This paper describes the factors that support recovery of public health infrastructure (PHI), including conditions that facilitated or hindered recovery in United States (US) territories impacted by hurricanes Irma and Maria. A deductive approach was used to categorize data from five organizations that received crisis hurricane recovery (CHR) funds from the Centers for Disease Control and Prevention.* Spending was grouped into five infrastructure gaps: (1) human resources, (2) informatic upgrades, (3) equipment, (4) minor repairs, and (5) preventive maintenance. Unanticipated PHI costs, facilitators, and hinderances to PHI recovery were identified. Most (72 percent) of the $53,529,823 CHR funding was used to address infrastructure gaps in (1) human resources (56 percent), (2) informatics (16 percent), (3) equipment (13 percent), (4) minor repairs (10 percent), and (5) preventive maintenance (5 percent). Most of the requests (56 percent) to redirect funds were associated with unanticipated costs in initial work plans and budgets. The use of administrative partners, planning tools, dedicated staff, streamlined procedures, eg, contracts, and cost sharing facilitated PHI recovery. The most common hindrance to PHI recovery were delays in procurement and shipping. In summary, investments in dedicated funding to upgrade, repair, or replace critical structures and systems for infectious disease surveillance, laboratory capacity, vector control, environmental health inspections, and vaccine storage and administration in Puerto Rico and the US Virgin Islands after Hurricanes Irma and Maria contributed to their recovery capacity. These findings may inform funding and resource allocation considerations for PHI recovery in the US territories.

Complementary foods and beverages (CFB) are key components of an infant's diet in the second 6 months of life. This manuscript summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFB sometime before 6 months. The primary mode of feeding (i.e., human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFB is associated with the timing of introduction and types of CFB reported. FMF infants (42%) are more likely to be introduced to CFB before 4 months compared to HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed including fruit, grains, dairy, proteins, and solid fats. Compared to HMF infants of the same age, FMF infants consume more total energy (845 vs. 631 kcal) and protein (22 vs. 12 g) from all sources, and more energy (345 vs. 204 kcal) and protein (11 vs. 6 g) from CFB alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs. 7%), zinc (54% vs. <3%), and protein (27% vs. <3%). FMF infants are more likely to have early introduction (<12 months) to fruit juice (45% vs. 20%) and cow's milk (36% vs. 24%). Dietitians and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could further refine findings from this analysis.

BACKGROUND: BMI z-scores (BMIz) based on the Centers for Disease Control and Prevention (CDC) growth charts among children do not accurately characterise BMI levels among children with very high BMIs. These limitations may be particularly relevant in longitudinal and intervention studies, as the large changes in the L (normality) and S (dispersion) parameters with age can influence BMIz. AIM: To compare longitudinal changes in BMIz with BMI expressed as a percentage of the 95th percentile (%BMIp95) and a modified z-score calculated as log(BMI/M)/S. SUBJECTS AND METHODS: A total of 45 414 2-4-year-olds with severe obesity (%BMIp95 ≥ 120). RESULTS: Changes in very high BMIz levels differed from the other metrics. Among severely obese 2-year-old girls, for example, the mean BMIz decreased by 0.6 SD between examinations, but there were only small changes in BMIp95 and modified BMIz. Some 2-year-old girls had BMIz decreases of >1 SD, even though they had large increases in BMI, %BMIp95 and modified BMIz. CONCLUSIONS: Among children with severe obesity, BMIz changes may be due to differences in the transformations used to estimate levels of BMIz rather than to changes in body size. The BMIs of these children could be expressed relative to the 95th percentile or as modified z-scores.

