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OBJECTIVE: This study aimed to evaluate snack food-group composition by weight status among United States adolescents. METHODS: Cross-sectional analysis of adolescent food-group-component intake from snacking occasions using two 24-hour dietary recalls from the 2007 through 2018 National Health and Nutrition Examination Survey (NHANES; n = 5264; 12–19 years) was conducted. ANCOVA models evaluated food intakes by BMI percentile (BMI%; normal weight [NW]

Background and Objectives Current assessment tools for long-term care environments have limited generalizability or ability to be linked to specific quality outcomes. To discriminate between different care models, tools are needed to assess important elements of the environmental design. The goal of this project was to systematically evaluate the reliability and validity of the Environmental Audit Screening Evaluation (EASE) tool to better enable identification of best models in long-term care design to maintain quality of life for persons with dementia and their caregivers. Research Design and Methods Twenty-eight living areas (LAs) were selected from 13 sites similar in organizational/operational commitment to person-centered care but with very different LA design. LAs were stratified into three categories (traditional, hybrid, and household) based primarily on architectural/interior features. Three evaluators rated each LA using the Therapeutic Environment Screening Scale (TESS-NH), Professional Environmental Assessment Protocol (PEAP), Environmental Audit Tool (EAT-HC) and EASE. One of each type of LA was reassessed approximately one month after the original assessment. Results EASE scores were compared against the scores of three existing tools to evaluate its construct validity. The EAT-HC was most closely related to the EASE r=0.88). The PEAP and the TESS-NH were less correlated to the EASE (r=0.82 and 0.71, respectively). Analysis of variance indicated that the EASE distinguished between traditional and homelike settings (0.016), but not hybrid LAs. Inter-rater and inter-occasion reliability and agreement of the EASE were consistently high. Discussion and Implications Neither of the two US-based existing environmental assessment tools (PEAP and TESS-NH) discriminated between the three models of environments. The EAT-HC was most closely aligned with the EASE and performed similarly in differentiating between the traditional and household models, but dichotomous scoring of the EAT-HC fails to capture environmental nuances. The EASE tool is comprehensive and accounts for nuanced design differences across settings.

For the first time, the 2020-2025 Dietary Guidelines for Americans provide specific guidance regarding the types of foods and beverages that should be offered in the first 2 years of life. Milk, in various forms (eg, human milk, infant formula, and cow's milk) contributes a large proportion of key nutrients to the diets of infants and toddlers in the United States.The aim of this study was to determine the types of milk (human milk, infant formula, and other milk) fed to US infants and toddlers in the past 12 years and to describe trends over time.This was a cross-sectional analysis of 2-day, 24-hour dietary recalls.Data from the 2007-2018 National Health and Nutrition Examination Survey were used for these analyses. Infants and toddlers aged 0 through 23.9 months with 2 days of dietary recall data (n = 3,079) were included.The main outcome was proportion of infants and toddlers fed different milk types.Survey-adjusted weighted percentages were used to report sociodemographic characteristics and the proportion of subjects fed each milk type category by age group and survey cycles. Binary and multinomial logistic regressions were used to assess differences in subject characteristics by age groups.Sociodemographic characteristics did not differ by age group. The proportion of infants aged 0 to6 months fed infant formula only was 60.2% in 2007-2012 and 44.8% in 2013-2018. The proportion of infants aged 6 to12 months fed partially hydrolyzed infant formula only was 7.3% in 2007-2012 and 13.1% in 2013-2018. In toddlers (12 months old), cow's milk was the predominant milk type in both 2007-2012 and 2013-2018.The percentage of infants fed any human milk increased over the past decade. Unsweetened cow's milk was the most predominate milk type consumed among toddlers.

Objectives. To identify the effect of a Breakfast in the Classroom (BIC) initiative on the foods and drinks students consume in the morning. Methods. Sixteen public schools in Philadelphia, Pennsylvania, that provide universal breakfast participated in a group randomized trial to examine the effects of BIC with complementary nutrition promotion between 2013 and 2016. Control schools (n = 8) offered breakfast in the cafeteria before school. Baseline data were collected from 1362 students in grades 4 to 6. Endpoint data were collected after 2.5 years. Students self-reported the foods and drinks they consumed in the morning. Results. At endpoint, there was no effect of the intervention on breakfast skipping. Nearly 30% of intervention students consumed breakfast foods or drinks from multiple locations, as compared with 21% of control students. A greater proportion of intervention students than control students consumed 100% juice, and a smaller proportion consumed sugar-sweetened beverages and foods high in saturated fat and added sugar. Conclusions. A BIC initiative led to improvements in the types of foods and drinks students consumed in the morning. However, the program did not reduce breakfast skipping and increased the number of locations where students ate.

