Mary E Cogswell

Emory University, Atlanta, GA, United States

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Publications (93)533.39 Total impact

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    ABSTRACT: Little information is available on temporal trends in sodium intake in the U.S. population using urine sodium excretion as a biomarker. Our aim was to assess 1988-2010 trends in estimated 24-h urine sodium (24hUNa) excretion among U.S. adults (age 20-59 y) participating in the cross-sectional NHANES. We used subsamples from a 1988-1994 convenience sample, a 2003-2006 one-third random sample, and a 2010 one-third random sample to comply with resource constraints. We estimated 24hUNa excretion from measured sodium concentrations in spot urine samples by use of calibration equations (for men and women) derived from the International Cooperative Study on Salt, Other Factors, and Blood Pressure study. Estimated 24hUNa excretion increased over the 20-y period [1988-1994, 2003-2006, and 2010; means ± SEMs (n): 3160 ± 38.4 mg/d (1249), 3290 ± 29.4 mg/d (1235), and 3290 ± 44.4 mg/d (525), respectively; P-trend = 0.022]. We observed significantly higher mean estimated 24hUNa excretion in each survey period (P < 0.001) for men compared with women (31-33%) and for persons with a higher body mass index (BMI; 32-35% for obese vs. normal weight) or blood pressure (17-26% for hypertensive vs. normal blood pressure). After adjusting for age, sex, and race-ethnicity, temporal trends in mean estimated 24hUNa excretion remained significant (P-trend = 0.004). We observed no temporal trends in mean estimated 24hUNa excretion among BMI subgroups, nor after adjusting for BMI. Although several limitations apply to this analysis (the use of a convenience sample in 1988-1994 and using estimated 24hUNa excretion as a biomarker of sodium intake), these first NHANES data suggest that mean estimated 24hUNa excretion increased slightly in U.S. adults over the past 2 decades, and this increase may be explained by a shift in the distribution of BMI.
    Journal of Nutrition 03/2014; · 4.20 Impact Factor
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    ABSTRACT: Background: Median urine iodine concentration (UIC; µg/L) in spot urine samples is recommended for monitoring population iodine status. Other common measures are iodine:creatinine ratio (I/Cr; µg/g) and estimated 24-hr urine iodine excretion (UIE; I/Cr*predicted 24-hr Cr; µg/d). Despite different units, these measures are often used interchangeably, and it is unclear how they compare with the reference standard 24-hr UIE. Methods: Volunteers aged 18-39y collected all their urine samples for 24-hours (n=400); voids from morning, afternoon, evening, overnight, and a composite 24-h sample were analyzed for iodine. We calculated median observed 24-hr UIE and 24-hr UIC, and spot UIC, I/Cr, and 2 measures of estimated UIE calculated using predicted 24-hr Cr from published estimates by Kesteloot & Joosens (varies by age and sex) and published equations by Mage (varies by age, sex, race, and anthropometric measures). We examined mean differences and relative difference across iodine excretion levels using Bland-Altman plots. Results: Median 24-hr UIE was 173.6 µg/d and 24-hr UIC was 144.8 µg/L. From timed spot urine samples, estimates were UIC: 147.3-156.2 µg/L, I/Cr: 103.6-114.3 µg/g, estimated 24-hr UIE (Kesteloot & Joosens): 145.7-163.3 µg/d, and estimated 24-hr UIE (Mage): 176.5-187.7 µg/d. Iodine measures did not vary consistently by timing of spot urine collection. Compared with observed 24-hr UIE, on average, estimated (Mage) 24-hr UIE was not significantly different, while estimated 24-hr UIE (Kesteloot& Joosens) was significantly different for some race/sex groups. Compared with 24-hr UIC, on average, spot UIC did not differ. Conclusions: Estimates of UIC, I/Cr, and estimated 24h-hr UIE (I/Cr*predicted 24-hr Cr) from spot urine samples should not be used interchangeably. Estimated 24-hr UIE, where predicted 24-hr Cr varies by age, sex, race, and anthropometric measures and was calculated with prediction equations using data from the sample, was more comparable to observed 24-hr UIE than when predicted 24-hr Cr was from published estimates from a different population. However, currently no cutoffs exist to interpret population estimated 24-hr UIE values.
