00067613392Dev Med Child NeurolDev Med Child NeurolDevelopmental medicine and child neurology0012-16221469-874922937873446752310.1111/j.1469-8749.2012.04402.xHHSPA698893ArticleHealth risk behaviors among young adults with spina bifidaSoeMinn M1SwansonMark E1BolenJulie C1ThibadeauJudy K1JohnsonNatalie2Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GAUniversity of Tennessee Chattanooga/Erlanger Baroness Hospital, Chattanooga, TN, USACorrespondence to Dr Minn M. Soe at Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop A24, 1600 Clifton Road NE, Atlanta, GA 30333. msoe@cdc.gov116201503920121120121562015541110571064© 2012 Mac Keith Press2012AIM

Persons with spina bifida who adopt unhealthy lifestyles could be at increased risk of adverse health outcomes because the presence of spina bifida may magnify this risk. We estimated overall and age-specific prevalence of selected health risk behaviors (HRBs) in young people with spina bifida and examined the association between HRBs and depression.

METHOD

We performed analyses on data obtained from individuals with spina bifida (n=130; mean age 23y SD 4y 5mo; 64 males, 66 females; 64% lumbosacral lesion; 77% with shunt) who participated in a population-based survey conducted by the Arkansas Spinal Cord Commission in 2005.

RESULTS

Compared with national estimates, young people with spina bifida tend to eat less healthy diets, do less exercise, and engage inmore sedentary activities. Respondents were less likely to use substances (alcohol, tobacco, illegal drugs), which peaked among 25 to 31 year olds. About 90% saw a doctor in the previous year. Nearly one half reported mild or major depressive symptoms. In the logistic regression analysis after controlling for potential confounders (age, sex, ethnic group, education, employment, marital status, living arrangement, level of lesion, presence of shunt, mobility, self-rated health and healthcare utilization), major depressive symptoms were associated with current alcohol drinking (adjusted odds ratio: 4.74; 95% CI 1.18–19.04).

INTERPRETATION

Young adults with spina bifida exhibit unhealthy behaviors that continue into their late 20s. The findings highlight the need to increase awareness of their health risk profiles in the spina bifida community and show opportunities for mental health and health risk screening and counseling by healthcare providers.

Individuals with spina bifida live longer now than ever before because of advances in medical science1 and at least 75% of children born with a spina bifida can be expected to reach early adulthood.2 The growth of this adult population has stimulated interest in their health and well-being1 but we know relatively little about their health risk behaviors (HRBs) and emotional wellbeing.3 Recent studies suggest that adolescents with a chronic condition are as likely or more likely to engage in risky behaviors than their healthy peers.46 Persons with spina bifida who adopt unhealthy lifestyles could be at increased risk of adverse health outcomes because the presence of spina bifida may magnify this risk.4

Despite the growing body of literature on health and risky behaviors among adolescents, relevant research among young adults has received less attention. The contextual influences that shape risky behaviors, health outcomes and access to healthcare generally change at the transitional period of young adulthood during which young adults fare worse than adolescents in many areas such as injury and substance use.7 Better understanding of how health and risky behaviors change with age has important ramifications for the timely delivery of age-appropriate services.

Studies on adolescents show that anxiety and depressive disorders are associated with risky behaviors.8,9 Since young persons with spina bifida are at greater risk of depressed mood, low self-worth and suicidal ideation when compared with comparison individuals who are able-bodied,10 exploring the relationship between depression and HRBs may highlight the need for more intentional screening and monitoring of mental health and HRBs.

A few studies that focused on unhealthy lifestyles among individuals with developmental disabilities have reported that adolescents with developmental disabilities including spina bifida11 and young adults with developmental disabilities such as cerebral palsy and mental retardation*12 are more likely to engage in sedentary lifestyles and poor diets and less likely to drink alcohol, use illicit drugs or smoke when compared with peers without developmental disabilities. Although some studies have addressed perceived health or health-related quality of life among young adults with spina bifida,13 there are no population-based studies that examine HRBs in this group. Therefore, our study had three objectives: (1) to estimate the prevalence of certain HRBs among young adults with spina bifida; (2) to characterize the distributions of HRBs by age and compare them with similar aged adults from the general population; and (3) to examine the association between HRBs and depression.