Nutrient-dense foods, which are often low in energy density (ED), are recommended for a healthy diet in infants and children. How ED changes during the transition from a complementary diet in infancy to a conventional diet is unknown.We aimed to describe the ED, the amount of energy (e.g., kcal) per weight (e.g., g), of food or beverage in infants and preschool-age children. It was hypothesized that ED would be higher among older children.The ED of food (ED-Food Only) and of food and all beverages excluding human milk and infant formula (ED-Food and Beverages) of children's (6 mo-5 y) diets were examined overall and by age subgroups using data from the NHANES (2009-2018). Survey-adjusted linear regression followed by pairwise comparisons were used to compare ED across age subgroups. The percentages of calories consumed from low-, medium-, and high-ED foods across age subgroups were also examined.Mean ED-Food Only was 1.21 kcal/g (95% CI: 1.13, 1.29 kcal/g) among 6- to 11-mo-olds and 1.62 kcal/g (95% CI: 1.54, 1.69 kcal/g) among 12- to 17-mo-olds (P 0.05). ED-Food and Beverages was higher across consecutive age subgroups from 0.99 kcal/g (95% CI: 0.96, 1.02 kcal/g) in 12-17 mo through 3 y (1.22 kcal/g; 95% CI: 1.19, 1.26 kcal/g; P 0.05). Mean percentage of calories consumed from low-ED food (≤1.0 kcal/g) became lower with age from 6- to 11-mo-olds (47.3%; 95% CI: 44.3%, 50.4%) through 18- to 23-mo-olds (16.2%; 95% CI: 14.5%, 17.9%; P 0.05). A greater percentage of calories was consumed from high-ED food (≥3.0 kcal/g) among 18- to 23-mo-olds (39.0%; 95% CI: 37.1%, 40.9%) than among 12- to 17-mo-olds (34.0%; 95% CI: 32.0%, 35.9%; P 0.05).ED increased across age subgroups, driven by a decrease in the percentage of calories consumed from low-ED food and an increase in the percentage of calories consumed from high-ED food.

Increases in life expectancy mean that an unprecedented number of individuals are reaching centenarian status, often with complex health concerns. We analyzed nationally representative hospital admissions data (2000–2009) from the National Inpatient Study (NIS) for 52,618 centenarians (aged 100–115 years, mean age 101.4). We predicted length of stay (LOS) via negative binomial models and total inflation adjusted costs via fixed effects regression analysis informed by descriptive data. We also identified hospitalizations due to ambulatory care-sensitive conditions defined by AHRQ Prevention Quality Indicators. Mean LOS decreased from 6.1 to 5.1 days, while over the same time period the mean total adjusted charges rose from USD 13,373 to USD 25,026 in 2009 dollars. Black, Hispanic, Asian, or other race centenarians had higher cost stays compared to White, but only Black and Hispanic centenarians had significantly greater mean length of stay. Comorbidities predicted greater length of stay and higher costs. Centenarians admitted on weekends had higher costs but shorter length of stay. In total, 29.4% of total costs were due to potentially preventable hospitalizations for total charges (2000–2009) of USD 341.8M in 2009 dollars. Centenarian hospitalizations cost significantly more than hospitalization for any other group of elderly in the U.S.

Self-care is a multicomponent set of capacities that influence beliefs about health and well-being.We examined the relationship between self-care capacity, age, and disability status with two perceptions of well-being in a cohort of Medicare beneficiaries.The current study is part of a multisite research project to determine factors associated with cross-sectional and longitudinal morbidity and mortality trajectories observed in Medicare beneficiaries. Variable selection was informed by the health disparities and outcomes model. Using data from the 2013 Medicare Current Beneficiary Survey and logistic regression models, we determined associations between self-care capacity, including indicators of self-care ability and self-care agency and two perceptions of well-being. Participants were divided into four groups based on how they qualified for Medicare: (a) over 65 years of age, and below 65 years of age and disabled because of (b) physical or (c) mental disorder, or (d) disabled and could not be classified as physically or mentally disabled as the primary cause of eligibility.Self-care ability limitations in activities of daily living (ADL), instrumental activities of living (IADL), and social activity participation were associated with both health perceptions. Those with physical disabilities reported more ADL and IADL limitations when compared with the other eligibility groups and were significantly more likely to have negative health perceptions. Those with serious mental illness were most likely to report the most severe IADL limitations. The over 65 years of age group reported less self-care incapacity than the other three eligibility types. Other components of self-care, including health literacy, agency, and health behaviors, significantly influenced perceptions of health. Women and people identifying as non-Whites were more likely to have negative health perceptions.Self-care capacity is a complex construct, and its varied elements have differential relationships with perceptions of well-being. Those with physical disabilities reported more self-care limitations, poorer perceived health, and more health worries than the other groups. Still, there were different patterns of self-care capacities in the serious mental illness type-especially in IADL limitations. The study adds empirical evidence to previous research documenting inequities in health outcomes for women and non-Whites. Findings provide empirical support for the health disparities and outcomes model.