    Thyroid: official journal of the American Thyroid Association 12/2013; · 2.60 Impact Factor
  • American Journal of Hypertension 10/2013; 26(10):1178-80. · 3.67 Impact Factor
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    ABSTRACT: Collecting a 24-h urine sample is recommended for monitoring the mean population sodium intake, but implementation can be difficult. The objective was to assess the validity of published equations by using spot urinary sodium concentrations to predict 24-h sodium excretion. This was a cross-sectional study, conducted from June to August 2011 in metropolitan Washington, DC, of 407 adults aged 18-39 y, 48% black, who collected each urine void in a separate container for 24 h. Four timed voids (morning, afternoon, evening, and overnight) were selected from each 24-h collection. Published equations were used to predict 24-h sodium excretion with spot urine by specimen timing and race-sex subgroups. We examined mean differences with measured 24-h sodium excretion (bias) and individual differences with the use of Bland-Altman plots. Across equations and specimens, mean bias in predicting 24-h sodium excretion for all participants ranged from -267 to 1300 mg (Kawasaki equation). Bias was least with International Cooperative Study on Salt, Other Factors, and Blood Pressure (INTERSALT) equations with morning (-165 mg; 95% CI: -295 mg, 36 mg), afternoon (-90; -208, 28), and evening (-120; -230, -11) specimens. With overnight specimens, mean bias was least when the Tanaka (-23; 95% CI: -141, 95) or Mage (-145; -314, 25) equations were used but was statistically significant with the Tanaka equations in females (216-243 mg) and the Mage equations in races other than black (-554, -372 mg). Significant over- and underprediction occurred across individual sodium excretion concentrations. Using a single spot urine, INTERSALT equations may provide the least biased information about population mean sodium intakes among young US adults. None of the equations evaluated provided unbiased estimates of individual 24-h sodium excretion. This trial was registered at as NCT01631240.
    American Journal of Clinical Nutrition 09/2013; · 6.50 Impact Factor
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    ABSTRACT: Data are limited on usual sodium and potassium intakes relative to age-specific recommendations and the sodium:potassium ratio in infants and preschoolers, especially among those aged <2 y, who are black or breastfed. The usual sodium intake above the Tolerable Upper Intake Levels (ULs), potassium intakes above Adequate Intakes (AIs), the sodium:potassium ratio, and sodium density (mg/kcal) among US infants and preschoolers by age group, as applicable, were estimated and compared by race-ethnicity and current breastfeeding status. Data were analyzed among 3 groups of children (aged 7-11 mo, 1-3 y, and 4-5 y) from the NHANES 2003-2010 by using measurement error models. Seventy-nine percent of children aged 1-3 y and 87% of those aged 4-5 y exceeded their sodium UL; among non-Hispanic black children, the estimates were 84% and 97%, respectively. For potassium, 97% of infants, 5% of children aged 1-3 y, and 0.4% aged 4-5 y met their AIs. Compared with non-Hispanic whites and Mexican Americans, non-Hispanic black infants and preschoolers had higher mean sodium density and sodium:potassium ratios. Currently breastfed infants and children consumed, on average, less sodium than those who were not breastfed (382 ± 53 compared with 538 ± 22 mg in those aged 7-11 mo and 1154 ± 88 compared with 1985 ± 24 mg in those aged 1-3 y, respectively), but the sodium:potassium ratio did not differ. Most US preschoolers, particularly non-Hispanic blacks, consume too much sodium, and nearly all do not consume enough potassium. Data that suggest that currently breastfed infants consume less sodium than do those who are not breastfeeding merit further investigation.
