Preventive Medicine

Dietary Guidance and New School Meal Standards: Schoolchildren's Whole Grain Consumption Over 1994–2014 Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Biing-Hwan Lin, Joanne F. Guthrie, Travis A. Smith Introduction Since 2005, the federal government's Dietary Guidelines for Americans have recommended at least half of total grain intake be whole grains. Beginning with the 2012–2013 school year, the U.S. Department of Agriculture updated school meal regulations to align with this recommendation. Methods Nationally representative food consumption survey data spanning 1994–2014 were analyzed in 2018 to construct a sample of 17,016 schoolchildren aged 5–19 years. Regression models were used to examine changes in whole grain/total grain intake by food source. For school-obtained foods, changes in whole grain intake are decomposed into changes in propensity (proportion of students consuming whole grains) and intensity (amount consumed by whole grain consumers). Results The whole grain/total grain ratio from all sources fell from 9.67% (1994–1998) to 7.6% (2005–2006) before climbing to 13.48% (2013–2014). Home-prepared foods topped the whole grain/total grain ratio among all sources until surpassed by school foods in 2013–2014 (17.16% vs 21.48%). The whole grain/total grain ratio from school rose from 4.02% to 21.48% during 1994–2014. Among those consuming school foods, increased intensity contributed more than propensity to increases in whole grain intake from school between 2005–2010 and 2011–2012; the opposite occurred between 2011–2012 and 2013–2014 because of increasing propensity, from one in four to one in two students consuming whole grains. Conclusions During 1994–2006, the whole grain/total grain ratio of schoolchildren's diets declined, contrary to expert advice. Following the 2012 U.S. Department of Agriculture school meal regulations, both the propensity and the intensity of whole grain consumption from school rose considerably, demonstrating the important role school meals may play in improving children's diets.

Correction Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s):

Preventive Medicine Physicians and the Centers for Disease Control and Prevention's 6|18 Initiative Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Catherine J. Livingston, Robert D. Allison, David W. Niebuhr, Kevin M. Sherin, Victoria C. Costales, Manijeh Berenji, Tanya M. Phares, Lee S. Caplan, Lidia Nelkovski, Laura C. Seeff, Christa M. Singleton

Lay Advisor Interventions in Rural Populations: A Systematic Review and Meta-analysis Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Sonal J. Patil, Melissa Lewis, Erin M. Tallon, Nuha K. Wareg, Katie S. Murray, Susan G. Elliott, James J. Stevermer, Robin L. Kruse, David R. Mehr Context Age-adjusted death rates for heart disease are higher in rural areas than in urban areas. Lay advisors could potentially facilitate improvement in cardiovascular health outcomes. The aim of this systematic review and meta-analysis is to estimate lay advisor intervention effects on cardiovascular health metrics in rural populations. Evidence acquisition Searches of databases including MEDLINE, CINAHL, and Scopus from 1975 through October 2017 retrieved 323 citations, of which 272 abstracts were reviewed. Two authors independently abstracted data from eligible studies. Analysis was conducted in March 2018. Evidence synthesis Of 21 articles included in the systematic review, eight were RCTs and 13 were pre- and post-intervention studies. Of the RCTs, three took place in the U.S. Only two studies had low risk of bias. Using a random effects model, meta-analysis of six RCTs (1,641 participants) showed that lay advisor interventions in rural residents were associated with improvement in HbA1c of 0.4% (95% CI=0.13, 0.66, p=0.004, I2=60.65%). From four RCTs (873 participants), lay advisor interventions significantly improved BMI with pooled effect of 2.18 (95% CI=1.13, 3.24, p<0.001, I2=0.00%). Most studies had normal baseline blood pressure and cholesterol levels before intervention, and no significant effects were noted for these outcomes. Diverse types of measures used for diet, physical activity, and smoking precluded statistical synthesis. Conclusions Lay advisor interventions had significant positive effects on glycemic control and BMI for rural residents; however, further rigorous studies are needed in U.S. rural populations, and elements of effective lay advisor interventions require further investigation.

Summer School, School Disengagement, and Substance Use During Adolescence Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Sarah A. Stoddard, Philip Veliz Introduction Youth who fall behind academically are at increased risk for school disengagement, school dropout, and substance use. Summer school is an opportunity for youth to complete needed coursework yet has not been utilized as a venue for substance use prevention. To date, little is known about the rates of summer school attendance among adolescents or the relationship between summer school attendance, school disengagement, and substance use. The purpose of this study is to assess the characteristics of summer school attendance over the past 20 years and to examine the associations between summer school attendance, indicators of school disengagement, and recent substance use among eighth-grade students. Methods Data from the Monitoring the Future cross-sectional study of eighth-grade students (1997–2016; n=111,033) was used to examine the association between summer school attendance and recent substance use (e.g., past 2-week/30-day marijuana use). Bivariate associations controlling for sociodemographics and school disengagement (e.g., truancy) were assessed. Analyses were completed in 2018. Results School disengagement and substance use were associated with summer school attendance; however, when controlling for indicators of school disengagement, summer school attendance was not associated with substance use. Interaction effect models found that summer school attendance weakened the association between indicators of school disengagement and substance use. Conclusions These findings suggest that students with a high propensity to use substances do attend summer school. Summer school may be a venue to deliver information on the risk of alcohol or other drugs to a population of at-risk students.