Poor sleep quality is prevalent among older adults, but limited data document associations between frailty and quality of life comparing individuals living in the community with those in nursing homes. This cross-sectional study (conducted between August and November 2019) included 831 older adults (mean age 76.5 years) from Slovenia’s community and nursing home settings. The results showed comorbidity in 38% of community-dwelling older adults and 31% of older adults in nursing homes. The prevalence of frailty among community-dwelling older adults was 36.5%, and among older adults in a nursing home was 58.5%. A total of 76% of community-dwelling older adults and 95.8% of nursing home residents reported poor sleep quality. Sleep quality and frailty predict 42.3% of the total variability of quality of life for older adults in nursing homes and 34.8% for community-dwelling older adults. The study’s results indicate that the quality of life can be affected by factors (e.g., worse sleep quality and frailty) among older adults, regardless of being a resident or from the community. Understanding how sleep quality is affected by social, environmental, and biological factors can help improve sleep quality and potentially the quality of life of older adults.

Aim Topographic complexity is widely accepted as a key driver of biodiversity, but at the patch‐scale, complexity–biodiversity relationships may vary spatially and temporally according to the environmental stressors complexity mitigates, and the species richness and identity of potential colonists. Using a manipulative experiment, we assessed spatial variation in patch‐scale effects of complexity on intertidal biodiversity. Location 27 sites within 14 estuaries/bays distributed globally. Time period 2015–2017. Major taxa studied Functional groups of algae, sessile and mobile invertebrates. Methods Concrete tiles of differing complexity (flat; 2.5‐cm or 5‐cm complex) were affixed at low–high intertidal elevation on coastal defence structures, and the richness and abundance of the colonizing taxa were quantified after 12 months. Results The patch‐scale effects of complexity varied spatially and among functional groups. Complexity had neutral to positive effects on total, invertebrate and algal taxa richness, and invertebrate abundances. However, effects on the abundance of algae ranged from positive to negative, depending on location and functional group. The tidal elevation at which tiles were placed accounted for some variation. The total and invertebrate richness were greater at low or mid than at high intertidal elevations. Latitude was also an important source of spatial variation, with the effects of complexity on total richness and mobile mollusc abundance greatest at lower latitudes, whilst the cover of sessile invertebrates and sessile molluscs responded most strongly to complexity at higher latitudes. Conclusions After 12 months, patch‐scale relationships between biodiversity and habitat complexity were not universally positive. Instead, the relationship varied among functional groups and according to local abiotic and biotic conditions. This result challenges the assumption that effects of complexity on biodiversity are universally positive. The variable effect of complexity has ramifications for community and applied ecology, including eco‐engineering and restoration that seek to bolster biodiversity through the addition of complexity.

BACKGROUND: Centenarian studies are important sources for understanding of factors that contribute to longevity and healthy aging. Clinico-neuropathological finding is a key in identifying pathology and factors contributing to age-related cognitive decline and dementia in the oldest old. OBJECTIVE: To characterize the cross-sectional relationship between neuropathologies and measures of premortem cognitive performance in centenarians. METHODS: Data were acquired from 49 centenarians (≥98 years) from the Georgia Centenarian Study. Cognitive assessment from the time point closest to mortality was used (

This poster will share the results from a research initiative funded by the National Institutes of Health to assess the validity of the Environmental Audit Scoring Evaluation (EASE) tool in its ability to distinguish between different types of skilled care models based on the environmental and operational practices that can be observed and documented. The EASE tool was compared against three existing tools; PEAP, TESS-NH, and EAT-HC. Twenty-eight living areas in nursing homes across the state of Kansas identified as a traditional, household, or hybrid model were observed. The scores of the EASE were compared against the scores of three existing tools in order to evaluate its construct validity. The EAT-HC was most closely related to the EASE, with an R-value of 0.8817. The PEAP and the TESS-NH were less correlated to the EASE, with R-values of 0.8175 and 0.7097, respectively. Results found that the EASE was able to distinguish between traditional and homelike settings, though it could not identify hybrid models with a high degree of certainty. The analysis of variance between homelike and traditional homes was significant at 0.016, while the variance between homelike and hybrid and between hybrid and traditional were not significant. Inter-rater reliability of the EASE was consistently high (.96 and above). The outcomes demonstrated the EASE tool was able to assess the homelike characteristics of the environment of nursing homes better than or equally as well as previously validated tools.

BACKGROUND: Poor sleep quality predicts poor quality of life, poor self-rated health, and chronic diseases and mental disorders among older adults. The Pittsburgh Sleep Quality Index (PSQI) is the most widely used self-report measure of sleep quality in older adults. OBJECTIVES: This study aimed to assess internal reliability, face validity, content validity and internal consistency of the Slovenian version of the PSQI (PSQI-SLO) for sleep quality in older adults. METHODS: A cross-sectional study was used to evaluate content and face validity as well as reliability (ɑ, ω and item-total correlations). Residents of 13 nursing homes and community-dwelling older adults from all regions of Slovenia were sampled. A total of 831 participants aged 65 years and older participated in the study between March and August 2019. RESULTS: All items were successfully translated to Slovenian. A minor cultural adaptation was made to improve the clarity of the meaning of all items. None of the items had an item content validity index (I-CVI) score lower than 0.50. Kappa indices were excellent for half of the items and good for the remainder. Internal consistency agreed with prior research (ɑ=0.74). Intraclass correlation coefficient for global PSQI-SLO was 0.62 (p < 0.001). The total score of PSQI-SLO (8.09±3.64 (95%, CI=7.85-8.34)) was expected and comparable. Fifty-eight and four tenths’ percent (95%, CI=55%-62%) had at least one chronic disease and 40% (95%, CI=37%-42%) lived in a nursing home. CONCLUSIONS: PSQI-SLO showed adequate internal consistency and test-retest reliability, and adequate construct and criterion validity. The instrument can be important in assessing older adults' subjective sleep quality in nursing homes, home environment and clinical settings. IMPLICATIONS FOR PRACTICE: The instrument can assess sleep efficiency among older adults in different settings and can help nursing staff develop a high-quality approach to reduce sleep deficiency.