    American Journal of Clinical Nutrition 08/2013; · 6.50 Impact Factor
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    ABSTRACT: The objective of this review is to evaluate the literature on the association between mild, moderate, and binge prenatal alcohol exposure and child neurodevelopment. Meta-analysis with systematic searches of MEDLINE (1970 through August 2012), EMBASE (1988 through August 2012), and PsycINFO(®) (1970 through August 2012) and examination of selected references. From 1,593 articles, we identified 34 presenting data from cohort studies that met our inclusion criteria. Information on study population, outcomes, measurement instruments, timing and quantification of alcohol exposure, covariates, and results was abstracted. Outcomes included academic performance, attention, behavior, cognition, language skills, memory, and visual and motor development. The quality of each article was assessed by 2 researchers using the Newcastle-Ottawa Scale. Based on 8 studies of 10,000 children aged 6 months through 14 years, we observed a significant detrimental association between any binge prenatal alcohol exposure and child cognition (Cohen's d [a standardized mean difference score] -0.13; 95% confidence interval [CI], -0.21, -0.05). Based on 3 high-quality studies of 11,900 children aged 9 months to 5 years, we observed a statistically significant detrimental association between moderate prenatal alcohol exposure and child behavior (Cohen's d -0.15; 95% CI, -0.28, -0.03). We observed a significant, albeit small, positive association between mild-to-moderate prenatal alcohol exposure and child cognition (Cohen's d 0.04; 95% CI, 0.00, 0.08), but the association was not significant after post hoc exclusion of 1 large study that assessed mild consumption nor was it significant when including only studies that assessed moderate alcohol consumption. None of the other completed meta-analyses resulted in statistically significant associations between mild, moderate, or binge prenatal alcohol exposure and child neuropsychological outcomes. Our findings support previous findings suggesting the detrimental effects of prenatal binge drinking on child cognition. Prenatal alcohol exposure at levels less than daily drinking might be detrimentally associated with child behavior. The results of this review highlight the importance of abstaining from binge drinking during pregnancy and provide evidence that there is no known safe amount of alcohol to consume while pregnant.
    Alcoholism Clinical and Experimental Research 08/2013; · 3.42 Impact Factor
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    ABSTRACT: We reviewed methods of studies assessing restaurant foods' sodium content and nutrition databases. We systematically searched the 1964-2012 literature and manually examined references in selected articles and studies. Twenty-six (5.2%) of the 499 articles we found met the inclusion criteria and were abstracted. Five were conducted nationally. Sodium content determination methods included laboratory analysis (n = 15), point-of-purchase nutrition information or restaurants' Web sites (n = 8), and menu analysis with a nutrient database (n = 3). There is no comprehensive data system that provides all information needed to monitor changes in sodium or other nutrients among restaurant foods. Combining information from different sources and methods may help inform a comprehensive system to monitor sodium content reduction efforts in the US food supply and to develop future strategies. (Am J Public Health. Published online ahead of print July 18, 2013: e1-e10. doi:10.2105/AJPH.2013.301442).
    American Journal of Public Health 07/2013; · 3.93 Impact Factor
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    ABSTRACT: Because of the logistic complexity, excessive respondent burden, and high cost of conducting 24-h urine collections in a national survey, alternative strategies to monitor sodium intake at the population level need to be evaluated. We conducted a calibration study to assess the ability to characterize sodium intake from timed-spot urine samples calibrated to a 24-h urine collection. In this report, we described the overall design and basic results of the study. Adults aged 18-39 y were recruited to collect urine for a 24-h period, placing each void in a separate container. Four timed-spot specimens (morning, afternoon, evening, and overnight) and the 24-h collection were analyzed for sodium, potassium, chloride, creatinine, and iodine. Of 481 eligible persons, 407 (54% female, 48% black) completed a 24-h urine collection. A subsample (n = 133) collected a second 24-h urine 4-11 d later. Mean sodium excretion was 3.54 ± 1.51 g/d for males and 3.09 ± 1.26 g/d for females. Sensitivity analysis excluding those who did not meet the expected creatinine excretion criterion showed the same results. Day-to-day variability for sodium, potassium, chloride, and iodine was observed among those collecting two 24-h urine samples (CV = 16-29% for 24-h urine samples and 21-41% for timed-spot specimens). Among all race-gender groups, overnight specimens had larger volumes (P < 0.01) and lower sodium (P < 0.01 -P = 0.26), potassium (P < 0.01), and chloride (P < 0.01) concentrations compared with other timed-spot urine samples, although the differences were not always significant. Urine creatinine and iodine concentrations did not differ by the timing of collection. The observed day-to-day and diurnal variations in sodium excretion illustrate the importance of accounting for these factors when developing calibration equations from this study.
