BACKGROUND:The specialization of human fat deposits is an inquiry of special importance in the study of fetal growth. It has been theorized that maternal lower-body fat is designated specifically for lactation and not for the growth of the fetus. OBJECTIVE:Our goal was to compare the contributions of maternal upper-body versus lower-body adiposity to infant birth weight. We hypothesized that upper-body adiposity would be strongly associated with infant birth weight and that lower-body adiposity would be weakly or negligibly associated with infant birth weight-after adjusting for known determinants. STUDY DESIGN:In this prospective cohort study, 355 women initiated medical pre-natal care during the first trimester of pregnancy at The University of Oklahoma Health Sciences Center during 1990-1993. Maternal anthropometric measurements were assessed at the first clinic visit: (a) height; (b) weight; (c) circumferences of the upper arm, forearm, and thigh; and, (d) skin-fold measurements of the bicep, subscapular region, and thigh. RESULTS:Infant birth weight was regressed on known major determinants to create the foundational model. Maternal anthropometric variables subsequently were added one at a time into this multiple regression model. The highest contribution by a single anthropometric variable to infant birthweight was, in order: subscapular skin-fold, forearm circumference, and thigh circumference. With one upper-body (subscapular skin-fold) and one lower-body (circumference of the thigh) adiposity measure in the model, the z-score regression coefficient (s.e.) was 85.7g (30.8) [p=0.0057] for maternal subscapular skin-fold and 19.0g (31.6) [p=0.5477] for circumference of the thigh. When the second-best upper-body contributor to infant birthweight (circumference of the forearm) was entered with one lower-body measure into the model, the z-score regression coefficient (s.e.) was 77.5g (38.5) [p=0.0451] for maternal forearm circumference and 14.1g (38.5) [p=0.7146] for circumference of the thigh. When both subscapular skinfold and forearm circumference were added to the model in place of BMI, the explained variance (r2=0.5478) was similar to the model using BMI (r2=0.5487). CONCLUSION:Upper-body adiposity - whether operationalized by subscapular skin-fold or circumference of the forearm - was a markedly larger determinant of infant birth weight than lower-body adiposity.

Despite warnings that drinking during pregnancy is unsafe, many women are still at risk for an alcohol-exposed pregnancy (AEP). This article describes the outcomes of a web-based, self-guided change intervention designed to lower the risk for AEPs in a community. A sample of 458 women, between the ages of 18 and 44 years and at risk for an AEP (i.e., any drinking in the past 30 days and not using reliable contraception), participated in the study. A total of 58% of the women enrolled in the self-guided change intervention were no longer at risk for an AEP at the 4-month follow-up. Sublevel analysis revealed that mail and online versions of the intervention were equally successful at reducing risk for an AEP. This study represents a successful implementation of a web-based, self-guided change intervention to reduce risk for an AEP, an intervention with community-wide reach due to the Internet platform.

Background: Although epidemiological data indicate that White women are more likely to drink and binge drink before pregnancy, fetal alcohol syndrome (FAS) is more common in the Black population than among Whites in the United States. Differences in drinking cessation between Black and White women who become pregnant may help explain the disparity in FAS rates.Methods: The study sample was comprised of 280,126 non-Hispanic Black and White women, ages 18 to 44, from the Behavioral Risk Factor Surveillance System (BRFSS) 2001 to 2005 data sets. Predictors of reduction in alcohol consumption (in drinks per month) and binge drinking (> 4 drinks on one occasion) by pregnant and non-pregnant women were identified with logistic regression. The effect of interactions of pregnancy status with age, education, and Black or White race on drinks per month and binge occasions were explored using analysis of variance (ANOVA).Results: Pregnant White women averaged 79.5% fewer drinks per month than non-pregnant White women (F = 1250.1, p < 0.001), and 85.4% fewer binge drinking occasions (F = 376, p < 0.001). Pregnant Black women averaged 58.2% fewer drinks per month than non-pregnant Black women (F = 31.8, p < 0.001) and 64.0% fewer binge occasions (F = 13.8, p < 0.001). Compared to Black women, White women appear to make a 38% greater reduction in drinks per month, and a 33% greater reduction in binge occasions.Conclusions: Non-Hispanic White women appear more likely to reduce drinks per month and binge drinking occasions than non-Hispanic Black women during pregnancy. These findings may help explain disparities in FAS in the United States, though this cross-sectional sample does not permit claims of causation. To better describe the impact of differential drinking reduction on FAS rates, future studies of longitudinal data should be done.