Beyond Race Disparities: Accounting for Socioeconomic Status in Diabetes Self-Care Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Lyndsay A. Nelson, Michael T. Ackerman, Robert A. Greevy, Kenneth A. Wallston, Lindsay S. Mayberry Introduction Among patients with type 2 diabetes, racial disparities are prevalent across a variety of outcomes; however, inconsistent disparities in determinants of outcomes warrants exploring the impact of other, related factors. This study sought to examine whether disparities in health literacy, numeracy, self-care behaviors, and HbA1c persisted between non-Hispanic blacks and non-Hispanic whites after applying a robust adjustment for socioeconomic status (SES). Methods From 2016 to 2018, adult patients with type 2 diabetes (N=444) were recruited from primary care clinics. Participants self-reported demographics; indicators of SES (i.e., income, education, health insurance, housing status, and financial strain); subjective health literacy and numeracy; and self-care behaviors. Participants also completed an HbA1c test. In 2018, differences were examined between non-Hispanic blacks and non-Hispanic whites in health literacy, numeracy, self-care, and HbA1c, first unadjusted and then adjusted using propensity score weighting. Results In unadjusted analyses, compared with non-Hispanic whites, non-Hispanic blacks had lower health literacy (p=0.039) and numeracy (p<0.001); less medication adherence (p=0.009); use of information for dietary decisions (p=0.013); and problem eating behaviors (p<0.001; i.e., non-Hispanic blacks reported fewer problems); and higher HbA1c levels (p=0.005). After adjusting for all SES indicators, only the reverse disparity in problem eating behaviors (p=0.016) and the disparity in HbA1c (p=0.011) remained. Conclusions Findings highlight the importance of considering SES when examining disparities in health-related skills and behaviors. Moving beyond education and income to inclusion of more comprehensive markers of SES can improve understanding of how SES may contribute to disparities and the ability to appropriately target factors leading to inequality.

Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Lewei (Allison) Lin, Talya Peltzman, John F. McCarthy, Elizabeth M. Oliva, Jodie A. Trafton, Amy S.B. Bohnert Introduction To inform overdose prevention, this study assessed both recent trends in opioid overdose mortality across opioid categories and receipt of prescription opioid analgesics among Veterans who died from overdose in the Veterans Health Administration. Methods Using Veterans Health Administration records linked to National Death Index data, annual cohorts (2010–2016) of Veterans who received Veterans Health Administration care were obtained and were examined by opioid overdose categories (natural/semisynthetic opioids, heroin, methadone, and other synthetic opioids) on (1) overdose rates and changes in rates adjusted for age, sex, and race/ethnicity; and (2) Veterans Health Administration prescription opioid receipt. Analyses were conducted in 2018. Results The overall rate of opioid overdose among Veterans increased from 14.47 per 100,000 person-years in 2010 to 21.08 per 100,000 person-years in 2016 (adjusted rate ratio=1.65, 95% CI=1.51, 1.81). There was a decline in methadone overdose (adjusted rate ratio=0.66, 95% CI=0.51, 0.84) and no significant change in natural/semisynthetic opioid overdose (adjusted rate ratio=1.08, 95% CI=0.94, 1.24). However, the synthetic opioid overdose rate (adjusted rate ratio=5.46, 95% CI=4.41, 6.75) and heroin overdose rate (adjusted rate ratio=4.91, 95% CI=3.92, 6.15) increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Conclusions Opioid overdose rates among Veterans Health Administration Veterans increased because of increases in heroin and synthetic opioid overdose rates. Prescriptions of opioids declined among patients who died from all categories of opioid overdose; by 2016, only a minority received an opioid analgesic from Veterans Health Administration within 3 months of overdose. Future prevention efforts should extend beyond patients actively receiving opioid prescriptions.

Cancer Symptom Recognition and Anticipated Delays in Seeking Care Among U.S. Adults Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Katharine A. Rendle, Elizabeth A. Sarma, Samantha L. Quaife, Kelly D. Blake, Richard P. Moser, Jerry M. Suls, Heather M. Edwards, Sarah C. Kobrin Introduction Early stage diagnosis strongly predicts cancer survival. Recognition of potential symptoms of cancer may improve survival by reducing time to seeking care. Methods Telephone interviews with a population-representative sample of English-speaking adults (aged ≥50 years) in the U.S. (N=1,425) were conducted in 2014 using an instrument adapted from the International Cancer Benchmarking Partnership Awareness and Beliefs about Cancer survey. Anticipated time to seeking care for four cancer symptoms (persistent cough, rectal bleeding, mole changes, and breast changes) was assessed, and delay was defined as waiting >2 weeks. Recognition of symptoms as potential cancer signs was assessed dichotomously. Multivariate logistic regression models were used to assess associations between symptom recognition and anticipated delay, adjusting for demographics, cancer experience, self-reported health, and healthcare access. Analyses were weighted and conducted in 2017. Results Symptom recognition varied but was relatively high across all symptoms (76.9%–95.5%). Anticipated delay varied by symptom and was highest for persistent cough (41.2%) and lowest for rectal bleeding (9.1%). For rectal bleeding (AOR=2.65, 95% CI=1.31, 5.36) and mole changes (AOR=3.30, 95% CI=1.48, 7.33), anticipated delay was more likely among individuals who did not recognize the symptom as a warning sign. Adults with lower education levels (p<0.05) and African Americans (p<0.05) were less likely to delay for some symptoms. Conclusions Lack of symptom recognition was associated with anticipated delay in seeking care for some cancer symptoms. Differences in recognition and delays by symptom could be driven partly by screening messaging or by ambiguity and functional impact of each symptom.