    Journal of Nutrition 06/2013; · 4.20 Impact Factor
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    ABSTRACT: BACKGROUND Beyond perinatal folic acid supplementation, the need for additional prenatal prophylaxis of iron with or without other micronutrients remains unclear. We aim to investigate the maternal and infant health effects of iron plus folic acid and multiple micronutrient supplements vs folic acid alone when provided to pregnant women with no or mild anemia. METHODS In this randomized double-blind controlled trial, 18 775 nulliparous pregnant women with mild or no anemia were enrolled from 5 counties of northern China from May 2006 through April 2009. Women were randomly assigned to daily folic acid (400 μg) (control), folic acid-iron (30 mg), or folic acid, iron, and 13 additional vitamins and minerals provided before 20 weeks gestation to delivery. Primary outcome was perinatal mortality. Secondary outcomes included neonatal and infant mortality, preterm delivery, birth weight, birth length, gestational duration, and maternal hemoglobin concentration and anemia. RESULTS A total of 92.7% of women consumed 80% to 100% of supplements as instructed. On average, women consumed 177 supplements. Compared with daily prenatal folic acid, supplementation with iron-folic acid with or without other micronutrients did not affect the rate of perinatal mortality (8.8, 8.7, and 8.3, respectively) per 1000 births, and relative risks (RRs) were 1.00 (95% CI, 0.68-1.46; P = .99) and 0.94 (95% CI, 0.64-1.39; P = .76), respectively. Risk of other adverse maternal and infant outcomes also did not differ, except that RRs for third-trimester maternal anemia were 0.72 (95% CI, 0.63-0.83; P < .001) and 0.71 (95% CI, 0.62-0.82; P < .001), respectively. CONCLUSION Prenatal iron-folic acid and other micronutrient supplements provided to Chinese women with no or mild anemia prevented later pregnancy anemia beyond any benefit conferred by folic acid alone but did not affect perinatal mortality or other infant outcomes. TRIAL REGISTRATION Identifier: NCT00133744.
    JAMA Internal Medicine 01/2013; · 10.58 Impact Factor
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    ABSTRACT: Studies indicate high sodium and low potassium intake can increase blood pressure suggesting the ratio of sodium-to-potassium may be informative. Yet, limited studies examine the association of the sodium-to-potassium ratio with blood pressure and hypertension. We analyzed data on 10,563 participants aged ≥20 years in the 2005-2010 National Health and Nutrition Examination Survey who were neither taking anti-hypertensive medication nor on a low sodium diet. We used measurement error models to estimate usual intakes, multivariable linear regression to assess their associations with blood pressure, and logistic regression to assess their associations with hypertension. The average usual intakes of sodium, potassium and sodium-to-potassium ratio were 3,569 mg/d, 2,745 mg/d, and 1.41, respectively. All three measures were significantly associated with systolic blood pressure, with an increase of 1.04 mmHg (95% CI, 0.27-1.82) and a decrease of 1.24 mmHg (95% CI, 0.31-2.70) per 1,000 mg/d increase in sodium or potassium intake, respectively, and an increase of 1.05 mmHg (95% CI, 0.12-1.98) per 0.5 unit increase in sodium-to-potassium ratio. The adjusted odds ratios for hypertension were 1.40 (95% CI, 1.07-1.83), 0.72 (95% CI, 0.53-0.97) and 1.30 (95% CI, 1.05-1.61), respectively, comparing the highest and lowest quartiles of usual intake of sodium, potassium or sodium-to-potassium ratio. Our results provide population-based evidence that concurrent higher sodium and lower potassium consumption are associated with hypertension.
