a cross-sectional survey study

Background U.S. Hispanic physicians constitute a considerable professional collective, and they may be most suited to attend to the health education needs of the growing U.S. Hispanic population. These educational needs include tobacco use prevention and smoking cessation. However, there is a lack of information on Hispanic physicians' tobacco intervention practices, their level of awareness and use of cessation protocols, and the type of programs that would best address their tobacco training needs. The purpose of this study was to assess the tobacco intervention practices and training needs of Hispanic physicians. Methods Data was collected through a validated survey instrument among a cross-sectional sample of self-reported Hispanic physicians. Data analyses included frequencies, descriptive statistics, and factorial analyses of variance. Results The response rate was 55.5%. The majority of respondents (73.3%) were middle-age males. Less than half of respondents routinely performed the most basic intervention: asking patients about smoking status (44.4%) and advising smoking patients to quit (42.2%). Twenty-five percent assisted smoking patients by talking to them about the health risks of smoking, providing education materials or referring them to cessation programs. Only 4.4% routinely arranged follow-up visits or phone calls for smoking patients. The majority of respondents (64.4%) indicated that they prescribe cessation treatments to less than 20% of smoking patients. A few (4.4%) routinely used behavioral change techniques or programs. A minority (15.6%) indicated that they routinely ask their patients about exposure to tobacco smoke, and 6.7% assisted patients exposed to secondhand smoke in understanding the health risks associated with environmental tobacco smoke (ETS). The most frequently encountered barriers preventing respondents from intervening with patients who smoke included: time, lack of training, lack of receptivity by patients, and lack of reimbursement by third party payers. There was no significant main effect of type of physician, nor was there an interaction effect (gender by type of physician), on tobacco-related practices. Conclusion The results indicate that Hispanic physicians, similarly to U.S. physicians in general, do not meet the level of intervention recommended by health care agencies. The results presented will assist in the development of tobacco training initiatives for Hispanic physicians.

Smoke free restaurant ordinance, compliance with the regulation to reduce exposure to environmental tobacco smoke while dining at local restaurants in San Antonio, Texas

This study is a secondary analysis of a survey developed by Dr. Jimmy Perkins and administered by San Antonio/Bexar County Metropolitan Health District. The survey was developed subsequent to the implementation of the city smoking ordinance effective January 1, 2004. The survey had a multi-purpose plan to establish the number of restaurants having smoke free status prior to and following the ordinance, determine compliance as it relates to a necessary smoking section and proper signage, and expose the rationale for restaurants to become smoke free. The data resulting from the survey was presented to the San Antonio/Bexar County Metropolitan Health District. The summary presented the types of establishments surveyed, smoking status of the establishment, reasons for the establishment becoming smoke free, compliance with smoking sections, compliance with signage requirements, awareness of ordinance, and chain status of the establishment. ^ The results of this study display the relationships among the variables previously mentioned. The following relationships have been examined and the outcomes have determined whether each is significant. After careful analysis, knowledge translates into compliance with signage regulations, which then translate into ordinance compliance. Size does matter as it relates to an establishment's number of employees and seating capacity. The smaller the establishment the more likely the establishment is to have become smoke free before the ordinance went into effect. Restaurants, rather than fast food establishments most commonly cited their reason for becoming smoke free was to comply with the ordinance and only ten percent of restaurants gave policy as the main reason for becoming smoke free. ^ This study is important for public health because the negative health effects of environmental tobacco smoke (ETS) are still an overwhelming problem in the United States (3). ETS is a Known Human Group A Carcinogen (5). The Environmental Protection Agency (EPA) has estimated that around 3,000 non-smoking Americans die every year from lung cancer caused by ETS (6). This information illustrates the importance of providing smoke free establishments, especially to non-smoking patrons. ^

Environmental tobacco smoke exposure, respiratory and cardiovascular health in restaurant and bar workers in Mexico