OBJECTIVES: US adolescents with overweight (OW) and obesity (OB) consume larger and more frequent snacks (i.e., foods consumed between meals) than adolescents with normal weight (NW); but, the food group sources of these snacks by body weight status remains largely unknown. This research aimed to evaluate snack food group composition by weight status among US adolescents. METHODS: Cross-sectional analysis evaluated 10 USDA Food Patterns Equivalents Database (FPED) components from snacking occasions using two, 24-hr dietary recalls among U.S. adolescents (n = 6,591;12–19 y) participating in the 2005–2016 National Health and Nutrition Examination Survey. Analysis of covariance was used to evaluate food intakes by weight status, adjusted for energy misreporting and other covariates. RESULTS: Consumption of added sugars, solid fats, and refined grains from snacks alone represented 64%, 38%, 32%, respectively, of recommended daily limits. Adolescents with OB consumed greater total daily energy from snacks (NW = 441(11)kcal; OW = 540(17)kcal; OB = 645(23)kcal, P

Young adulthood is a time when persons with type 1 diabetes (PWD) become more fully responsible for diabetes management. Establishing healthy diabetes routines during this period is foundational for successful management across adulthood, yet this age group experiences higher HbA1c levels and more frequent diabetes-related hospital visits than any other age group. New partnered relationships during young adulthood may play a crucial role in mitigating these risks. Long-term married couples with type 1 diabetes report poorer outcomes (lower self-care, lower physical health and higher HbA1c) when they report greater critical and overprotective behaviors from their spouse (Helgeson et al., 2019). Daily collaboration and support may be associated with poorer self-care (Berg et al., 2020). The objective of this study was to examine associations between daily communal coping and PWD blood glucose. Twenty-four young married couples (ages 20-37, M=25.7 years) wherein one spouse had T1D completed daily measures of communal coping (i.e., emotional support, instrumental support, over-protective behavior, illness avoidance, and controlling behavior) for 9 consecutive days. Daily average blood glucose and time-in-range were computed from PWD glucose meter or continuous blood glucose monitor. Results from multilevel models suggested that higher within-person (person mean centered) instrumental support (b = -1.38, p=.002) and overprotective (b = -1.36, p=.025) or controlling (b = -1.86, p=.027) spousal behaviors predicted lower PWD time-in-range. Higher between-person (grand-mean centered) overprotective spousal behaviors predicted higher PWD daily average blood glucose (b = 32.20, p=.002). Findings suggest that some young romantic partners may engage in behaviors that are associated with higher average PWD blood glucose and lower time-in-range. Disclosure J. B. Yorgason: None. J. Saylor: None. C. Berg: None. S. Rellaford: None. D. L. Steeger: None. A. Davey: None.

IntroductionComputerized neuropsychological testing is a cornerstone of sport-related concussion assessment. Female soccer players are at an increased risk for concussion as well as exposures to repetitive head impacts from heading a soccer ball. Our primary aim was to examine factorial validity of the Automated Neuropsychological Assessment Metrics (ANAM) neuropsychological test battery in computing the multiple neurocognitive constructs it purports to measure in a large cohort of interscholastic female soccer players.MethodsStudy participants included 218 interscholastic female soccer players (age = 17.0±0.7 year; mass = 55.5±6.8 kg; height = 164.7±6.6 cm) drawn from a large (850+) prospective database examining purposeful heading from four area high schools over a 10-year period. The ANAM-2001 measured neurocognitive performance. Three methods were used to identify integral constructs underlying the ANAM: (a) exploratory factor analysis (EFA), (b) first-order confirmatory factor analysis (CFA), and (c) hierarchical CFA.ResultsNeuropsychological phenomena measured by the ANAM-2001 were best reproduced by a hierarchical CFA organization, composed of two lower level factors (Simple Reaction Time, Mental Efficiency) and a single, general composite. Although the ANAM was multidimensional, only the composite was found to possess sufficient construct dimensionality and reliability for clinical score interpretation. Findings failed to uphold suppositions that the ANAM measures seven distinct constructs, or that any of its seven tests provide unique information independent of other constructs, or the composite, to support individual interpretation.ConclusionsOutcomes infer the ANAM possesses factorial-validity evidence, but only scores from the composite appear to sufficiently internally valid, and reliable, to support applied use by practitioners.