    PLoS ONE 01/2013; 8(10):e75289. · 3.73 Impact Factor
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    ABSTRACT: Sodium intake is related to blood pressure, an established risk factor for heart disease and stroke. Reducing intake may save billions in United States health care dollars annually. Efforts targeting sodium reductions make accurate monitoring vital, yet limited information exists on the accuracy of the current data to assess sodium intake in the United States population. In this symposium, new findings were presented on the accuracy of estimating population 24-h urinary excretion of sodium from spot urine specimens or sodium intake from 24-h dietary recalls. Differences in accuracy by sex, BMI, and race were apparent as well as by timing of spot urine collections. Although some published equations appear promising for estimating group means, others are biased. Individual estimates of sodium intake were highly variable and adjustment for within-individual variation in intake is required for estimating population prevalence or percentiles. Estimates indicated United States sodium intake remains high.
    Advances in Nutrition 01/2013; 4(5):560-2. · 3.20 Impact Factor
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    ABSTRACT: The average adult in the United States of America consumes well above the recommended daily limit of sodium. Average sodium intake is about 3 463 mg/day, as compared to the 2010 dietary guidelines for Americans recommendation of < 2 300 mg/day. A further reduction to 1 500 mg/day is advised for people 51 years or older; African Americans; and people with high blood pressure, diabetes, or chronic kidney disease. In the United States of America, the problem of excess sodium intake is related to the food supply. Most sodium consumed comes from packaged, processed, and restaurant foods and therefore is in the product at the time of purchase. This paper describes sodium reduction policies and programs in the United States at the federal, state, and local levels; efforts to monitor the health impact of sodium reduction; ways to assess consumer knowledge, attitudes, and behavior; and how these activities depend on and inform global efforts to reduce sodium intake. Reducing excess sodium intake is a public health opportunity that can save lives and health care dollars in the United States and globally. Future efforts, including sharing successes achieved and barriers identified in the United States and globally, may quicken and enhance progress.
    Revista Panamericana de Salud Pública 10/2012; 32(4):301-6. · 0.85 Impact Factor
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    ABSTRACT: To assess the association between usual dietary sodium intake and blood pressure among US children and adolescents, overall and by weight status. Children and adolescents aged 8 to 18 years (n = 6235) who participated in NHANES 2003-2008 comprised the sample. Subjects' usual sodium intake was estimated by using multiple 24-hour dietary recalls. Linear or logistic regression was used to examine association between sodium intake and blood pressure or risk for pre-high blood pressure and high blood pressure (pre-HBP/HPB). Study subjects consumed an average of 3387 mg/day of sodium, and 37% were overweight/obese. Each 1000 mg per day sodium intake was associated with an increased SD score of 0.097 (95% confidence interval [CI] 0.006-0.188, ∼1.0 mm Hg) in systolic blood pressure (SBP) among all subjects and 0.141 (95% CI: -0.010 to 0.298, ∼1.5 mm Hg) increase among overweight/obese subjects. Mean adjusted SBP increased progressively with sodium intake quartile, from 106.2 mm Hg (95% CI: 105.1-107.3) to 108.8 mm Hg (95% CI: 107.5-110.1) overall (P = .010) and from 109.0 mm Hg (95% CI: 107.2-110.8) to 112.8 mm Hg (95% CI: 110.7-114.9; P = .037) among those overweight/obese. Adjusted odds ratios comparing risk for pre-HBP/HPB among subjects in the highest versus lowest sodium intake quartile were 2.0 (95% CI: 0.95-4.1, P = .062) overall and 3.5 (95% CI: 1.3-9.2, P = .013) among those overweight/obese. Sodium intake and weight status appeared to have synergistic effects on risk for pre-HBP/HPB (relative excess risk for interaction = 0.29 (95% CI: 0.01-0.90, P < .05). Sodium intake is positively associated with SBP and risk for pre-HBP/HPB among US children and adolescents, and this association may be stronger among those who are overweight/obese.