METHODParticipants

The data for current analyses were obtained from a 2005 statewide survey conducted by the Arkansas Spinal Cord Commission (ASCC) to assess the development of secondary conditions among young individuals with spina bifida. With funding from the Centers for Disease Control and Prevention, the survey was targeted at individuals aged 12 to 31 years with spina bifida who were registered in the ASCC registry. The questionnaire was developed at the University of Arkansas for Medical Sciences (UAMS) and ethical approval for the study was obtained from its institutional review board. Trained case managers conducted face-to-face interviews at the home of individuals with spina bifida. After the interview, those aged 16 years or older were also asked privately to complete a self-administered supplemental questionnaire on substance use and sexual behaviors. Written informed consent was collected from all participants aged 18 years or older. For individuals under 18 years of age, parental consent and participant’s assent were obtained. Given that the current study involved substance abuse, the analyses were restricted to individuals aged 16 years or older.

Variables

Sociodemographic characteristics analyzed were age, sex, race, education, employment, marital status, and living arrangement (Table I). Health-related conditions comprised level of lesion, history of shunt, mobility, bowel and urinary incontinence, depression and health self-rating.

Symptoms of depression were assessed and scored using a 20-item questionnaire of the Center for Epidemiological Studies Depression Scale (CES-D).14 CES-D scores of 16 to 26 are considered indicative of experiencing mild depressive symptoms and scores of 27 or more indicate major depressive symptoms.15 We obtained a Cronbach’s alpha coefficient of 0.88, indicating a good internal consistency of the scale.

Health-related behaviors were selected among the Leading Health Indicators for Healthy People 2020:16 physical activity (exercise, watching television); dietary habits; substance abuse (cigarette smoking, alcohol drinking, illegal drug use), and healthcare utilization (Table II). Appendix A shows the questions related to these behaviors from the 2005 ASCC survey and describes how the responses were categorized to identify HRBs.

Statistical analysis

We estimated the overall prevalence of each HRB and characterized its age distribution. We examined the trends of prevalence of individual HRBs across age groups by the Cochran–Armitage test. We also compared the prevalence of HRBs among respondents with national estimates for peers in the general population obtained from the 2005 Behavioral Risk Factor Surveillance System Survey,17 the 2005 Youth Risk Behavior Surveillance – United States,18 and the 2005 National Survey on Drug Use and Health: national findings19 using the χ2 goodness-of-fit test. We conducted multivariable logistic regression to model HRBs by age after adjusting for covariates that were differentially distributed among age groups. The logistic model parameter represents an odds ratio, which is an approximation to the relative risk under rare disease assumption.20 Separate logistic regression models were run to examine the association between depression and individual HRBs, controlling for potential confounders (age, sex, ethnic group, education, employment, marital status, living arrangement, level of lesion, presence of shunt, mobility, self-rated health and healthcare utilization) that are associated with depression and HRBs found in the literature. We conducted regression diagnostics to check for model fitness and multi-collinearity between independent variables. We used SAS statistical software (version 9.3; SAS Institute, Cary, North Carolina, USA) for all analyses. Statistical significance was assessed at the p<0.05 level and all tests were two-sided.

RESULTS

A total of 153 individuals with spina bifida aged 12 to 31 years participated in the face-to-face interviews, a completion rate of 75% (10% refused the interview, 8% were unreachable, 5% had severe cognitive limitations21 and 2% were deceased). For the current study, we focused on 130 individuals (64 males, 66 females) who were 16 years or older and completed the supplemental questionnaire on substance abuse. To validate the population-based nature of our sample, we applied a previously estimated crude prevalence of spina bifida (3.07 per 10 000 population aged 0–19y; 95% CI 2.96–3.17)22 to the 2005 population of Arkansas aged 15 to 29 years (n=590 333). The expected number of people with spina bifida aged 15 to 29 years in 2005 was 181 (95% CI 174–187), which was comparable with the number in our overall sample plus non-respondents. The mean age of the participants was 23 years (SD 4y 5mo). The demographic characteristics and health-related conditions of participants are presented in Table I. The distributions of participants by these characteristics did not differ significantly among three age groups (16–19y, 20–24y, 25–31y), except for marital status, living arrangement, bowel incontinence and history of shunt surgery (p<0.05). There were no sex differences in the distributions of HRBs (data not shown).

Physical activity and diet

A majority of respondents reported neither eating healthy food regularly nor engaging in regular physical activity but reported watching television for 3 or more hours/day, independent of age (Table II). The prevalence of self-reported overweight increased significantly with age. Young adults in their late 20s were three times as likely to report being overweight as those in their late teens in multivariable analysis.