OBJECTIVE: To examine the associations among several body mass index (BMI) metrics (z-scores, percent of the 95th percentile (%BMIp95) and BMI minus 95th percentile (DeltaBMIp95) as calculated in the growth charts from the Centers for Disease Control and Prevention (CDC). It is known that the widely used BMI z-scores (BMIz) and percentiles calculated from the growth charts can differ substantially from those that directly observed in the data for BMIs above the 97th percentile (z = 1.88). STUDY DESIGN: Cross-sectional analyses of 8.7 million 2- to 4-year-old children who were examined from 2008 through 2011 in the CDC's Pediatric Nutrition Surveillance System. RESULTS: Because of the transformation used to calculate z-scores, the theoretical maximum BMIz varied by >3-fold across ages. This results in the conversion of very high BMIs into a narrow range of z-scores that varied by sex and age. Among children with severe obesity, levels of BMIz were only moderately correlated (r ~ 0.5) with %BMIp95 and DeltaBMIp95. Among these children with severe obesity, BMIz levels could differ by more than 1 SD among children who had very similar levels of BMI, %BMIp95 and DeltaBMIp95 due to differences in age or sex. CONCLUSIONS: The effective upper limit of BMIz values calculated from the CDC growth charts, which varies by sex and age, strongly influences the calculation of z-scores for children with severe obesity. Expressing these very high BMIs relative to the CDC 95th percentile, either as a difference or percentage, would be preferable to using BMI-for-age, particularly when assessing the effectiveness of interventions.

OBJECTIVE: Although the Centers for Disease Control and Prevention (CDC) growth charts are widely used, BMI-for-age z-Scores (BMIz) are known to be uninformative above the 97th percentile. This study compared the relations of BMIz and other BMI metrics (%BMIp95 , percent of 95th percentile, and DeltaBMIp95 , BMI minus 95th percentile) to circumferences, skinfolds, and fat mass. We were particularly interested in the differences among children with severe obesity (%BMIp95 ≥ 120). METHODS: Data was used from 30,003 2- to 19-year-olds who were examined from 1999-2000 through 2013-2014 in the National Health and Nutrition Examination Survey (NHANES). RESULTS: The theoretical maximum BMIz based on the growth charts varied by more than threefold across ages. The BMI metrics were strongly intercorrelated, but BMIz was less strongly related to the adiposity measures than were DeltaBMIp95 and %BMIp95 . Among children with severe obesity, circumferences and triceps skinfold showed almost no association with BMIz (r ≤ 0.10), whereas associations with %BMIp95 and DeltaBMIp95 ranged from r = 0.32 to 0.79. Corresponding associations with fat mass / height2 ranged from r = 0.40 (BMIz) to r =0.82 (%BMIp95 ) among 8- to 19-year-olds. CONCLUSIONS: Among children with severe obesity, BMIz is only weakly associated with other measures of body fatness. Very high BMIs should be expressed relative to the CDC 95th percentile, particularly in studies that evaluate obesity interventions.

In response to the release of the National HIV/AIDS Strategy, the Centers for Disease Control and Prevention developed the “Enhanced Comprehensive HIV Prevention Planning” (ECHPP) project, which provided support to health departments in 12 Metropolitan Statistical Areas with the highest AIDS prevalence to strengthen local HIV programs. We describe a case study of how one MSA, Miami-Dade County, developed and implemented a locally tailored plan. Examples include actions to reinforce local partnerships and identify neighborhoods with highest unmet needs; an improved condom distribution system to assist local HIV care providers; collaboration with local stakeholders to establish a new walk-in center for transgender client needs; and overcoming incompatibilities in health department and Ryan White program computer record systems to facilitate faster and more efficient patient services. These examples show how jurisdictions both within Florida and elsewhere can create low-cost and sustainable activities tailored to improve local HIV prevention needs.