Environmental tobacco smoke (ETS) is a well established health hazard, being causally associated to lung cancer and cardiovascular disease. ETS regulations have been developed worldwide to reduce or eliminate exposure in most public places. Restaurants and bars constitute an exception. Restaurants and bar workers experience the highest ETS exposure levels across several occupations, with correspondingly increased health risks. In Mexico, previous exposure assessment in restaurants and bars showed concentrations in bars and restaurants to be the highest across different public and workplaces. Recently, Mexico developed at the federal level the General Law for Tobacco Control restricting indoors smoking to separated areas. AT the local level Mexico City developed the Law for the Protection of Non-smokers Health, completely banning smoking in restaurants and bars. Studies to assess ETS exposure in restaurants and bars, along with potential health effects were required to evaluate the impact of these legislative changes and to set a baseline measurement for future evaluations.^ A large cross-sectional study conducted in restaurants and bars from four Mexican cities was conducted from July to October 2008, to evaluate the following aims: Aim 1) Explore the potential impact of the Mexico City ban on ETS concentrations through comparison of Mexico City with other cities. Aim 2). Explore the association between ETS exposure, respiratory function indicators and respiratory symptoms. Aim 3). Explore the association between ETS exposure and blood pressure and heart rate.^ Three cities with no smoking ban were selected: Colima (11.5% smoking prevalence), Cuernavaca (21.5% smoking prevalence) and Toluca (27.8% smoking prevalence). Mexico City (27.9% smoking prevalence), the only city with a ban at the time of the study, was also selected. Restaurants and bars were randomly selected from municipal records. A goal of 26 restaurants and 26 bars per city was set, 50% of them under 100 m2. Each establishment was visited during the highest occupancy shift, and managers and workers answered to a questionnaire. Vapor-phase nicotine was measured using passive monitors, that were activated at the beginning and deactivated at the end of the shift. Also, workers participated at the beginning and end of the shift in a short physical evaluation, comprising the measurement of Forced Expiratory Volume in the first second (FEV1) and Peak Expiratory Flow (PEF), as well as blood pressure and heart rate.^ A total of 371 establishments were invited, 219 agreed to participate for a 60.1% participation rate. In them, 828 workers were invited, 633 agreed to participate for a 76% participation rate. Mexico City had at least 4 times less nicotine compared to any of the other cities. Differences between Mexico City and other cities were not explained by establishment characteristics, such as ventilation or air extraction. However, differences between cities disappeared when ban mechanisms, such as policy towards costumer's smoking, were considered in the models. An association between ETS exposure and respiratory symptoms (cough OR=1.27, 95%CI=1.04, 1.55) and respiratory illness (asthma OR=1.97, 95%CI=1.20, 3.24; respiratory illness OR=1.79, 95%CI=1.10, 2.94) was observed. No association between ETS and phlegm, wheezing or respiratory infections was observed. No association between ETS and any of the spirometric indicators was observed. An association between ETS exposure and increased systolic and diastolic blood pressure at the end of the shift was observed among non-smokers (systolic blood pressure beta=1.51, 95%CI=0.44, 2.58; diastolic blood pressure beta=1.50, 95%CI=0.72, 2.28). The opposite effect was observed in heavy smokers, were increased ETS exposure was associated with lower blood pressure at the end of the shift (systolic blood pressure beta=1.90, 95%CI=-3.57, -0.23; diastolic blood pressure beta=-1.46, 95%CI=-2.72, -0.02). No association in light smokers was observed. No association for heart rate was observed. ^ Results from this dissertation suggest Mexico City's smoking ban has had a larger impact on ETS exposure. Ventilation or air extraction, mechanisms of ETS control suggested frequently by tobacco companies to avoid smoking bans were not associated with ETS exposure. This dissertation suggests ETS exposure could be linked to changes in blood pressure and to increased respiratory symptoms. Evidence derived from this dissertation points to the potential negative health effects of ETS exposure in restaurants and bars, and provides support for the development of total smoking bans in this economic sector. ^

The role of environmental tobacco smoke in the development and exacerbation of asthma among children in developing countries: A systematic review