Substance abuse

Among respondents, cigarette smoking (28%) and alcohol drinking (28%) were more frequently reported than behaviors such as binge drinking (15%) and lifetime illegal drug use (18%). Among illegal drug users, marijuana, pain pills (aspirin, acetaminophen [paracetamol], hydrocodone, oxycodone) and anti-anxiety drugs (alprazolam) were most frequently reported. Substance abuse (alcohol/tobacco/illegal drug use) was highest among respondents aged 25 to 31 years. The prevalence of current alcohol drinking and history of illegal drug use increased significantly with age. After controlling for confounders, the odds of reporting illicit drug use among respondents in their late 20s were nearly 10 times that among those in their late teens.

Depression and self-rated health

About half of the respondents experienced mild or major depressive symptoms (Table I), with no significant change across age groups. Self-rated poor health started high in late teen years (20% reported fair–poor health) and continued to climb through young adulthood (32% reported fair–poor health) although the trend was not statistically significant. Multivariable logistic regression showed that individuals with major depressive symptoms were 4.7 times as likely to report drinking alcohol as individuals without major depressive symptoms (Table III). No other independent factors in the same model were associated with alcohol abuse except level of education where those with education level of high school or less were less likely to drink alcohol than those with education greater than high school.

Comparison of HRBs and depression among respondents with the general population

About 22% of 18 to 24 year olds in the 2005 Arkansas general population did not exercise during the past month17 compared with 74%of respondents who did not engage in regular physical activity (p<0.001). The proportion of respondents who reported not eating whole grains/fruits/vegetables regularly was 75% compared with 12% among 18 to 24 year olds from the general population who did not consume at least a daily serving of fruits/vegetables17 (p<0.001). About 83% of late teen respondents watched television for 3 or more hour/day compared with 39% among Arkansas high school students18 (p<0.001). Overall and age-specific, the prevalence of substance abuse among participants was lower than that reported for the USA general population.19 The prevalence of past month alcohol drinking among respondents (28%) was lower than the national estimate for 16 to 29 year olds (57%) (p<0.001). The prevalence of past month tobacco smoking among respondents (28%) was lower than the national estimate for 16 to 29 year olds (35%) (p=0.08). Similarly, lifetime marijuana use (3%) was lower among late adolescence respondents than the national estimate for early adolescence 12 to 17 year olds (17%) (p=0.02). The prevalence of depressive symptoms among respondents (48%) was higher than the national estimate of current depression (within 2wks preceding the survey) among 18 to 34 year olds in the general population (10%)19 (p<0.01).

DISCUSSION

Our study is the first population-based study to examine HRBs among young adults with spina bifida. We observed that a significant proportion of young adults with spina bifida have led unhealthy lifestyles and engaged in one or more risky behaviors. Alcohol abuse was positively associated with major depression. Depression and low self-rated health were highly prevalent. Compared with similar aged adults in the general population, young people with spina bifida tend to eat less healthy diets, do less exercise and engage more in sedentary activities. Also, young people with spina bifida were less likely to abuse tobacco, alcohol and illicit drugs, and when they did, it was at later ages. Nearly 90% of the study participants saw a doctor in the past year indicating a greater opportunity for screening and monitoring of mental health and HRBs. Webb23 has pointed out that the general healthcare needs of adults with spina bifida (including health risk screening and counseling) are sometimes overlooked because so much emphasis is placed on spina bifida specific care.

That significant proportions of respondents were not engaged in any form of regular physical activity and spend time in sedentary activity may indicate challenges being encountered by young people with spina bifida for access to physical and leisure activities. These challenges may include the lack of facilities adaptive for physical activities of the spina bifida population, transportation issues accessing available facilities and difficulties obtaining personal assistance to engage in these activities.11,24 Attitudinal and motivational factors25 and medical contraindications may also play a role in the lack of physical activity. Our observation of poor dietary habits among respondents is consistent with a Canadian study of adolescents with physical disabilities that reported a lower likelihood of eating fresh produce but a higher likelihood of eating high-fat foods in comparison with a national sample.11 Poor dietary habits and low levels of regular physical activity may partly explain high prevalence of being overweight reported by respondents. These observations are important because limited physical activity and poor dietary habits, which cause obesity, are modifiable and obesity can be reduced, if not entirely prevented.26 Part of good childcare should include early efforts with family engagement to encourage physical activity and healthy eating to prevent obesity in this population.