Aims The first aim examined the relationship between sleep behaviors (duration, napping, and social jetlag) and hemoglobin A1c (HbA1c) among emerging young adults (EYAs) with T1DM between 18 and 25 years old, who are living on a college campus. The second aim characterized the gender differences in glucose management, sleep behaviors, caffeine intake, and nighttime technology. Methods A cross-sectional study of eligible participants used a convenience sample of eligible participants. Using Research Electronic Data Capture (REDCap), participants completed surveys about diabetes management, caffeine intake, nighttime technology use, and sleep-related behaviors. Data were analyzed using correlation and multiple linear regression to predict HbA1c from sleep behaviors, adjusting for covariates. Results Participants (N = 76) average years with T1DM was 10.25 ± 5.70. Compared to females, males had a longer sleep duration lower HbA1c levels. HbA1c levels were negatively correlated with weekday sleep (r = −0.24, p = 0.03) and positively correlated with napping (r = 0.34, p = 0.003). After adjusting for covariates, participants who napped had a higher HbA1c level (β = 0.74, p = 0.03) compared with non-nappers. Conclusions Higher HbA1c levels were found among EYAs with T1DM in college who were nappers and had a longer sleep duration. Modifying sleep behaviors may be an appropriate target to improve glycemic control.

The Breakfast in the Classroom (BIC) initiative, a common approach to implementing the federal School Breakfast Program, is advocated as a method to improve students' academic performance. However, the influences of BIC on academic outcomes are unclear.To examine the effect of a BIC initiative which provided free, universal BIC on attendance and standardized test performance over 2.5 years, vs free universal breakfast served in the cafeteria before school, among students in an urban school district serving a low-income population.Secondary analysis of data from a cluster randomized controlled trial conducted between 2013 and 2016; 16 kindergarten through eighth-grade public schools in Philadelphia, PA, were enrolled and randomized to condition. Baseline data for 1,362 fourth- through sixth-grade students were provided by the school district. Midpoint data were collected after 1.5 years and endpoint data after 2.5 years.Schools were eligible in the case that ≥50% of students qualified for free or reduced-priced meals, did not offer BIC, and received programming as part of the US Department of Agriculture Supplemental Nutrition Assistance Program. Parents consented for their children to participate.Intervention schools provided BIC and breakfast-related nutrition-promotion activities. Control schools provided breakfast in the cafeteria before the school day.Student attendance and standardized exam scores.Weighted generalized estimating equations were used to evaluate differences in outcomes between conditions at midpoint and endpoint.The BIC initiative did not influence attendance (β ± standard error = .004 ± .06; P = 0.94) or standardized reading exam scores (β ± standard error = .02 ± .06; P = 0.79) after 2.5 years. Students in BIC initiative schools had lower standardized math exam scores than those in control schools, although this difference was small (β ± standard error = -.20 ± .07; P = 0.005).BIC did not improve academic outcomes among students attending low-income, urban schools.

OBJECTIVE The primary purpose of this study was to examine associations of objectively measured sleep duration with weight changes in black and Hispanic mothers over the first postpartum year. METHODS Data were from 159 mothers (69% black, 32% Hispanic). Nocturnal sleep duration was assessed using wrist actigraphy at 6 weeks and 5 months post partum, examined as a continuous variable and in categories (

Injuries sustained from traumatic brain injury (TBI) culminate in both cognitive and neuromuscular deficits. Patients often progress to higher functioning on the Rancho continuum even while mobility deficits persist. Although prior studies have examined physical performance among persons with chronic symptoms of TBI, less is known about the relatively acute phase of TBI as patients prepare for rehabilitation discharge. The aims of this cross-sectional study were to (a) compare balance and gait performance in 20 ambulant persons with moderate to severe TBI who were nearing rehabilitation discharge with their age-matched controls and (b) describe performance with thresholds for fall risk and community navigation. During a designed task circuit, 40 participants (20 persons with TBI and 20 controls) performed the Timed Up and Go (TUG), gait velocity, and Walking and Remembering tests. Balance testing included the Fullerton Advanced Balance Scale (FABS) and instrumented Modified Clinical Test for Sensory Interaction in Balance (MCTSIB). Statistical analyses included analysis of covariance for group comparisons and a multivariate analysis of covariance for MCTSIB sway velocities with anthropometric controls. The TBI group (mean [ M] age = 42, standard deviation [ SD] =19.5 years; 70% males) performed significantly more poorly on all mobility tests ( p

OBJECTIVE To characterize associations of snacking frequency with weight status among US children aged 1 to 5 years. METHODS Participants were children (n = 4,669) aged 1 to 5 years in the 2005 to 2014 National Health and Nutrition Examination Survey (NHANES). Snacking was assessed by two 24-hour dietary recalls using definitions that considered "snack" occasions as well as other foods/beverages consumed between meals. Overweight/obesity (OW/OB) was defined using percentile cutoffs: ≥ 97.7th weight-for-length (

Randomized controlled trials of blood pressure (BP) lowering and antihypertensive medication use on cognitive outcomes have often been disappointing, reporting mixed findings and small effect sizes. We evaluate the extent to which cognitive assessment protocols used in these trials approach state-of-the-art. Overall, we find that a primary focus on cognition and the systematic selection of cognitive outcomes across trials take a backseat to other trial goals. Twelve trials investigating change in cognitive functioning were examined and none met criteria for state-of-the-art assessment, including use of at least 4 tests indexing 2 cognitive domains. Four trials investigating incident dementia were also examined. Each trial used state-of-the-art diagnostic criteria to assess dementia, although follow-up periods were relatively short, with only 2 trials lasting for at least 3 years. Weaknesses in each trial may act to obscure or weaken the positive effects of BP lowering on cognitive functioning. Improving trial designs in terms of cognitive outcomes selected and length of follow-up periods employed could lead to more promising findings. We offer logical steps to achieve state-of-the-art assessment protocols, with examples, in hopes of improving future trials.