    PEDIATRICS 09/2012; 130(4):611-9. · 4.47 Impact Factor
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    ABSTRACT: The American Heart Association (AHA), Institute of Medicine (IOM), and US Departments of Health and Human Services and Agriculture (USDA) Dietary Guidelines for Americans all recommend that Americans limit sodium intake and choose foods that contain potassium to decrease the risk of hypertension and other adverse health outcomes. We estimated the distributions of usual daily sodium and potassium intakes by sociodemographic and health characteristics relative to current recommendations. We used 24-h dietary recalls and other data from 12,581 adults aged ≥20 y who participated in NHANES in 2003-2008. Estimates of sodium and potassium intakes were adjusted for within-individual day-to-day variation by using measurement error models. SEs and 95% CIs were assessed by using jackknife replicate weights. Overall, 99.4% (95% CI: 99.3%, 99.5%) of US adults consumed more sodium daily than recommended by the AHA (<1500 mg), and 90.7% (89.6%, 91.8%) consumed more than the IOM Tolerable Upper Intake Level (2300 mg). In US adults who are recommended by the Dietary Guidelines to further reduce sodium intake to 1500 mg/d (ie, African Americans aged ≥51 y or persons with hypertension, diabetes, or chronic kidney disease), 98.8% (98.4%, 99.2%) overall consumed >1500 mg/d, and 60.4% consumed >3000 mg/d-more than double the recommendation. Overall, <2% of US adults and ~5% of US men consumed ≥4700 mg K/d (ie, met recommendations for potassium). Regardless of recommendations or sociodemographic or health characteristics, the vast majority of US adults consume too much sodium and too little potassium.
    American Journal of Clinical Nutrition 08/2012; 96(3):647-57. · 6.50 Impact Factor
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    ABSTRACT: We reviewed the published literature to assess the association between maternal periconceptional physical activity and the risk for major, non-chromosomal, birth defects and whether this varies by pre-pregnancy obesity. We conducted a systematic literature search of MEDLINE, EMBASE, and CINAHL databases. Data were abstracted from all articles that met our inclusion criteria and included information on physical activity intensity (mild, moderate, and vigorous) and modality (i.e., standing, lifting, other). We assessed occupational and recreational physical activity separately. The quality of included articles was assessed using the Newcastle-Ottawa Scale. Of 3316 screened articles, 11 were included in this review. Of the four studies that assessed prolonged standing, two reported a positive association with risk for some birth defects; null associations were observed in the other two studies. Associations between heavy lifting or other occupational physical activity exposures and risk for birth defects were inconsistent. A protective association between leisure-time physical activity (i.e., active sports, swimming) and some birth defects (e.g., neural tube defects), was suggested by the results of two studies. Only one study reported assessment of possible effect modification by maternal body mass index (BMI). Our review suggests that there may be some associations between occupational and leisure-time physical activities and some, major non-chromosomal, birth defects, but relatively limited published research exists on these associations. Further research in this area should include differentiation of birth defects phenotypes, valid assessments of all domains of physical activity, including household and transportation activity, and account for the potential influence of pre-pregnancy BMI.