Fetal Alcohol Syndrome (FAS) occurs in approximately 3 of 1,000 live births in the general population of the U.S. and is the leading known cause of mental retardation. The Midwest Regional Fetal Alcohol Syndrome Training Center (MRFASTC) surveyed 1,000 licensed occupational therapists (OT) of the American Occupational Therapists Association in a six-state Midwest region, including Missouri, Iowa, Nebraska, Kansas, Oklahoma, and Arkansas to assess knowledge and attitudes regarding FAS. Nearly 20% of the OTs responded. Of the respondents, nearly 94% regarded at least 1 drink per day as being 'heavy' in a pregnant woman. There was an increase in the number of respondents who thought it was acceptable to consume 1 drink or more with each advancing trimester of pregnancy. 92% of the OTs indicated a willingness to counsel a mother of a child having FAS, but 96% indicated a poor to fair ability to select valid and reliable assessment instruments for screening a child for FAS. Only 6% of the OT respondents indicated a good-excellent ability to conduct brief interventions on alcohol cessation for women. The data collectively indicate OTs possess similarities to other health care providers, including physicians and psychologists, in the misunderstanding or deficits of knowledge and skills associated with FAS and that they are largely unprepared to provide intervention for women 'at risk' for FAS, or to recognize correctly FAS in children. There is a demonstrated need, and desire, by the practicing OTs for continued education related to alcohol abuse associated with FAS.

Prenatal exposure to alcohol is a leading preventable cause of birth defects and developmental disabilities. Individuals exposed to alcohol during fetal development can have physical, mental, behavioral, and learning disabilities, with lifelong implications. These conditions are known as fetal alcohol spectrum disorders (FASDs). Health care professionals play a crucial role in identifying women at risk for an alcohol-exposed pregnancy and in identifying the effects of prenatal alcohol exposure among individuals. The Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities has funded four universities as FASD Regional Training Centers (RTCs). The RTCs, in collaboration with the CDC and the National Organization on Fetal Alcohol Syndrome, are developing, implementing, and evaluating educational curricula for medical and allied health students and practitioners and seeking to have the curricula incorporated into training programs at each grantee's university or college, into other schools throughout the region, and into the credentialing requirements of professional boards. This article highlights some of the innovative training approaches that the RTCs are implementing to increase knowledge regarding FASDs and the ability of health professionals to identify, treat, and prevent these conditions.

Background Conduct a comprehensive survey of FASD knowledge, skill, and attitudes regarding recognition, diagnosis, treatment, and prevention among family physicians in the Midwest. Methods A 35 question survey on FASD recognition, diagnosis, treatment, and prevention was sent to a random sample of 1,000 active members of the AAFP from Missouri and the 5 surrounding states. Results Twelve percent of participants returned surveys. The mean age was 44 years, 64% were male, 86.3% were Caucasian, and 43.6% were from rural areas. The survey revealed that the great majority of family physicians possess general knowledge about FAS and the effects of alcohol on children, including the importance of early diagnosis and reducing secondary disabilities. However, the survey revealed significant deficits when it came to recognition and diagnosis of FAS, with the great majority of family physicians uncertain about the facial dysmorphology features associated with FAS. In addition, the majority had not made or referred a child for the diagnosis of FAS during the past year, and if they had made the diagnosis, they had not used an evidence-based protocol to do so. Significant barriers to making the diagnosis of FAS were identified, including inadequate training and the belief that better qualified specialists were available to make the diagnosis. Regarding treatment, a significant majority of family physicians had not received any clinical training in the care of children with FAS, and those who had received training felt it was only of fair quality. Regarding prevention, only 12.8% of family physicians asked when seeing a new pediatric patient if the child was exposed to alcohol in utero. Finally, many family physicians reported that education materials on FASD were not available in their area, and many believed the presence of these educational resources would be extremely helpful if they were available. Conclusions While family physicians possess a general knowledge base about FAS, FASD, and alcohol use during pregnancy, significant knowledge deficits exist in the area of prevention, diagnosis, and treatment, and significant barriers make completion of these tasks difficult in practice. Inadequate clinical training in medical school, residency, and continuing education venues may be a prime reason why these deficits occurred.