The observation of overall and age-specific prevalence of substance abuse among respondents which was lower than national estimates19 is in agreement with other studies.11,12 The low level of engagement of smoking, alcohol and illicit drugs among individuals with spina bifida may be partially explained by the high level of parental/family supervision in their social activities27 and/or lack of opportunity resulting from mobility and financial constraints on exposure to the social environment that could potentially influence negative behaviors.11,12 Although the prevalence of substance abuse among individuals with spina bifida may be low, that participants with major depression were more likely to drink alcohol is a cause for concern because it can lead to worsening of adverse health and social outcomes. Previous studies among young people in the general population have shown that substance use and risky sexual behaviors are often associated with anxiety and depressive disorders.8,9 As nearly half of young respondents were experiencing depression comparable with other clinic- or community-based studies,10,28 screening and counseling on both mental health disorders and substance abuse should be a priority for healthcare providers in both primary and specialty care settings.

It is noteworthy that the mode of substance abuse was highest among individuals with spina bifida in their late 20s, though only illegal drug abuse and alcohol drinking showed significant positive trends possibly because of the limited sample size. By contrast, the risk profile among the general population shows a peak in the early 20s.7 Young individuals with spina bifida may be experiencing an especially prolonged transition to adult roles and responsibilities with diminished parental supervision and the weakening of the safety net that normally supports adolescents and younger children such as school and quality healthcare, which are important contextual factors associated with unhealthy living and risky behaviors.7 Though adolescents with spina bifida are capable of high levels of independent functioning across multiple domains, they are at risk of delays in development of self-management and independence,29 and are therefore less likely to move into marriage, parenthood and employment at the same rates or age as typical young adults. This was reflected in our study where the majority of respondents in their late 20s was not employed (69%), remained unmarried (88%) and still lived with families for their assistance (43%).

Overall delays in social maturation and independence and the lack of traditional supportive systems may explain the late onset of substance abuse among young adults with spina bifida. As with the general population,8,9 the presence of poor health and depression also add to the risk of substance abuse. The loss of the traditional supports of education and child-specific healthcare,7 plus the ambivalence of being dependent on family,30 puts the young adult with spina bifida in a vulnerable position. Feeling less powerful in mastering one’s life and feeling less healthy may magnify depression and threaten the development of independence and self-management of health. Health status is already compromised and slowly starts to decline (data not shown) with accumulation of physical symptoms over time. This may lead to a fatalistic life view5 which could be reflected in unhealthy behaviors such as tobacco, drug and alcohol abuse among respondents in their late 20s. Declining health status may also decrease motivation to seek out intimate relationships like marriage. This health status, along with loss of public insurance, transportation challenges and depressive symptoms, may also limit the pursuit of regular employment. To counteract these trends, interventions such as peer support, group counseling and specific skills training may be necessary to help young adults with spina bifida to maintain a more positive and hopeful outlook. Ongoing healthcare is also needed to monitor for specific organ-system progression (e.g. renal function, shoulder girdle overuse).

The strength of our study is that it is based on a statewide population with spina bifida rather than a clinic sample and that it has valuable information to examine unhealthy lifestyles among young adults with spina bifida in their late teens and 20s. However, it has certain limitations. First, the study was cross-sectional and causality could not be assessed. Second, since the ASCC state-based registry is service-oriented, there may be individuals who remained unregistered, although we believe most young people with spina bifida were captured by the system, based on our calculation of the expected number of individuals with spina bifida in Arkansas. Even among those registered, 25% did not complete the interview for a number of reasons. Third, a direct comparison group of healthy peers was not feasible because the sample was obtained from a spinal cord disability registry. Fourth, in addition to recall bias, self-reporting of conditions may change over time because of the maturity of those reporting, e.g. 28-year-olds may report their weight more accurately or honestly than 17-year-olds. Fifth, the sensitive nature of questions such as illicit drug abuse may underestimate usage. Sixth, due to survey exclusion criteria, the results may not be generalizable to those with spina bifida who have a severe cognitive limitation. Lastly, since this supplementary study on HRBs was part of a large survey, only a limited number of questions on HRBs were asked. For example, a distinction between experimental versus habitual abuse of substances was not made. A larger population-based study more focused on HRBs and predisposing psychosocial and environmental factors, could answer these additional questions.