BACKGROUND: Provider adherence to best practice guidelines (ask, advise, refer [AAR]) for addressing child tobacco smoke exposure (TSE) motivates parents to reduce TSE. However, high-risk, vulnerable populations of smokers may require more intensive treatment. We hypothesized that a pragmatic, multilevel treatment model including AAR coupled with individualized, telephone-based behavioral counseling promoting child TSE reduction would demonstrate greater child TSE reduction than would standard AAR. METHODS: In this 2-arm randomized controlled trial, we trained pediatric providers in systems serving low-income communities to improve AAR adherence by using decision aid prompts embedded in routine electronic health record assessments. Providers faxed referrals to the study and received ongoing AAR adherence feedback. Referred participants were eligible if they were daily smokers, >17 years old, and spoke English. Participants were randomly assigned to telephone-based behavioral counseling (AAR and counseling) or nutrition education (AAR and attention control). Participants completed prerandomization and 3-month follow-up assessments. RESULTS: Of providers, >80% (n = 334) adhered to AAR procedures and faxed 2949 referrals. Participants (n = 327) were 83% women, 83% African American, and 79% low income (below poverty level). Intention-to-treat logistic regression showed robust, positive treatment effects: more parents in AAR and counseling than in AAR and attention control eliminated all sources of TSE (45.8% vs 29.9%; odds ratio 1.99 [95% confidence interval 1.44–2.74]) and quit smoking (28.2% vs 8.2%; odds ratio 3.78 [95% confidence interval 1.51–9.52]). CONCLUSIONS: The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

Declining national rates of current tobacco use to an all-time low of 15.1% represents a public health victory. Undermining this progress, however, are smoking rates of up to 50% among high-risk, low-income populations. Current FDA-approved treatments for nicotine dependence are ineffective with between 70-95% of treatment-seekers relapsing within the first year of attempted abstinence. Thus, identification of novel intervention targets to optimize response to currently available treatments for nicotine dependence is a critical next step. One such target may be sleep insomnia. Insomnia is a clinically verified nicotine withdrawal symptom but, to date, addressing insomnia or other sleep disturbance symptoms as an adjunctive smoking cessation therapy has yet to be fully considered. To this end, this manuscript presents a narrative review of: (1) sleep continuity and architecture in smokers versus nonsmokers; (2) effects of nicotine abstinence on sleep; (3) possible mechanisms linking sleep with smoking cessation outcomes; (4) plausible adjunctive sleep therapies to promote smoking cessation; (5) possible treatments for unhealthy sleep in smokers; and (6) directions for future research. Taken together, this will provide conceptual support for sleep therapy as an adjunctive treatment for smoking cessation. Implications This narrative literature review presents a comprehensive discussion of the relationship between habitual sleep and cigarette smoking. The extent to which unhealthy sleep in smokers may be a viable intervention target for promoting response to smoking cessation treatment is considered. Ultimately, this review provides conceptual support for sleep therapy as an adjunctive treatment for smoking cessation.

Efforts to prevent postpartum weight retention in extant clinical trials of African American women have proven exceedingly challenging. The primary purpose of this pilot study was to determine whether a behavioral intervention implemented in early pregnancy through 6 months postpartum could increase the proportion of African American women who were at or below their early pregnancy weights by 6 months postpartum. We additionally evaluated whether mothers' postpartum weight loss could be maintained at 12 months postpartum. Participants were 66 socioeconomically disadvantaged African American women (36% overweight, 64% obese) randomly assigned to a behavioral intervention or usual care group. The intervention, implemented from early pregnancy to 6 months postpartum, promoted weight control through: (1) empirically supported behavior change goals; (2) interactive self-monitoring text messages; (3) weekly to monthly health coach calls; and (4) skills training and support through Facebook. In modified intent-to-treat analyses, participants assigned to the intervention were significantly more likely to be at or below their early pregnancy weights by 6 months postpartum compared to usual care (56% vs. 29%, p = 0.04). At 12 months postpartum, the maternal weight difference between intervention and usual care groups was not maintained (41% vs. 38% respectively at or below early pregnancy weights, p = 0.83). Findings suggest that a combined pregnancy and postpartum weight control intervention improves 6 month weight outcomes in socioeconomically disadvantaged African American women with obesity. Longer interventions may be needed to overcome late postpartum weight gain among this high risk group. Clinical trial registration number: ClinicalTrials.gov identifier NCT01530776, Highlights • A combined pregnancy and postpartum intervention reduced 6 month weight retention. • By12 months postpartum, the intervention's weight effect was not maintained. • Longer interventions may be needed to overcome late postpartum weight gain.