    Birth Defects Research Part A Clinical and Molecular Teratology 05/2012; 94(7):521-31. · 2.27 Impact Factor
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    ABSTRACT: The USA currently fortifies enriched cereal grain products (ECGP) with folic acid at 140 μg/100 g. In addition, folic acid can be voluntarily added to ready-to-eat cereals (RTEC) up to 400 μg/serving and it is found in many dietary supplements, most often at a dose of 400 μg. We sought to model folic acid intake under various fortification and supplementation scenarios. The National Health and Nutrition Examination Survey is a population-based cross-sectional survey representative of the non-institutionalized, civilian US population. Information on folic acid intake is collected in two 24 h dietary recalls and survey questions on dietary supplement use, which allows estimation of usual total folic acid intake. We modelled five different levels of folic acid fortification in ECGP, while varying the amounts in RTEC and dietary supplements. United States. US adults (n 14 353) aged ≥19 years; non-pregnant women of childbearing age (n 4272). The percentage of adults with usual daily folic acid intake above the tolerable upper intake level of 1000 μg was influenced more by the typical amount in supplements, while the median intake was influenced more by the ECGP fortification level. By manipulating the amount in at least two sources, it was possible to shift the distribution such that more women of childbearing age consumed the recommended intake of 400 μg of folic acid without increasing the percentage of adults with intake above the tolerable upper intake level. The results varied among population subgroups. Our results suggest that combined strategies are required to meet population recommendations for folic acid intake.
    Public Health Nutrition 03/2012; 15(7):1216-27. · 2.25 Impact Factor
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    ABSTRACT: Recent recommendations from the American Heart Association aim to improve cardiovascular health by encouraging the general population to meet 7 cardiovascular health metrics: not smoking; being physically active; having normal blood pressure, blood glucose and total cholesterol levels, and weight; and eating a healthy diet. To examine time trends in cardiovascular health metrics and to estimate joint associations and population-attributable fractions of these metrics in relation to all-cause and cardiovascular disease (CVD) mortality risk. Study of a nationally representative sample of 44,959 US adults (≥20 years), using data from the National Health and Nutrition Examination Survey (NHANES) 1988-1994, 1999-2004, and 2005-2010 and the NHANES III Linked Mortality File (through 2006). All-cause, CVD, and ischemic heart disease (IHD) mortality. Few participants met all 7 cardiovascular health metrics (2.0% [95% CI, 1.5%-2.5%] in 1988-1994, 1.2% [95% CI, 0.8%-1.9%] in 2005-2010). Among NHANES III participants, 2673 all-cause, 1085 CVD, and 576 IHD deaths occurred (median follow-up, 14.5 years). Among participants who met 1 or fewer cardiovascular health metrics, age- and sex-standardized absolute risks were 14.8 (95% CI, 13.2-16.5) deaths per 1000 person-years for all-cause mortality, 6.5 (95% CI, 5.5-7.6) for CVD mortality, and 3.7 (95% CI, 2.8-4.5) for IHD mortality. Among those who met 6 or more metrics, corresponding risks were 5.4 (95% CI, 3.6-7.3) for all-cause mortality, 1.5 (95% CI, 0.5-2.5) for CVD mortality, and 1.1 (95% CI, 0.7-2.0) for IHD mortality. Adjusted hazard ratios were 0.49 (95% CI, 0.33-0.74) for all-cause mortality, 0.24 (95% CI, 0.13-0.47) for CVD mortality, and 0.30 (95% CI, 0.13-0.68) for IHD mortality, comparing participants who met 6 or more vs 1 or fewer cardiovascular health metrics. Adjusted population-attributable fractions were 59% (95% CI, 33%-76%) for all-cause mortality, 64% (95% CI, 28%-84%) for CVD mortality, and 63% (95% CI, 5%-89%) for IHD mortality. Meeting a greater number of cardiovascular health metrics was associated with a lower risk of total and CVD mortality, but the prevalence of meeting all 7 cardiovascular health metrics was low in the study population.