In summary, a notable proportion of young individuals with spina bifida exhibit unhealthy behaviors that continue into their late 20s. To promote healthy behaviors and quality of life in this population, it is necessary to increase awareness of their health risk profile among people with spina bifida and their caregivers. Although substance use is less common than expected for their age among young people with spina bifida, the presence of low self-rated health, depression and its relationship with certain HRBs warrants continued monitoring of physical and mental health by healthcare providers. Discussions should also begin during childhood with a focus on helping the child work toward mastering a fully independent life such as educational and vocational achievement, independent living, healthy lifestyle choices and social participation. Finally, promoting access to accommodative social support and preventive services would increase the chances of successful adult living for individuals with spina bifida.

UK usage: learning disability

ACKNOWLEDGEMENTS

We thank Drs Michael Fox and Rodolfo Valdez for their reviews of this manuscript and the staff of the Arkansas Spinal Cord Commission (ASCC) and the University of Arkansas for Medical Sciences (UAMS) for their devoted engagement in the development and design of the survey, data collection and data management. We also extend our gratitude to the participants with spina bifida and their families whose selfless participation in this project made the current analysis possible. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

ABBREVIATIONHRB

Health risk behavior

REFERENCESDiciannoBEKurowskiBGYangJMJRehabilitation and medical management of the adult with spina bifidaAm J Phys Med Rehabil20088710261050BowmanRMMcLoneDGGrantJATomitaTItoJASpina bifida outcome: a 25-year prospectivePediatr Neurosurg20013411412011359098SawyerSMMacneeSTransition to adult health care for adolescents with spina bifida: research issuesDev Disabil Res Rev201016606520419772SawyerSMDrewSYeoMSBrittoMTAdolescents with a chronic condition: challenges living, challenges treatingLancet20073691481148917467519SurisJCMichaudPAAkreCSawyerSMHealth risk behaviors in adolescents with chronic conditionsPediatrics2008122e1113e111818977960SurisJCPareraNSex, drugs and chronic illness: health behaviours among chronically ill youthEur J Public Health20051548448816162596ParkMJPaulMulye TAdamsSHBrindisCDIrwinCEThe health status of young adults in the United StatesJ Adolesc Health20063930531716919791HaarasiltaLMMarttunenMJKaprioJAAroHMCorrelates of depression in a representative nationwide sample of adolescents (15–19 years) and young adults (20–24 years)Eur J Public Health20041428028515369034HallforsDDWallerMWFordCAHalpernCTBrodishPHIritaniBAdolescent depression and suicide risk: association with sex and drug behaviorAm J Prev Med20042722423115450635AppletonPLEllisNCMinchomPELawsonVBöllVJonesPDepressive symptoms and self-concept in young people with spina bifidaJ Pediatr Psychol1997227077229383931SteeleCAKalninsIVRossenBEBiggarDWBortolussiJAJutaiJWAge-related health risk behaviors of adolescents with physical disabilitiesSoz Praventivmed20044913214115150865RurangirwaJVan Naarden BraunKSchendelDYeargin-AllsoppMHealthy behaviors and lifestyles in young adults with a history of developmental disabilitiesRes Dev Disabil20062738139916051462VerhoefMPostMWBarfHAvan AsbeckFWGooskensRPrevoAJPerceived health in young adults with spina bifidaDev Med Child Neurol20074919219717355475RadloffLSThe use of the center for epidemiologic studies depression scale in adolescents and young-adultsJ Youth Adolesc19912014916624265004ZichJMAttkissonCCGreenfieldTKScreening for depression in primary care clinics: the CES-D and the BDIInt J Psychiatr Med199020259277Leading Health Indicators for Healthy People 2020Letter reportWashington, DCInstitute of Medicine of the National Academiesaccessed 1 May 2012[Internet] Available from http://www.iom.edu/~/media/Files/Report%20Files/2011/Leading-Health-Indicators-for-Healthy-People-2020/Leading%20Health%-20Indicators%202011%20Report%20Brief.pdf2005 Behavioral Risk Factor Surveillance System SurveyAtlanta, GACenters for Disease Control and Preventionaccessed 1 May 2012[Internet] Available from http://www.cdc.gov/brfss/technical_infodata/surveydata/2005.htmYouth Risk Behavior Surveillance – United States, 2005Atlanta, GACenters for Disease Control and Preventionaccessed 1 May 2012[Internet] Available from http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdfSubstance Abuse and Mental Health Services AdministrationResults from the 2005 National Survey on Drug Use and Health: national findingsWashington, DCUS Department of Health & Human Services, Office of Applied Studiesaccessed 1 May 2012[Internet] Available from http://oas.samhsa.gov/nsduh/2k5nsduh/2k5results.htmRothmanKJGreenlandSRothmanKJGreenlandSMeasures of effect and measures of associationModern Epidemiology19982nd edn.Philadelphia, PALippincott–Raven Publishers50KatzmanRBrownTFuldPPeckASchechterRSchimmelHValidation of a short orientation-memory-concentration test of cognitive impairmentAm J Psychiatry19831407347396846631ShinMBesserLMSiffelCPrevalence of spina bifida among children and adolescents in 10 regions in the United StatesPediatrics201012627427920624803WebbTSMedical care of adults with spina bifidaJ Pediatr Rehabil Med2009231121791790RimmerJHRileyBWangERauworthAJurkowskiJPhysical activity participation among persons with disabilities: barriers and facilitatorsAm J Prev Med20042641942515165658BuffartLMWestendorpTvan den Berg-EmonsRJStamHJRoebroeckMEPerceived barriers to and facilitators of physical activity in young adults with childhood-onset physical disabilitiesJ Rehabil Med20094188188519841838SimeonssonRJMcMillenJSHuntingtonGSSecondary conditions in children with disabitities: Spina bifida as a case exampleMent Retard Dev Disabil Res Rev2002819820512216064MargalitMLeisure activities of cerebral-palsied childrenIsr J Psychiatry Relat Sci1981182092147333797BellinMHZabelTADiciannoBECorrelates of depressive and anxiety symptoms in young adults with spina bifidaJ Pediatr Psychol20103577878919880443BuranCFSawinKJBreiTJFastenauPSAdolescents with myelomeningocele: activities, beliefs, expectations, and perceptionsDev Med Child Neurol20044624425215077702HolmbeckGNDevineKAPsychosocial and family functioning in spina bifidaDev Disabil Res Rev201016404620419770APPENDIX-A: The 2005 Arkansas Spinal Cord Commission survey questions

