Background Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients. Methods The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines-2010 update. Results Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered. Conclusions Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.

Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association.

INTRODUCTION: "Food deserts," areas characterized by poor access to healthy and affordable food, may contribute to social and spatial disparities in diet and diet-related health outcomes. However, the extent to which food deserts exist is debated. We review the evidence for the existence of food deserts in socioeconomically disadvantaged areas. METHODS: We conducted a systematic review of primary, quantitative, observational studies, published in English or French, that used geographic or market-basket approaches in high-income countries. The literature search included electronic and hand searches and peer-reviewed and grey literature from 1966 through 2007. We also contacted key researchers to identify other studies. We analyzed the findings and quality of the studies qualitatively. RESULTS: Forty-nine studies in 5 countries met inclusion criteria; the amount and consistency of the evidence varied by country. These studies were a mix of geographic and market-basket approaches, but the methodologic quality of studies and completeness of reported findings were mixed. We found clear evidence for disparities in food access in the United States by income and race. Findings from other high-income countries were sparse and equivocal. CONCLUSION: This review suggests that food deserts exist in the United States, where area-level deprivation compounds individual disadvantage. Evidence for the existence of food deserts in other high-income nations is weak.

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A systematic review of food deserts, 1966-2007.

http://stacks.cdc.gov/view/cdc/33275/cdc_33275_DS1.pdf

Activity space environment and dietary and physical activity behaviors: A pilot study

Micronutrients, vitamins and minerals accessible from the diet, are essential for biologic activity. Micronutrient status varies widely throughout pregnancy and across populations. Women in low-income countries often enter pregnancy malnourished, and the demands of gestation can exacerbate micronutrient deficiencies with health consequences for the fetus. Examples of efficacious single micronutrient interventions include folic acid to prevent neural tube defects, iodine to prevent cretinism, zinc to reduce risk of preterm birth, and iron to reduce the risk of low birth weight. Folic acid and vitamin D might also increase birth weight. While extensive mechanistic and association research links multiple antenatal micronutrients with plausible materno-fetal health advantages, hypothesized benefits have often been absent, minimal or unexpected in trials. These findings suggest a role for population context in determining health responses and filling extensive gaps in knowledge. Multiple micronutrient supplements reduce the risks of being born with low birth weight, small for gestational age or stillborn in undernourished settings, and justify micronutrient interventions with antenatal care. Measurable health effects of gestational micronutrient exposure might persist into childhood but few data exists on potential long-term benefits. In this Review, we discuss micronutrient intake recommendations, risks and consequences of deficiencies, and the effects of interventions with a particular emphasis on offspring.

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Micronutrient deficiencies in pregnancy worldwide: health effects and prevention

Pesticides used in agriculture are designed to protect crops against unwanted species, such as weeds, insects, and fungus. Many compounds target the nervous system of insect pests. Because of the similarity in brain biochemistry, such pesticides may also be neurotoxic to humans. Concerns have been raised that the developing brain may be particularly vulnerable to adverse effects of neurotoxic pesticides. Current requirements for safety testing do not include developmental neurotoxicity. We therefore undertook a systematic evaluation of published evidence on neurotoxicity of pesticides in current use, with specific emphasis on risks during early development. Epidemiologic studies show associations with neurodevelopmental deficits, but mainly deal with mixed exposures to pesticides. Laboratory experimental studies using model compounds suggest that many pesticides currently used in Europe – including organophosphates, carbamates, pyrethroids, ethylenebisdithiocarbamates, and chlorophenoxy herbicides – can cause neurodevelopmental toxicity. Adverse effects on brain development can be severe and irreversible. Prevention should therefore be a public health priority. The occurrence of residues in food and other types of human exposures should be prevented with regard to the pesticide groups that are known to be neurotoxic. For other substances, given their widespread use and the unique vulnerability of the developing brain, the general lack of data on developmental neurotoxicity calls for investment in targeted research. While awaiting more definite evidence, existing uncertainties should be considered in light of the need for precautionary action to protect brain development.