Fetal alcohol exposure affects approximately 1% to 3% of live births in the United States. Family physicians are in a unique position to reduce the incidence of alcohol-exposed pregnancy. Fetal alcohol exposure can be minimized through 2 general approaches: reducing alcohol consumption or increasing effective contraception among childbearing-aged women who engage in "at-risk" drinking and encouraging pregnant women to abstain from alcohol. Although no safe level of alcohol consumption during pregnancy is established, women who binge drink are more likely to deliver infants with physical and cognitive-developmental anomalies. Screening tools, such as quantity/frequency questions, the TWEAK and the T-ACE, developed specifically for prenatal care, are more useful with women than the CAGE and Michigan Alcohol Screening Test ( MAST). Screening alone seems to reduce alcohol use among pregnant women. Brief interventions, including education about alcohol's effects on the developing fetus, are effective among women not responding to screening. Unfortunately, many barriers exist to effective implementation of alcohol-exposed pregnancy (AEP) prevention in the clinical setting. Designing effective office base systems so the entire burden of implementing AEP prevention activities does fall solely on the family physician is critical.

OBJECTIVES:Prenatal exposure to alcohol interferes with fetal development and is the leading preventable cause of birth defects and developmental disabilities. The purpose of this study was to identify current knowledge, diagnosis, prevention, and intervention practices related to fetal alcohol syndrome and related conditions by members of the American Academy of Pediatrics.METHODS:This study was developed collaboratively by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. Questionnaires were mailed to a 3% random sample (n = 1600) of American Academy of Pediatrics members in the United States. General pediatricians, pediatric subspecialists, and pediatric residents were included.RESULTS:Participation rate was 55% (n = 879). Respondents almost universally knew the teratology and clinical presentation of fetal alcohol spectrum disorders. However, they were less likely to report comfort with routine pediatric care of these children. Whereas 62% felt prepared to identify and 50% felt prepared to diagnose, only 34% felt prepared to manage and coordinate the treatment of children with fetal alcohol spectrum disorders. Even fewer (n = 114 [13%]) reported that they routinely counsel adolescent patients about the risks of drinking and pregnancy.CONCLUSIONS:The survey confirms that pediatricians are knowledgeable about fetal alcohol syndrome but do not feel adequately trained to integrate the management of this diagnosis or prevention efforts into everyday practice. Furthermore, the respondents were not active in routine anticipatory guidance with adolescents for prevention of alcohol-affected pregnancies. The development, dissemination, and implementation of best practice tools for prevention, diagnosis, and referral of fetal alcohol syndrome that are specific for general and subspecialist pediatricians are recommended.

Background Despite warnings to the contrary, many women continue to drink alcohol during pregnancy, placing their infants at risk for Fetal Alcohol Spectrum Disorder (FASD). Previous studies in high-risk populations have documented knowledge deficits about the effects of alcohol drunk during pregnancy among highrisk groups. Improving knowledge about the effects of alcohol use during pregnancy and FASD may result in high-risk women abstaining during pregnancy, lowering the incidence of FASD. Objective Increase FASD knowledge and awareness among African Americans in St. Louis through a targeted media campaign. Methods Utilizing community input, a multidisciplinary team designed a targeted media campaign built around four FASD prevention messages. Formative research revealed significant FASD knowledge deficits among African Americans in the city of St. Louis, and agreement about the appropriateness of our materials. Distribution channels for our campaign included visual, audio, and print advertisements, direct marketing to the community, public relations/media interviews, displays at community events, and educational videos for high school students. A quasi-experimental design was conducted to assess the effectiveness of our campaign with random digit dial surveys being conducted pre- and post-intervention in St. Louis and in a control community, Kansas City. Results Our media campaign ran from October 2002 until March 2004. Survey results revealed that 70.8 % of participants remembered our campaign in St. Louis with the most individuals, 22.9%, hearing our message over 20 times. The most frequent FAS prevention messages remembered were the “no safe level,” and the “no safe time” messages. The most remembered distribution channels were television and billboards in St. Louis. There was a small but statistically significant decline in knowledge scores comparing our post-intervention results with our pre-intervention results in St. Louis; however, we did find evidence of a dose-response relationship. Knowledge scores increased in direct proportion to the number of times respondents heard our message. It appears that our FAS prevention messages had to be heard 10 or more times in order to improve FAS prevention knowledge among African American women. Conclusions Our targeted media campaign was ineffective in improving FAS knowledge among the general population of African American women in Saint Louis; however, we did document that hearing our prevention message at least ten times did produce the change in knowledge we were hoping to produce in our target population. Future targeted media campaigns directed to at-risk groups should ensure high frequency of message penetration.