Health risk factorQuestionnaire itemResponse in questionnaireHealth risk behaviorResponse category
Healthcare utilizationWhen was the last time you were seen by your doctor?

Less than a month ago

Between 1mo and 1y ago

More than 1y but <2y ago

More than 2y but <3y ago

More than 3y ago

Not seen a doctor in the past yearYes=response 3–5No=response 1–2
Physical activityDuring the past 30d, did you exercise to lose weight or to keep from gaining weight?

Yes

No

No exercise in the past monthYes= response 0No= response 1
Do stretching exercises at least 3 times a week

Never

Sometimes

Often

Regularly

No stretching exerciseYes=response 1–2No=response 3–4
Exercise for about 20 min at least 3 times a week

Never

Sometimes

Often

Regularly

No exercise for 20minutesYes=response 1–2No=response 3–4
Do supervised exercise (like going to gym, physical education or fitness class)

Never

Sometimes

Often

Regularly

No supervised exerciseYes=response 1–2No=response 3–4
Do fun physical activities (like walking, swimming, rolling, wheelchair sports)

Never

Sometimes

Often

Regularly

No fun physical activityYes=response 1–2No=response 3–4
On an average day, how many total hours do you watch TV, play video games, or use the computer?

I do not watch television, play video games, or use the computer

<1h per day

1h per day

2h per day

3h per day

4h per day

5 or more hour per day

Watch television ≥3hYes=response 5–7No=response 1–4
Dietary habitsInclude whole grains, raw fruits, and raw vegetables in my diet

Never

Sometimes

Often

Regularly

Not eating grain/fruit/vegetables regularlyYes=response 1–2No=response 3–4
Eat a lot of different healthy foods every day

Never

Sometimes

Often

Regularly

Not eating healthy food regularlyYes=response 1–2No=response 3–4
Substance abuse
SmokingDuring the past 30d, on how many days did you smoke cigarettes?

0d

1 or 2d

3–5d

6–9d

10–19d

20–29d

All 30d

Current cigarettes smokerYes=response 2–7No=response 1
Alcohol abuseDuring the past 30d, on how many days did you have at least one drink of alcohol?

0d

1 or 2d

3–5d

6–9d

10–19d

20–29d

All 30d

Current alcohol drinkerYes=response 2–7No=response 1
Binge drinkingDuring the past 30d, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?

0 d

1 or 2d

3–5d

6–9d

10–19d

20–29d

All 30d

Current binge drinkerYes=response 2–7No=response 1
Illicit drugHave you ever used illegal drugs?

