District Wellness Policy Nutrition Standards Are Associated with Healthier District Food Procurement Practices in the United States

Food procurement policies often exist to require that schools purchase foods with specific nutrient standards. Such policies are increasingly being used with the hope of improving access to healthier foods and beverages. Local wellness policies, required in any school district that participates in Federal Child Nutrition Programs, often contain specific nutrition standards that detail what can be sold to students during the school day. This study investigated the extent to which nutrition standards in wellness policies may be associated with healthier nutrition standards in district-level purchasing specifications. Cross-sectional data from the 2014–2015 school year for 490 school food authorities from 46 states and the District of Columbia were collected as part of the School Nutrition and Meal Cost Study and the National Wellness Policy Study. Survey-adjusted multivariable logistic regression models were computed to examine the association between district wellness policy nutrition standards and corresponding district food purchasing specifications. Results show that having a district wellness policy with corresponding nutrition standards and being in a rural area were associated with district food purchasing specifications for specific nutrients. These findings contribute to the literature to suggest that having a wellness policy with detailed nutrition standards may help to increase access to healthier foods and beverages.     

Rehabilitation of Patients with Extended Facial and Craniofacial Resection

Surgery of benign and malignant disease of the nose and sinuses can result in disfigurement and disability. Many patients have speech, mastication, and swallowing problems, anosmia, and pain. If the orbit is retained, visual loss, dystopia, diplopia, and epiphora can occur. This study reviews the senior author's experience with 34 patients over the last 18 years. Group and case analyses demonstrate that in patients with cancer, the eye can be preserved if one anatomical boundary is retained beyond a negative frozen section margin. Dystopia can be prevented by reconstruction of the floor with skin and fascial grafts or flaps. Epiphora can be reduced by repair of the medial canthus and dacryocystorhinostomy. Evidence is presented for prosthetic management of speech and swallowing and restoration of cheek contour. Case examples are used to illustrate the surgical techniques.     

Budget- and Priority-Setting Criteria at State Health Agencies in Times of Austerity: A Mixed-Methods Study

Objectives. We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity.Methods. We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate).Results. Respondents identified 5 key criteria: whether a program was viewed as “mission critical,” the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed.Conclusions. We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.The governmental public health enterprise continues to face myriad financial and other challenges, including eroding infrastructure, lack of political support, and increasing health problems associated with behavioral health. Since the 2008 economic downturn, thousands of public health jobs have been eliminated, growth has been stifled, and the public health workforce has continued to shrink because of attrition and retirement.1,2 During times of scarcity, the means of allocating resources is of particular interest and importance. However, the characterization and study of resource allocation decision-making is more common in health care compared with public health, where knowledge is limited, especially among national health care systems in developed nations.3–8 Globally, there is a growing interest in the systematic setting of priorities in health care and public health in developing countries, where funds are in shorter supply.4,9–18 A much greater proportion of total health dollars in the United States are spent on health care compared with public health, which is about 3% of total health spending by some estimates.19 This emphasis on spending for health care has created a dearth in research on setting of priorities and budgets in public health; we are not aware of any studies that have examined criteria use in public health priority setting at state health agencies (SHAs), although a few have examined priority setting in local health departments (LHDs). Two studies in particular indicated that the most important priority-setting criteria employed in LHDs were funding availability, mandates, being the sole provider, the size and scope of consequences, politics, and public interest or acceptability.20,21 In 2011, the Association of State and Territorial Health Officials (ASTHO) released their Profile of State Public Health, Volume 2, providing the first collection of revenue and expenditure data that allowed for meaningful comparisons of public health spending across SHAs. These were the first data available in recent years regarding actual spending by SHAs, but these data sets did not capture processes: how SHAs set budgets and why they give priority to the areas they do. We focused on 1 particular component of the priority-setting process—criteria use—because of the critical role criteria were found to play in setting budgets and priorities more broadly in the course of this study, and as reported elsewhere.22     

Association between Nutrition Policies and Student Body Mass Index

In response to concerns about childhood obesity, many US states have implemented policies to limit the sale of unhealthy foods and beverages (e.g., snacks, desserts, and sugary drinks) sold in competition with school meal programs (i.e., competitive foods) in order to improve the nutritional environment of schools and support student health. This study measured state-level competitive food and beverage policies that require foods and beverages sold in à la carte lines, vending machines, and school stores to meet strong nutrition standards and tested the hypothesis that students living in states with stronger laws would have lower body mass index (BMI)-for-age percentiles. BMI data from a national sample of 1625 students attending 284 schools from the School Nutrition and Meal Cost Study were linked to state laws coded as part of the National Wellness Policy Study. A survey-adjusted linear regression model accounting for student and school-level characteristics showed that stronger state nutrition policies were associated with lower student BMI scores (coefficient: −0.06, 95% CI: −0.12, −0.00). Additional models indicated that stronger state policies were significantly associated with fewer unhealthy foods and beverages available in schools. These findings suggest that strong regulations on competitive foods and beverages may lead to improvements in the nutritional quality of the school environment and student BMI. Thus, current federal standards regulating snacks in US schools (i.e., Smart Snacks) are an important element of a comprehensive strategy to improve the school nutrition environment and reduce rates of childhood obesity.