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Potential developmental neurotoxicity of pesticides used in Europe

Background The ‘deprivation amplification’ hypothesis suggests that residents of deprived neighbourhoods have universally poorer access to highquality food environments, which in turn contributes to the development of spatial inequalities in diet and diet-related chronic disease. This paper presents results from a study that quantified access to grocery stores selling fresh fruit and vegetables in four environmental settings in Scotland, UK. Methods Spatial accessibility, as measured by network travel times, to 457 grocery stores located in 205 neighbourhoods in four environmental settings (island, rural, small town and urban) in Scotland was calculated using Geographical Information Systems. The distribution of accessibility by neighbourhood deprivation in each of these four settings was investigated. Results Overall, the most deprived neighbourhoods had the best access to grocery stores and grocery stores selling fresh produce. Stratified analysis by environmental setting suggests that the least deprived compared with the most deprived urban neighbourhoods have greater accessibility to grocery stores than their counterparts in island, rural and small town locations. Access to fresh produce is better in more deprived compared with less deprived urban and small town neighbourhoods, but poorest in the most affluent island communities with mixed results for rural settings. Conclusions The results presented here suggest that the assumption of a universal ‘deprivation amplification’ hypothesis in studies of the neighbourhood food environment may be misguided. Associations between neighbourhood deprivation and grocery store accessibility vary by environmental setting. Theories and policies aimed at understanding and rectifying spatial inequalities in the distribution

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Neighbourhood food environment and area deprivation: spatial accessibility to grocery stores selling fresh fruit and vegetables in urban and rural settings

Objective: Neighbourhood differences in access to fresh fruit and vegetables may explain social inequalities in diet. Investigations have focused on variations in cost and availability as barriers to the purchase and consumption of fresh produce; investigations of quality have been neglected. Here we investigate whether produce quality systematically varies by food store type, rural–urban location and neighbourhood deprivation in a selection of communities across Scotland. Design: Cross-sectional survey of twelve fresh fruit and vegetable items in 288 food stores in ten communities across Scotland. Communities were selected to reflect a range of urban–rural settings and a food retail census was conducted in each location. The quality of twelve fruit and vegetable items within each food store was evaluated. Data from the Scottish Executive were used to characterise each small area by deprivation and urban–rural classification. Setting: Scotland. Results: Quality of fruit and vegetables within the surveyed stores was high. Medium-sized stores, stores in small town and rural areas, and stores in more affluent areas tended to have the highest-quality fresh fruit and vegetables. Stores where food is secondary, stores in urban settings and stores in more deprived areas tended have the lowest-quality fresh produce. Although differences in quality were not always statistically significant, patterns were consistent for the majority of fruit and vegetable items. Conclusions: The study provides evidence that variations in food quality may plausibly be a micro-environmental mediating variable in food purchase and consumption and help partially explain neighbourhood differences in food consumption patterns.

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Variations in fresh fruit and vegetable quality by store type, urban–rural setting and neighbourhood deprivation in Scotland

Objectives: To develop an objective, nutrient-based, healthy eating indicator shopping basket (HEISB) tool for use in studies of access to healthy food. Design: Tool development used a literature search to identify previous practice, web information on current definition of healthy foods by the UK Food Standards Agency, and population-based dietary surveys to identify culturally acceptable foods. These findings were then appraised with respect to practical fieldwork considerations. Setting: The review took account of surveys undertaken in a range of geographical areas. Results: Previous tools have varied in the foods selected and the rationale for inclusion. Most have considered nutritional composition but no systematic definition has been used and foods have been subjectively classified as ‘less healthy’ or ‘more healthy’. Recent UK work on nutrient profiling enabled individual food items to be objectively assessed for inclusion. Data from national food surveys enabled commonly consumed and culturally acceptable foods to be identified. Practical considerations included item use in meals, convenience, price, and fieldwork constraints. Other issues including health and price discriminators as well as regional preferences were considered. The final HEISB tool comprised 35 items within the following categories ‐ 17 from fruit and vegetables, nine from potatoes, bread and cereal, five from fish/meats, three from dairy, and one from fatty and sugary foods. Conclusions: The tool provides a rational basis for examining access and availability of healthy foods in cross-sectional and longitudinal retail and consumer studies.

/pdf/the-development-of-a-healthy-eating-indicator-shopping-55rn1sihqs.pdf

Mathew Taylor

Papers

Neighbourhood food environment and area deprivation: spatial accessibility to grocery stores selling fresh fruit and vegetables in urban and rural settings

Variations in fresh fruit and vegetable quality by store type, urban–rural setting and neighbourhood deprivation in Scotland

The development of a healthy eating indicator shopping basket tool (HEISB) for use in food access studies-identification of key food items.