Feasibility of conducting a randomized trial to promote healthy eating,active play and sustainability awareness in early childhood curricula

We sought to evaluate the feasibility of conducting a randomized trial to evaluate the efficacy of a preschool/kindergarten curriculum intervention designed to increase 4-year-old children's knowledge of healthy eating, active play and the sustainability consequences of their food and toy choices. Ninety intervention and 65 control parent/child dyads were recruited. We assessed the study feasibility by examining recruitment and participation, completion of data collection, realization of the intervention and early childhood educators’ experiences of implementing the study protocol; our findings suggest the intervention was feasible to deliver. In addition, children's sustainability awareness of non-compostable and recyclable items increased. Children in the intervention group significantly reduced their sugary drink consumption and increased their vegetable intake at follow-up compared to control. We conclude with recommendations for revisions to the child interview and parent questionnaire delivery to ensure the roll out of the randomized trial is conducted efficiently and rigorously.     

Unrelated Future Costs and Unrelated Future Benefits: Reflections on NICE Guide to the Methods of Technology Appraisal

In this editorial, we consider the vexing issue of ‘unrelated future costs’ (for example, the costs of caring for people with dementia or kidney failure after preventing their deaths from a heart attack). The National Institute of Health and Care Excellence (NICE) guidance is not to take such costs into account in technology appraisals. However, standard appraisal practice involves modelling the benefits of those unrelated technologies. We argue that there is a sound principled reason for including both the costs and benefits of unrelated care. Changing this practice would have material consequences for decisions about reimbursing particular technologies, and we urge future research to understand this better. Copyright © 2016 John Wiley & Sons, Ltd.     

Pathways to Adaptive Emotion Regulation Among Adolescents from Low‐Income Families

The current study examined pathways to adolescent anger and sadness regulation in low‐income families. The sample included 206 families with adolescents age 10–18 years. Using a multimethod, multi‐informant approach, we assessed neighborhood violence, mutual emotional support, parental emotion coaching, and anger and sadness regulation. The findings indicated that high levels of mutual emotional support and emotion coaching and low levels of neighborhood violence were correlated with adolescent emotion regulation. In addition, the analyses demonstrated multiple pathways to emotion regulation. Specifically, neighborhood violence was directly and indirectly related to anger and sadness regulation. Moreover, mutual emotional support was indirectly related to emotion regulation via emotion coaching. Overall, there was little evidence of adolescent sex and age differences in the model. Implications regarding the socialization of adolescent emotion regulation are discussed.     

Caring for Tube‐Fed Children

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral‐motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech‐language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent‐child interaction is an important part of the assessment and treatment of the tube‐fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube‐fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.     

Characteristics of Hospitalized Children With a Diagnosis of Malnutrition

Introduction: Malnutrition is common in hospitalized patients in the United States. In 2010, 80,710 of 6,280,710 hospitalized children <17 years old had a coded diagnosis of malnutrition (CDM). This report summarizes nationally representative, person‐level characteristics of hospitalized children with a CDM. Methods: Data are from the 2010 Healthcare Cost and Utilization Project, which contains patient‐level data on hospital inpatient stays. When weighted appropriately, estimates from the project represent all U.S. hospitalizations. The data set contains up to 25 ICD‐9‐CM diagnostic codes for each patient. Children with a CDM listed during hospitalization were identified. Results: In 2010, 1.3% of hospitalized patients <17 years had a CDM. Since the data include only those with a CDM, malnutrition's true prevalence may be underrepresented. Length of stay among children with a CDM was almost 2.5 times longer than those without a CDM. Hospital costs for children with a CDM were >3 times higher than those without a CDM. Hospitalized children with a CDM were less likely to have routine discharge and almost 3.5 times more likely to require postdischarge home care. Children with a CDM were more likely to have multiple comorbidities. Conclusions: Hospitalized children with a CDM are associated with more comorbidities, longer hospital stay, and higher healthcare costs than those without this diagnosis. These undernourished children may utilize more healthcare resources in the hospital and community. Clinicians and policymakers should factor this into healthcare resource utilization planning. Recognizing and accurately coding malnutrition in hospitalized children may reveal the true prevalence of malnutrition.     