BACKGROUND: Reports on the relative importance of the diastolic and systolic blood pressures (DBP and SBP) in age-related cognitive decline are mixed. Investigating the relation between DBP/SBP and functional and structural brain changes could elucidate which of the 2 measures is more critically important for brain function and, consequently, cognitive impairment. METHODS: We investigated the association of SBP and DBP with cortical volume, cerebral blood flow (CBF), and white matter lesions (WML), in nondemented older adults with and without mild cognitive impairment (MCI; N = 265, 185 MCI, mean age = 64 years). Brachial blood pressure was measured twice while seated, and the average of the 2 measures was used. Cortical volume, gray matter (GM) CBF, and WML were estimated using T1-weighted imaging, arterial spin labeling, and fluid attenuation inversion recovery, respectively. RESULTS: Reduced cortical volume was associated with elevated DBP (β= −0.18, P = 0.034) but not with SBP (β = −0.10, P = 0.206). GM CBF was associated with DBP (β = −0.13, P = 0.048) but not with SBP (β = −0.07, P = 0.275). Likewise, CBF within brain regions where MCI patients showed hypoperfusion were only associated with DBP (DBP: β = −0.17, P = 0.005; SBP: β = −0.09, P = 0.120). WML volume was associated with both DBP (β = 0.20, P = 0.005) and SBP (β = 0.30, P < 0.001). For all measures, there was no interaction between DBP/SBP and cognitive status, indicating that these associations were independent of the cognitive status. CONCLUSIONS: Independently of the cognitive status, DBP is more critically important for GM volume and perfusion, whereas WML is associated with both blood pressures, likely reflecting long-term effect of hypertension and autoregulation dysfunction.

BACKGROUND: Black smokers have earlier development of lung disease as well as poorer sleep health than whites. RESEARCH QUESTION: In a sample of black smokers, to what extent does sleep health modify the association between smoking level and functional exercise capacity? DESIGN AND METHODS: Cross-sectional data from 209 black smokers (≥ 1 cigarette in last month), aged 40 to 65 years with no evidence of sleep-disordered breathing (apnea-hypopnea index < 15) or severe COPD (FEV(1) > 50%), were used for the current study. Self-reported smoking rate, objectively measured sleep efficiency (SE), total sleep time (TST), and the 6-min walk test (6MWT) for functional exercise capacity were the key assessments. RESULTS: The mean age was 54.8 years (SD, 5.96), and mean cigarettes smoked per day (cpd) was 8.71 (SD, 6.78). Mean SE was 69.9% (SD, 12.3%), and mean TST was 307.99 min (SD 92.2). In adjusted linear regression models of the 6MWT (meters), TST (slope estimate, –0.14; P = .14) and SE (slope estimate, –1.0; P = .19) were negatively associated with 6MWT. The smoking rate × SE interaction was highly significant (slope estimate, 0.18; P = .007) such that in individuals who smoked ≥ 10 cpd, every additional percentage of SE garnered an additional distance of 0.83 to 6.62 m. Similarly, the smoking rate × TST interaction was significant (slope estimate, 0.019; P = .03) such that in smokers who smoked ≥ 10 cpd, every additional minute of TST garnered an additional distance of 0.04 to 0.60 m. INTERPRETATION: Higher SE and, to a lesser extent, longer TST, in black adults who smoke ≥ 10 cpd is associated with better 6MWT performance. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT03534076; URL: www.clinicaltrials.gov.

SummaryBackground Snacking among US preschoolers has increased in recent decades, raising questions about whether snacking contributes to dietary excess. Objectives This research aimed to characterize snacking contributions to dietary excess and to evaluate associations with appetite and weight among preschool-aged children. Methods This study is a cross-sectional, observational study of 187 Hispanic low-income preschoolers. Three 24-h dietary recalls were used to assess snacking frequency and parameters of dietary excess including energy, saturated fat, trans fats and added sugars. Parental reports of child satiety responsiveness, food responsiveness, and enjoyment of food were obtained. Child height and weight were measured. Results Children consumed 28% (395 kcal) of daily energy from snacks eaten at 2.3 ± 1.0 occasions per day. Greater snacking frequency was associated with greater daily intakes of energy (p

SummaryBackground Paediatric observational studies demonstrate associations between sleep, television viewing and potential changes in daytime activity levels. Objective(s) To determine whether experimental changes in sleep lead to changes in children's sedentary and physical activities. Methods Using a within-subject counterbalanced design, 37 children 8–11 years old completed a 3-week study. Children slept their typical amount during a baseline week and were then randomized to increase or decrease mean time in bed by 1.5 h/night for 1 week; the alternate schedule was completed the final week. Children wore actigraphs on their non-dominant wrist and completed 3-d physical activity recalls each week. Results Children reported watching more television (p