Yes

No

Ever use of illicit drugYes= response 1No = response 0
Other analysis variable
  General healthHow do you describe your health in general?

Excellent

Very good

Good

Fair

Poor

Poor/fair healthYes= response 4–5No= response 1–3
  Self-reported overweightHow do you describe your weight?

Very underweight

Slightly underweight

About the right weight

Slightly overweight

Very overweight

OverweightYes=response 4–5No=response 1–3

In the article by van der Slot et al.1 the authors wish to point out that there was an error in Table III. The p value for Depressive symptoms (CES–D≥16) should read 0.008.

van der SlotWMANieuwenhuijsenCvan den Berg-EmonsRJGChronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsyDev Med Child Neurol20125483684222809436

Characteristics of young adults with spina bifida in Arkansas in 2005 (n=130)

Characteristicn (%)a
Age at interview (y)
  16–1935 (27)
  20–2438 (29)
  25–3157 (44)
Sex
  Male64 (49)
  Female66 (51)
Ethnic group
  White non-Hispanic104 (80)
  Black non-Hispanic21 (16)
  Other4 (3)
Highest level of education
  High school/general education development or lessb103 (79)
  Greater than high school26 (20)
Employment
  Competitive21 (16)
  Non-competitive17 (13)
  No job89 (69)
Marital status
  Married/co-inhabiting with a partner14 (11)
  Divorced/separated2 (2)
  Single112 (88)
Living arrangement
  Living with family with the need of family assistance56 (43)
  Living independently in family house with minimal assistance31 (24)
  Not living with family41 (32)
Level of lesion
  Thoracic47 (36)
  Lumbar71 (55)
  Sacral12 (9)
Ambulatory status
  Non-ambulatory (full-time wheelchair use)62 (48)
  Ambulatory63 (49)
Bowel incontinencec
  Frequently39 (30)
  Occasionally29 (22)
  Rare or none59 (45)
Urinary incontinenced
  Frequently44 (34)
  Occasionally29 (22)
  Rare or none54 (42)
Shunt surgery
  No shunt27 (21)
  Shunt with no history of revision20 (15)
  Shunt with history of revision80 (62)
Depressive symptomse62 (48)
  Normal (CES-D score <16)66 (52)
  Mild (CES-D score 16–26)40 (31)
  Major (CES-D score >26)22 (17)
Self-rating of general health
  Good/very good94 (72)
  Poor/fair36 (28)

Percentage may not add up to 100%due to missing values.

Only 3 stated middle school as highest level of education.

Categorized as frequently (usually daily, 3–4 times per week, 1–2 times per week), occasionally (3–4 times per month, 1–2 times per month), rare/none (less than once per month, 3–4 times per year, none).

Categorized as rare/none (rarely or never, dampness in underwear [<1/month]), occasionally (only at night, <1/week), frequently (at least 1/week, daily).

Quantified by the Center for Epidemiological Studies Depression (CES-D) scale (CES-D score ≥16 means presence of depressive symptoms).14

Overall and age-specific prevalence of health risk behaviors and multivariable analysis among young adults with spina bifida in Arkansas in 2005

Bivariate analysisLogistic regressiona


Health risk behaviorTotal P (%)16–19y20–24y25–31yTrendb p value20–24y25–31y





n P(%)n P(%)n P(%)aOR (95% CI)aOR (95% CI)
Physical activity and diet
  No exercise in the past 30d96 (74)27 (77)27 (71)42 (75)0.880.9 (0.3–2.8)1.0 (0.3–3.2)
  No stretching exercises for 3 times/week105 (81)28 (80)33 (87)44 (80)0.911.4 (0.4–5.5)1.0 (0.3–3.4)
  No exercise for 20 min for 3 times/week105 (81)27 (79)33 (87)45 (80)0.981.3 (0.3–4.8)0.8 (0.2–2.8)
  No supervised exercise (at gym/fitness class)120 (92)32 (91)37 (100)51 (91)0.76n/an/a
  No fun physical activities (like walking, swimming, rolling)92 (71)23 (66)31 (82)38 (68)0.992.2 (0.7–7.0)1.2 (0.4–3.4)
  Did not eat whole grains/raw fruits/vegetables often/regularly97 (75)26 (74)27 (71)44 (80)0.480.7 (0.2–2.2)1.4 (0.4–4.5)
  Did not eat healthy food often/regularly97 (75)29 (83)26 (68)42 (75)0.490.4 (0.1–1.3)0.6 (0.2–1.9)
  Watched television ≥3h108 (83)29 (83)32 (84)47 (84)0.901.1 (0.3–4.3)1.4 (0.4–5.7)
Substance use
  Current alcohol drinking36 (28)5 (15)12 (32)19 (35)0.052.3 (0.6–8.5)1.7 (0.5–6.3)
  Current binge drinking19 (15)3 (10)4 (11)12 (22)0.090.6 (0.1–3.4)1.1 (0.2–5.7)
  Current cigarette smoking36 (28)6 (19)11 (30)19 (35)0.131.3 (0.4–4.7)1.1 (0.3–3.9)
  Lifetime illicit drug abuse23 (18)1 (3)7 (19)15 (28)<0.015.1 (0.6–47.6)9.8 (1.1–88.8)
Healthcare utilization
  Not seen a doctor in the past year14 (11)2 (6)5 (13)7 (13)0.601.4 (0.2–9.9)1.3 (0.2–8.9)
Other
  Self-reported overweight64 (49)11 (31)18 (47)35 (61)0.011.5 (0.5–4.4)3.1 (1.1–8.8)