Evaluation of Handgrip Strength and Nutritional Risk of Congregate Nutrition Program Participants in Florida

The aim of this study was to determine if handgrip strength (HGS) is a predictor of nutritional risk in community-dwelling older adults. A cross-sectional study was carried out to determine the relationship between HGS and nutritional risk using SCREEN 1. The setting was Congregate Nutrition program meal sites (n = 10) in North Central Florida and included community-dwelling older adults participating in the Congregate Nutrition program. Older adults (n = 136; 77.1 ± 8.9 y; 45 M, 91 F) participated in the study. Nutritional risk was identified in 68% of participants, with 10% exhibiting clinically relevant weakness (men, HGS < 26 kg; women, HGS < 16 kg), suggesting a vulnerable population. HGS was weakly associated with nutritional risk as assessed by SCREEN 1 (AUC = 0.59), but alternate cutpoints, 33 kg for men (mean of both hands) and 22 kg for women (highest of either hand), provided the best comparison to nutritional risk. In community-dwelling older adults, HGS was weakly associated with nutritional risk assessed using traditional screening. However, as existing research supports the inclusion of HGS in malnutrition screening in acute care, further research into the usefulness of HGS and possibly other measures of functional status in nutrition risk screening of community-dwelling older adults may be warranted.     

l-Leucine Supplementation Worsens the Adiposity of Already Obese Rats by Promoting a Hypothalamic Pattern of Gene Expression that Favors Fat Accumulation

Several studies showed that l-leucine supplementation reduces adiposity when provided before the onset of obesity. We studied rats that were exposed to a high-fat diet (HFD) for 10 weeks before they started to receive l-leucine supplementation. Fat mass was increased in l-leucine-supplemented rats consuming the HFD. Accordingly, l-leucine produced a hypothalamic pattern of gene expression that favors fat accumulation. In conclusion, l-leucine supplementation worsened the adiposity of rats previously exposed to HFD possibly by central mechanisms.     

Dental Therapy: Evolving in Minnesota’s Safety Net

Objectives. We identified Minnesota’s initial dental therapy employers and surveyed dental safety net providers’ perceptions of dental therapy.Methods. In July 2011, we surveyed 32 Minnesota dental safety net providers to assess their prospective views on dental therapy employment options. In October 2013, we used an employment scan to reveal characteristics of the early adopters of dental therapy.Results. Before the availability of licensed dental therapists, safety net dental clinic directors overwhelmingly (77%) supported dental therapy. As dental therapists have become licensed over the past 2 years, the early employers of dental therapists are safety net clinics.Conclusions. Although the concept of dental therapy remains controversial in Minnesota, it now has a firm foundation in the state’s safety net clinics. Dental therapists are being used in innovative and diverse ways, so, as dental therapy continues to evolve, further research to identify best practices for incorporating dental therapists into the oral health care team is needed.Dental therapy has evolved as a way to address specific oral health care needs. In New Zealand and Australia, dental therapy began as a way to address poor oral health in children. High levels of untreated disease coupled with a workforce shortage led the UK government to supplement dental care with dental therapists as new members of the health care team. In Canada and for people served by the Alaska Native Tribal Health Consortium, an important factor in the creation of dental therapy was the opportunity to extend care to native communities that were often geographically isolated.1In the United States, many barriers impede access to oral health care for the nation’s most vulnerable populations, including lack of dental care coverage, an inadequate supply of dental providers (particularly in rural communities and inner cities), and the limitations of the dental Medicaid program.2–4 These concerns are mirrored in Minnesota.5 According to 2011 data from the Minnesota Department of Health, 56 of the 87 Minnesota counties are designated in whole or in part as dental health professional shortage areas.6 Populations living in health professional shortage areas have less access to routine primary care than do populations living in areas with an adequate health care workforce.7 Only one fourth of Minnesota dentists practice in rural areas. The current Minnesota dental workforce is also aging: 47% of dentists are older than 55 years, and 42% plan to retire within the next 10 years.8Additionally, Department of Human Services data reveals that 862 000 Minnesotans were enrolled in a Minnesota Health Care Program (MHCP) in 2012 (MHCPs include Medical Assistance [Minnesota’s Medicaid program] and MinnesotaCare).9 Our October 2013 analysis of historical Minnesota Department of Human Services data shows that the number of Minnesotans eligible for dental care through Medical Assistance increased 59% from 2004 to 2012.It is hard to estimate the number of individuals who have problems accessing routine dental care in Minnesota. A 2012 Robert Wood Johnson Foundation publication reported that whereas 80% of insured Minnesotans had a dental visit in 2010, only 58% of uninsured Minnesotans had a visit.10 The unmet oral health need is also conveyed by the high number of emergency department visits for preventable dental-related problems. Davis et al.11 found that in a single year patients made more than 10 000 emergency department visits to 5 major hospital systems in the Minneapolis–St. Paul metropolitan area. These patients incurred total charges of $5 million for dental issues such as toothaches and abscesses.People who are enrolled in an MHCP and other underserved populations often turn to safety net providers to receive their oral health care. Although previous literature conveys the impression that the “dental safety net” has no single definition, the American Dental Association describes the safety net as the