Maternal prenatal alcohol use is one of the leading preventable causes of birth defects and developmental disabilities. On the severe end of the spectrum of conditions related to drinking during pregnancy is fetal alcohol syndrome (FAS). Physicians and other health practitioners play a critical role in diagnosing FAS and in screening women of childbearing age for alcohol use during pregnancy. The Fetal Alcohol Syndrome Prevention Team at CDC's National Center on Birth Defects and Developmental Disabilities awarded funds to four medical school partners (Meharry and Morehouse Medical Colleges, St. Louis University, the University of Medicine and Dentistry of New Jersey, and the University of California at Los Angeles) to develop FAS regional training centers (RTCs). The RTCs are developing, implementing, evaluating, and disseminating educational curricula for medical and allied health students and practitioners that incorporate evidence-based diagnostic guidelines for FAS and other prenatal alcohol-related disorders.

Neutrality is the therapeutic stance of choice not only in family therapy but in family medicine as well (13). Neutrality allows the facts of the patient's condition and system to be accurately determined, encourages the easy negotiation of therapeutic goals and plans with the patient, and, probably most importantly, allows for the changing of tactics if feedback suggests that the current plan will not achieve the desired results. In short, neutrality encourages the free flow of the clinical management process as described by Taylor, Gordon, and Ashworth (16). Unfortunately, there are many threats to neutrality. One threat, and the subject of this paper, is the physician's own family-of-origin experience. Bowen was the first to describe how this past experience can lead to loss of objectivity in the therapeutic relationship (3, 4). His work has subsequently been expanded upon by others (10, 17), but his theory still predominates in the family-of-origin field. Bowen's theory states that a person's ability to maintain his objectivity, and thus his ability to act consistently with the therapeutic goals in any given emotionally charged, provider-patient relationship, is dependent on how well he or she was able to differentiate, or become a "self," in his or her family of origin. The more differentiated the therapist is, the less he or she "fuses" with or becomes a part of the patient's system. As the patient's system, especially his or her family, is often

Background Conduct a comprehensive survey of FASD knowledge, skill, and attitudes regarding recognition, diagnosis, treatment, and prevention among family physicians in the Midwest. Methods A 35 question survey on FASD recognition, diagnosis, treatment, and prevention was sent to a random sample of 1,000 active members of the AAFP from Missouri and the 5 surrounding states. Results Twelve percent of participants returned surveys. The mean age was 44 years, 64% were male, 86.3% were Caucasian, and 43.6% were from rural areas. The survey revealed that the great majority of family physicians possess general knowledge about FAS and the effects of alcohol on children, including the importance of early diagnosis and reducing secondary disabilities. However, the survey revealed significant deficits when it came to recognition and diagnosis of FAS, with the great majority of family physicians uncertain about the facial dysmorphology features associated with FAS. In addition, the majority had not made or referred a child for the diagnosis of FAS during the past year, and if they had made the diagnosis, they had not used an evidence-based protocol to do so. Significant barriers to making the diagnosis of FAS were identified, including inadequate training and the belief that better qualified specialists were available to make the diagnosis. Regarding treatment, a significant majority of family physicians had not received any clinical training in the care of children with FAS, and those who had received training felt it was only of fair quality. Regarding prevention, only 12.8% of family physicians asked when seeing a new pediatric patient if the child was exposed to alcohol in utero. Finally, many family physicians reported that education materials on FASD were not available in their area, and many believed the presence of these educational resources would be extremely helpful if they were available. Conclusions While family physicians possess a general knowledge base about FAS, FASD, and alcohol use during pregnancy, significant knowledge deficits exist in the area of prevention, diagnosis, and treatment, and significant barriers make completion of these tasks difficult in practice. Inadequate clinical training in medical school, residency, and continuing education venues may be a prime reason why these deficits occurred.