Excessive gestational weight gain (GWG) predicts adverse pregnancy outcomes and later obesity risk for both mother and child. Women who receive GWG advice from their obstetric clinicians are more likely to gain the recommended amount, but many clinicians do not counsel their patients on GWG, pointing to the need for new strategies. Electronic medical records (EMRs) are a useful tool for tracking weight and supporting guideline-concordant care, but their use for care related to GWG has not been evaluated. We performed in-depth interviews with 16 obstetric clinicians from a multi-site group practice in Massachusetts that uses an EMR. We recorded, transcribed, coded, and analyzed the interviews using immersion-crystallization. Many respondents believed that GWG had "a lot" of influence on pregnancy and child health outcomes but that their patients did not consider it important. Most indicated that excessive GWG was a big or moderate problem in their practice, and that inadequate GWG was rarely a problem. All used an EMR feature that calculates total GWG at each visit. Many were enthusiastic about additional EMR-based supports, such as a reference for recommended GWG for each patient based on pre-pregnancy body mass index, a "growth chart" to plot actual and recommended GWG, and an alert to identify out-of-range gains, features which many felt would remind them to counsel patients about excessive weight gain. Additional decision support tools within EMRs would be well received by many clinicians and may help improve the frequency and accuracy of GWG tracking and counseling.

Screen-media use among young children is highly prevalent, disproportionately high among children from lower-income families and racial/ethnic minorities, and may have adverse effects on obesity risk. Few systematic reviews have examined early intervention strategies to limit TV or total screen time; none have examined strategies to discourage parents from putting TVs in their children's bedrooms or remove TVs if they are already there. In order to identify strategies to reduce TV viewing or total screen time among children <12 years of age, we conducted a systematic review of seven electronic databases to June 2011, using the terms "intervention" and "television," "media," or "screen time." Peer-reviewed intervention studies that reported frequencies of TV viewing or screen-media use in children under age 12 were eligible for inclusion. We identified 144 studies; 47 met our inclusion criteria. Twenty-nine achieved significant reductions in TV viewing or screen-media use. Studies utilizing electronic TV monitoring devices, contingent feedback systems, and clinic-based counseling were most effective. While studies have reduced screen-media use in children, there are several research gaps, including a relative paucity of studies targeting young children (n = 13) or minorities (n = 14), limited long-term (>6 month) follow-up data (n = 5), and few (n = 4) targeting removing TVs from children's bedrooms. Attention to these issues may help increase the effectiveness of existing strategies for screen time reduction and extend them to different populations.

OBJECTIVE: To examine whether the obesity prevalence is increasing, level, or decreasing among young US children (aged <6 years) in the past decade; and to compare regional data to those of 2 national databases. METHODS: We analyzed data from 108,762 well-child visits (36,827 children) at a multisite pediatric practice in eastern Massachusetts during 1999-2008. By using the Centers for Disease Control and Prevention 2000 gender-specific growth charts, we defined obesity as weight-for-length ≥95th percentile for children aged <24 months and BMI ≥95th percentile for children aged 24 to <72 months. By using multivariable logistic regression, we estimated gender-specific obesity trends in 2 separate periods, 1999-2003 and 2004-2008, adjusting for age group, race/ethnicity, health insurance, and practice site. RESULTS: From 1999 to 2003, the obesity prevalence was fairly stable among both boys and girls. From 2004 to 2008, the obesity prevalence substantially decreased among both boys and girls. The decline in obesity prevalence during 2004-2008 was more pronounced among children insured by non-Medicaid health plans than among those insured by Medicaid. CONCLUSIONS: Among children aged <6 years at this multisite pediatric practice, obesity prevalence decreased during 2004-2008, which is in line with national data showing no increase in prevalence during this time period. The smaller decrease among Medicaid-insured children may portend widening of socioeconomic disparities in childhood obesity.