sum of the individuals, organizations, public and private agencies and programs involved in delivering oral health care services to people who, for reasons of poverty, culture, language, health status, geography or education, are unable to secure those services on their own.12^(p2)

Although safety net clinics provide a small portion of overall health care, they are an important resource for groups that face access barriers.13 Not surprisingly, safety net clinics have many challenges, including difficulties in recruiting and retaining dentists.4 Perhaps because of their staffing challenges, Minnesota’s safety net providers helped lead the way when the state began an initiative to create a midlevel dental provider to address the growing oral health concerns of the state. In 2009, Minnesota became the first state to establish licensure of dental therapists with an additional process for certification as an advanced dental therapist to extend oral health care to underserved populations. The legislation limits dental therapists to practice primarily in settings that serve low-income, uninsured, and underserved populations or in a dental health professional shortage area.14In response to the state mandate, the Minnesota Board of Dentistry simultaneously approved 2 programs for educating licensed dental therapists. The University of Minnesota School of Dentistry dental therapy education program was designed to educate dental therapy students alongside dental and dental hygiene students in a team environment. This collegial approach to education will facilitate the delivery of a single standard of care to all Minnesota patients regardless of provider type.15 The program, initially designed to educate students to the licensed dental therapy standards, has since been modified to educate its students to also be eligible for advanced dental therapy certification. The other approved program was initiated as a collaboration of 2 institutions in the Minnesota State Colleges and Universities system formally designated the state college system.The Minnesota State Colleges and Universities system developed a dental therapy program for Minnesota licensed dental hygienists, offering them the opportunity to become dual licensed, both as a dental hygienist and as a dental therapist. This program was designed from its inception to educate dental hygienists to become licensed dental therapists and to become eligible for advanced dental therapy certification. As of October 2013, 28 individuals have been licensed as dental therapists in Minnesota.16 Nationally, there is interest about where these providers are practicing and what is known about the early adopters who employ the dental therapists. An earlier survey the University of Minnesota conducted in 2010 with Minnesota general dentists revealed a negative attitude toward dental therapy.17 However, in light of the legislative mandate that therapists primarily treat underserved populations, it is not surprising that safety net clinics, rather than traditional private practices, have become the predominate employer of dental therapists in these early years. Thus, the attitudes of safety net clinic dental directors and administrators are of particular relevance. To better understand early adopters’ attitudes toward and motivations for hiring a dental therapist, we undertook a survey in July 2011 to assess Minnesota’s dental safety net providers’ prospective views on dental therapy employment options.