Environmental tobacco smoke (ETS) is an important indoor air pollutant associated with adverse effects on the respiratory health of the general population, especially people with asthma. ETS consists mainly of sidestream smoke from burning cigarettes and a smaller quantity of mainstream smoke which is exhaled by the smoker. At least one out of every three children is frequently exposed to ETS. ^ This paper reviewed the literature for studies on the role of ETS in the development and exacerbation of asthma among children in developing countries, specifically the low and middle income countries from the year 1980 to the present. The databases searched in this systematic review were: Ovid Medline; PubMed (National Library of Medicine); and Cumulative Index to Nursing and Allied Health (CINAHL) (EBSCOhost). Out of a total of 197 articles initially identified, only four studies (two from China, one from Macedonia and one from Brazil) were rated by two independent raters as being of high quality, and were selected for final abstraction, synthesis and evidence weighting. Results from these four studies suggests that, in developing countries, ETS exposure is associated with childhood asthma, and that asthma prevalence increases with an increase in the amount and duration of exposure to ETS. Similarly, exposure to ETS is associated with persistent cough, current night dry cough, and exacerbation of asthma symptoms. ^ Therefore, as is the case in developed nations, there is suggestive evidence in the literature that ETS exposure plays substantial role in the development and/or exacerbation of asthma among children in developing countries. To decrease the likelihood of new asthma development, enhance asthma control, and reduce the rate of medical service utilization in children exposed to ETS, smoking should be eliminated at home and in public places.^

Associations between ambient levels of combustion pollutants and small for gestational age infants in Texas

There is scant evidence regarding the associations between ambient levels of combustion pollutants and small for gestational age (SGA) infants. No studies of this type have been completed in the Southern United States. The main objective of the project presented was to determine associations between combustion pollutants and SGA infants in Texas using three different exposure assessments. ^ Birth certificate data that contained information on maternal and infant characteristics were obtained from the Texas Department of State Health Services (TX DSHS). Exposure assessment data for the three aims came from: (1) U.S. Environmental Protection Agency (EPA) National Air Toxics Assessment (NATA), (2) U.S. EPA Air Quality System (AQS), and (3) TX Department of Transportation (DOT), respectively. Multiple logistic regression models were used to determine the associations between combustion pollutants and SGA. ^ For the first study looked at annual estimates of four air toxics at the census tract level in the Greater Houston Area. After controlling for maternal race, maternal education, tobacco use, maternal age, number of prenatal visits, marital status, maternal weight gain, and median census tract income level, adjusted ORs and 95% confidence intervals (CI) for exposure to PAHs (per 10 ng/m3), naphthalene (per 10 ng/m3), benzene (per 1 µg/m3), and diesel engine emissions (per 10 µg/m3) were 1.01 (0.97–1.05), 1.00 (0.99–1.01), 1.01 (0.97–1.05), and 1.08 (0.95–1.23) respectively. For the second study looking at Hispanics in El Paso County, AORs and 95% confidence intervals (CI) for increases of 5 ng/m3 for the sum of carcinogenic PAHs (Σ c-PAHs), 1 ng/m3 of benzo[a]pyrene, and 100 ng/m3 in naphthalene during the third trimester of pregnancy were 1.02 (0.97–1.07), 1.03 (0.96–1.11), and 1.01 (0.97–1.06), respectively. For the third study using maternal proximity to major roadways as the exposure metric, there was a negative association with increasing distance from a maternal residence to the nearest major roadway (Odds Ratio (OR) = 0.96; 95% CI = 0.94–0.97) per 1000 m); however, once adjusted for covariates this effect was no longer significant (AOR = 0.98; 95% CI = 0.96–1.00). There was no association with distance weighted traffic density (DWTD). ^ This project is the first to look at SGA and combustion pollutants in the Southern United States with three different exposure metrics. Although there was no evidence of associations found between SGA and the air pollutants mentioned in these studies, the results contribute to the body of literature assessing maternal exposure to ambient air pollution and adverse birth outcomes. ^