    JAMA The Journal of the American Medical Association 03/2012; 307(12):1273-83. · 29.98 Impact Factor
  • Archives of internal medicine 01/2012; 172(1):76-8. · 11.46 Impact Factor
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    ABSTRACT: Folic acid can prevent neural tube defects (NTD). Hispanic women have a higher prevalence of NTD than non-Hispanic white (NHW) women and consume less folic acid. Among Hispanics, acculturation has been associated with lower intakes of natural folate. It is unknown if this same relationship is seen for fortified foods. This article describes the associations of acculturation factors with usual folate intakes from foods and supplements and compares the proportion that meets recommended intakes of folic acid of US Mexican American (MA) women with those of NHW women. For US NHW and MA women aged 15-44 y (n = 3167), usual folate intakes (i.e., natural food folate, folic acid from food, total folic acid [fortified foods plus supplements], and total folate) were estimated using measurement error models from NHANES 2001-2008. Compared with NHW women, MA women did not differ in their intake of natural food folate or folic acid from food. Similarly, compared with NHW women (332 ± 17.3 μg/d), the mean total usual folic acid intakes were lower among MA women who reported speaking Spanish (224 ± 24.9 μg/d) but not for MA women who reported speaking English (283 ± 36.2 μg/d). MA women were more likely than NHW women to consume a total folic acid intake <400 μg/d. MA women with lower acculturation factors were the most likely to have an intake <400 μg/d compared to NHW women. Public health efforts should focus on increasing total folic acid intake among MA women, emphasizing those with lower acculturation factors (e.g., MA women who report speaking Spanish).
    Journal of Nutrition 08/2011; 141(10):1889-97. · 4.20 Impact Factor
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    ABSTRACT: Various definitions, criteria, tests, and cutoffs have been used to define vitamin B-12 status; however, a need exists for the systematic study of vitamin B-12 status in the United States because of concerns about high folic acid intakes and the potential for associated adverse effects. The objective was to determine the effect of different cutoff choices on outcomes and of the different degrees of serum vitamin B-12 status, definable by the concurrent use of a functional and circulating marker as the first steps to developing a data-based consensus on the biochemical diagnosis of vitamin B-12 deficiency. Data from NHANES, a nationally representative cross-sectional survey, were examined for adults aged >19 y (mean ± SD age: 45 ± 1 y) from 1999 to 2004 (n = 12,612). Commonly used cutoffs had a greater effect on prevalence estimates of low vitamin B-12 status with the use of vitamin B-12 than with the use of methylmalonic acid (MMA; 3-26% and 2-6%, respectively). A cutoff of >148 pmol/L for vitamin B-12 and of ≤210 nmol/L for MMA resulted in significant misclassifications. Approximately 1% of adults had a clear vitamin B-12 deficiency (low vitamin B-12 and elevated MMA); 92% of adults had adequate vitamin B-12 status. A high percentage of younger women characterized the group with low vitamin B-12 and normal MMA (2% of adults) and may have falsely reflected low vitamin B-12. Adults with elevated MMA (5%) only were demographically similar (ie, by age and race) to the deficient group and may have included some individuals with early vitamin B-12 deficiency. These analyses indicate the challenges of assessing vitamin B-12 status when uncertainties exist about the appropriate cutoffs. Future studies should determine definable endpoints to achieve this goal.
    American Journal of Clinical Nutrition 06/2011; 94(2):552-61. · 6.50 Impact Factor

Publication Stats

3k Citations
533.39 Total Impact Points


  • 2013
    • Emory University
      • Department of Epidemiology
      Atlanta, GA, United States
  • 2011
    • Stanford University
      • Department of Pediatrics
      Stanford, CA, United States
  • 1995–2011
    • Centers for Disease Control and Prevention
      • • National Center for Chronic Disease Prevention and Health Promotion
      • • National Center on Birth Defects and Developmental Disabilities
      • • Division of Reproductive Health
      Druid Hills, GA, United States
  • 2001–2006
    • University of North Carolina at Chapel Hill
      • Department of Nutrition
      Chapel Hill, NC, United States
  • 2005
    • University of Florida
      Gainesville, Florida, United States
  • 2004
    • University of Pittsburgh
      • School of Medicine
      Pittsburgh, PA, United States