Hypertension control in Hispanics/Latinos lag behind general US trends by 10-15%. Intensive systolic blood pressure (SBP) management120 mm Hg may significantly reduce morbidity/mortality risk in adults with hypertension; less is known about cognition. We investigated cross-sectional associations of cognition with observed hypertension control at currently recommended (SBP140 mm Hg) and more intensive (SBP120 mm Hg) levels using baseline data from the Hispanic Community Health Study/Study of Latinos.From this multicenter cohort study, we focused on 1,735 Hispanic/Latino men and women ages 45-74 years with hypertension and verified antihypertensive use. Verbal fluency, information processing speed, learning, and memory were tested in Spanish or English.Separate linear regressions revealed that being on 1 vs.1 antihypertensive medication was not associated with cognition; however, individuals with SBP controlled to currently recommended levels outperformed individuals with uncontrolled SBP on verbal fluency [Beta = 1.44 (0.52), P0.01] and information processing speed [Beta = 3.01 (0.89), P0.001] in age-adjusted regression analyses; only information processing speed remained significant (P0.05) after additional adjustments including acculturation, health insurance, and other cardiovascular disease risk factors. When regrouping individuals based on more intensive SBP control, individuals with levels120 mm Hg outperformed individuals with higher SBP on verbal fluency regardless of adjustments (P0.01). More intensive rather than currently recommended levels of control associated with higher verbal fluency performance regardless of adjustments (P0.05).Individual cognitive test scores related to distinct SBP management with more intensive management appearing more robust against confounders. While cognitive associations with hypertension in Hispanics/Latinos may be multifactorial, different levels of SBP control should be considered in future prospective intervention studies.

Continued increases in life expectancy mean than an unprecedented number of individuals are reaching centenarian status, often with complex health concerns. Little research has addressed acute care experiences of centenarians. To address this knowledge gap, we analyzed 10 years of hospital admissions data from a total of 52618 centenarians (aged 100 to 115 years) in the nationally representative National Inpatient Study (NIS) with the aim of characterizing centenarian (mean age 101.4 years, 80% women, 24.2% non-White, 91.3% Medicare, 72.2% emergencies, 18.6% urgent) hospitalizations. Mean length of stay (LOS) decreased from 6.1 to 5.1 days (2000-2009). Over the same period, mean total charges rose from $13373 to $25026; they were $4478 lower for women than men and $4032 more for centenarians age 105 years and older than ages 100 to 104, despite comparable LOSs. Mean LOS was approximately 0.7 days longer for non-Whites than Whites, and mean total charges were approximately $6531 higher for non-Whites than Whites. The 10 most common admission diagnoses were consistent with frailty and end stage cognitive impairment including pneumonia, congestive heart failure, urinary tract infections, fracture of neck of femur, septicemia, fluid and electrolyte disorders, aspiration pneumonitis, acute cerebrovascular disease, acute myocardial infarction, and gastrointestinal hemorrhage, and 10.0% of centenarians died in hospital. We link individual-level data with hospital and state characteristics over the same time period in order to provide a more detailed analysis of individual and system-level characteristics that contribute toward health disparities in hospitalizations and health outcomes among centenarians.

BACKGROUND: Few studies simultaneously addressed associations between carotid flow velocities, blood pressure (BP), and cognitive function. MATERIALS AND METHODS: Subject without dementia (N = 1,684) underwent measurements of BP and biochemical markers. Mini-Mental State Examination (MMSE) and comprehensive neuropsychological tests were used to evaluate cognitive function. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured in common and internal carotid artery. Subjects with MMSE score of ≤24 (25th percentile) was defined as low MMSE. Multivariable linear and logistic regression were used to evaluate the relationship of cognitive function with carotid flow velocities and BP. RESULTS: Carotid flow velocities (PSV: standardized β = 0.067, P = 0.0009; and EDV: standardized β = 0.067, P = 0.0021) and systolic blood pressure (standardized β = −0.061, P = 0.005) were positively and negatively associated with MMSE, respectively, in the model with adjustments for age, sex, educational attainment, nutritional status, and smoking. Similar trends were noted for the associations between flow velocities and different neuropsychological tests. By multivariable logistic regression, the group with the lowest quartile (

The Centers for Disease Control and prevention estimates that 9.3% of adults in the United States have type 2 diabetes mellitus (T2DM), costing the nation over $245B each year in medical expenditures and reduced productivity. More personalized approaches to prevention that distinguish between individuals with high environmental versus biological risk for T2DM could further reduce public health burden. The present study provides an in-depth examination of the relationship between maternal age and age of T2DM onset in a sample of adults participating in 11 waves of the Health and Retirement Study between 1992 and 2012, as a potential way of disentangling biological and socioeconomic predictors of T2DM. Data for each participant was obtained from the wave in which he or she first reported being diagnosed with type II diabetes or the last wave observed. The final analytic sample consisted of 16,239 study participants. The main predictor variable utilized in the present study was maternal age, defined as the age of the mother (in years) at the birth of the participant. Cox proportional hazards regression was used to examine the effects of maternal age, demographics and health characteristics on time until type 2 diabetes onset. Advanced maternal age was a significant predictor of age of diabetes onset, operationalized quadratically and as the interaction between maternal age at birth and a binary indicator of whether the mother was ≥30 years at birth.