OBJECTIVE: To examine the associations of upward crossing of major percentiles in weight-for-length in the first 24 months of life with the prevalence of obesity at ages 5 and 10 years. DESIGN: Longitudinal study. SETTING: Multisite clinical practice. PARTICIPANTS: We included 44,622 children aged from 1 month to less than 11 years with 122,214 length/height and weight measurements from January 1, 1980, through December 31, 2008. MAIN EXPOSURE: The number of major weight-for-length percentiles crossed during each of four 6-month intervals, that is, 1 to 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months. MAIN OUTCOME MEASURES: Odds and observed prevalence of obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥95th percentile) at ages 5 and 10 years. RESULTS: Crossing upwards 2 or more weight-for-length percentiles was common in the first 6 months of life (43%) and less common during later age intervals. Crossing upwards 2 or more weight-for-length percentiles in the first 24 months was associated with elevated odds of obesity at ages 5 years (odds ratio, 2.08; 95% CI, 1.84-2.34) and 10 years (1.75; 1.53-2.00) compared with crossing less than 2 major percentiles. Obesity prevalence at ages 5 and 10 was highest among children who crossed upwards 2 or more weight-for-length percentiles in the first 6 months of life. CONCLUSIONS: Crossing upwards 2 or more major weight-for-length percentiles in the first 24 months of life is associated with later obesity. Upward crossing of 2 weight-for-length percentiles in the first 6 months is associated with the highest prevalence of obesity 5 and 10 years later. Efforts to curb excess weight gain in infancy may be useful in preventing later obesity.

OBJECTIVES: We developed and assessed AMIGAS (Amigas, Mujeres Latinas, Inform andonos, Gui andonos, y Apoy andonos contra el SIDA [friends, Latina women, informing each other, guiding each other, and supporting each other against AIDS]), a culturally congruent HIV prevention intervention for Latina women adapted from SiSTA (Sistas Informing Sistas about Topics on AIDS), an intervention for African American women. METHODS: We recruited 252 Latina women aged 18 to 35 years in Miami, Florida, in 2008 to 2009 and randomized them to the 4-session AMIGAS intervention or a 1-session health intervention. Participants completed audio computer-assisted self-interviews at baseline and follow-up. RESULTS: Over the 6-month follow-up, AMIGAS participants reported more consistent condom use during the past 90 (adjusted odds ratio [AOR]=4.81; P<.001) and 30 (AOR=3.14; P<.001) days and at last sexual encounter (AOR=2.76; P<.001), and a higher mean percentage condom use during the past 90 (relative change=55.7%; P<.001) and 30 (relative change=43.8%; P<.001) days than did comparison participants. AMIGAS participants reported fewer traditional views of gender roles(P=008), greater self-efficacy for negotiating safer sex (P<.001), greater feelings of power in relationships (P=.02), greater self-efficacy for using condoms (P<.001), and greater HIV knowledge (P=.009) and perceived fewer barriers to using condoms (P<.001). CONCLUSIONS: Our results support the efficacy of this linguistically and culturally adapted HIV intervention among ethnically diverse, predominantly foreign-born Latina women. (Am J Public Health. Published online ahead of print October 20, 2011:e1-e8. doi:10.2105/AJPH.2011.300340).

BACKGROUND: Some studies show that greater parental control over children's eating habits predicts later obesity, but it is unclear whether parents are reacting to infants who are already overweight. OBJECTIVE: To examine the longitudinal association between maternal feeding restriction at age 1 and body mass index (BMI) at age 3 and the extent to which the association is explained by weight for length (WFL) at age 1. METHODS: We studied 837 mother-infant pairs from a prospective cohort study. The main exposure was maternal feeding restriction at age 1, defined as agreeing or strongly agreeing with the following question: "I have to be careful not to feed my child too much." We ran multivariable linear regression models before and after adjusting for WFL at age 1. All models were adjusted for parental and child sociodemographic characteristics. RESULTS: 100 (12.0%) mothers reported feeding restriction at age 1. Mean (SD) WFL z-score at age 1 was 0.32 (1.01), and BMI z-score at age 3 was 0.43 (1.01). Maternal feeding restriction at age 1 was associated with higher BMI z-score at age 3 before (beta 0.26 (95% CI 0.05 to 0.48)) but not after (beta 0.00 (95% CI -0.17 to 0.18)) adjusting for WFL z-score at age 1. Each unit of WFL z-score at age 1 was associated with an increment of 0.57 BMI z-score units at age 3 (95% CI 0.51 to 0.62). CONCLUSIONS: We found that maternal feeding restriction was associated with children having a higher BMI at age 3 before, but not after, adjusting for WFL at age 1. One potential reason may be that parents restrict the food intake of infants who are already overweight.