An Educational Intervention to Improve Statin Use: Cluster RCT at the Primary Care Level in Argentina Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Pablo E. Gulayin, Alfredo Lozada, Andrea Beratarrechea, Laura Gutierrez, Rosana Poggio, Raúl Martín Chaparro, Marilina Santero, Walter Masson, Adolfo Rubinstein, Vilma Irazola Introduction Statins are essential drugs for high cardiovascular disease (CVD) risk management; however, there is still low adherence to good clinical practice guidelines for statin use at the primary care level in low- and middle-income countries. This study aimed to test whether a complex intervention targeting physicians improves treatment and control of hypercholesterolemia among patients with moderate to high CVD risk in Argentina. Study design Cluster RCT. Setting/participants Ten primary care centers from the public healthcare system of Argentina. Intervention Primary care physicians in the intervention group received an educational program with three main components: (1) an intensive 2-day training workshop; (2) educational outreach visits; and (3) a mobile health application installed on the physician's smartphones. Main outcome measures Reduction in mean low-density lipoprotein cholesterol level, reduction in mean Framingham risk score, proportion of patients receiving an appropriate statin dose, and mean annual number of primary care center visits. Results Data were analyzed in 2017–2018. Between April 2015 and April 2016, a total of 357 participants were enrolled (179 patients in the intervention group and 178 in the control group). The global follow-up rate was 97.2%. At the end of the follow-up period, there was no difference in low-density lipoprotein cholesterol levels in any of the follow-up points among the groups. Mean CVD risk had a significant net difference in the first 6 months in the intervention group versus the control group (–4.0, 95% CI = –6.5, –1.5). At the end of follow-up, there was an absolute 41.5% higher rate of participants receiving an appropriate statin dose in the intervention group versus the control group. Conclusions Although the intervention did not reach a reduction in cholesterol levels, it had a significant positive impact on the promotion of adequate use of clinical practice guidelines. Trial registration This study is registered at www.clinicaltrials.gov NCT02380911.

Association of Worksite Food Purchases and Employees’ Overall Dietary Quality and Health Publication date: July 2019 Source: American Journal of Preventive Medicine, Volume 57, Issue 1 Author(s): Jessica L. McCurley, Douglas E. Levy, Eric B. Rimm, Emily D. Gelsomin, Emma M. Anderson, Jenny M. Sanford, Anne N. Thorndike Introduction Most Americans spend half their waking hours at work and consume food acquired there. The hypothesis was that the healthfulness of worksite food purchases was associated with employees’ overall diet and health. Methods Participants were 602 hospital employees who regularly used worksite cafeterias and enrolled in a health promotion study in 2016–2018. All cafeterias used traffic-light labels (green=healthy, yellow=less healthy, red=unhealthy). A Healthy Purchasing Score was calculated for each participant by summing weighted proportions of cafeteria items purchased over a 3-month observation period (red=0, yellow=0.5, green=1; range, 0–1). Healthy Eating Index scores (range, 0–100) were calculated based on two 24-hour dietary recalls. BMI, blood pressure, and HbA1c were measured. Hypertension and prediabetes/diabetes diagnoses were determined by self-reported and clinical data. Regression analyses examined dietary quality and diagnoses by tertile of Healthy Purchasing Score (T1=least healthy purchases, T3=most healthy), adjusting for demographics. All data were collected before the start of the intervention and were analyzed in 2018. Results Mean age was 43.6 years (SD=12.2), 79% were female, and 81% were white. Mean BMI was 28.3 kg/m2 (SD=6.5); 21% had hypertension, and 27% had prediabetes/diabetes. Mean Healthy Eating Index was 60.4 (SD=12.5); mean Healthy Purchasing Score was 0.66 (SD=0.15). Healthier purchases were associated with healthier Healthy Eating Index scores (T1=55.6, T2=61.0, T3=64.5, p<0.001) and lower obesity prevalence (T1=38%, T2=29%, T3=24%, p<0.001); similar patterns were observed for hypertension and prediabetes/diabetes. Conclusions Worksite food purchases were associated with overall dietary quality and cardiometabolic risk. Interventions to increase healthfulness of food choices at work may improve employees’ health.