Young adults in their late teens (aged 16–19y) were treated as the referent group, after controlling for marital status, living arrangement, bowel incontinence, and shunt surgery which were differentially distributed across three age groups.

Cochran–Armitage test for trend. P(%)=prevalence; aOR=adjusted odds ratio; n/a=not available due to quasi-complete separation of data points detected.

Bivariate and multivariable analysis to examine association between individual health risk behaviors and depressive symptoms among young adults with spina bifida in Arkansas in 2005

Bivariate analysisLogistic regressiona


Health risk behaviorNormalMinor depressionMajor depressionχ2 p valueMinor depressionMajor depression





n P(%)n P(%)n P(%)aOR (95% CI)aOR (95% CI)
Physical activity and diet
  No exercise in the past 30d49 (74)30 (75)17 (77)0.961.1 (0.4–3.0)0.7 (0.2–2.7)
  No stretching exercises for 3 times/week54 (82)31 (80)19 (86)0.801.1 (0.4–3.5)0.5 (0.1–2.6)
  No exercise for 20 min for 3 times/week55 (85)32 (80)17 (77)0.691.7 (0.5–5.5)1.4 (0.3–6.0)
  No supervised exercise (at gym/fitness class)62 (94)37 (95)20 (91)0.78bn/an/a
  No fun physical activities (like walking, swimming, rolling)45 (68)31 (78)15 (68)0.560.9 (0.3–2.5)0.9 (0.2–3.1)
  Did not eat whole grains/raw fruits/vegetables often/regularly51 (79)29 (73)16 (73)0.741.9 (0.7–5.6)1.6 (0.4–5.9)
  Did not eat healthy food often/regularly49 (74)33 (83)14 (64)0.260.5 (0.1–1.6)1.9 (0.5–7.3)
  Watched TV ≥3h54 (82)33 (83)20 (91)0.590.7 (0.2–2.3)2.8 (0.4–18.0)
Substance use
  Current alcohol drinking18 (28)8 (21)10 (48)0.081.3 (0.4–4.1)4.7 (1.2–19.0)
  Current binge drinking8 (13)5 (13)6 (29)0.191.9 (0.4–8.7)3.1 (0.6–15.4)
  Current cigarette smoking19 (29)7 (18)10 (48)0.060.4 (0.1–1.5)1.7 (0.4–6.5)
  Illicit drug ever used in lifetime12 (19)6 (15)5 (24)0.720.7 (0.2–2.8)1.2 (0.2–5.8)
Healthcare utilization
  Not seen a doctor in the past year7 (11)4 (11)2 (9)0.99bn/an/a

No depression/depressive symptoms’ was treated as the reference group, after controlling for sociodemographics (age at interview, sex, race/ethnicity, education level, marital status, living with family or not, employment), degree of spina bifida severity (level of lesion, presence of shunt, mobility), self-rated health and healthcare utilization that are potentially associated with depression and health risk behaviors in the literature.

p value from Fisher’s exact test. P(%)=prevalence; aOR=adjusted odds ratio; n/a=not available due to quasi-complete separation of data points detected.

What this paper adds

In young adults with spina bifida, substance use peaks in their late 20s.

Nearly half had mild or major depressive symptoms.

Nearly 90% had a doctor visit in the past year, offering opportunities for screening and counseling for health risk behaviors and depression.