The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States

Factors associated with participation in a walking intervention for veterans who smoke and have chronic pain

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720-3550] (sedentary) (n = 65), 7307 [IQR: 5952-8533] (not sedentary) (n = 24), and 3196 [IQR: 2237-5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation.Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016.

Incidence rates of bladder and kidney cancers among US military servicemen: comparison with the rates in the general US population

OBJECTIVE

The military population may differ from the general population in factors related to bladder and kidney cancers. However, incidence rates of these cancers have not been systematically compared between the two populations. This study compared incidence rates of bladder and kidney cancers between active-duty servicemen and men in the general US population.

METHODS

Data were obtained from the Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database. Included were 18-59-year-old active-duty servicemen in ACTUR and men in SEER who were diagnosed with malignant bladder and kidney cancers from 1990 to 2013. Age-adjusted rates, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were compared between the two populations by age, race, and cancer stage.

RESULTS

Incidence rates were lower in ACTUR than SEER for bladder cancer overall (IRR = 0.55, 95% CI, 0.48-0.62) and by age (except ages 50-59), race, and tumor stage. For ages 50-59, rates did not differ between the populations. Kidney cancer incidence rates were lower in the military for younger groups and Black men, but higher for ages 50-59.

CONCLUSION

Lower bladder and kidney cancer incidence in ACTUR, notably in younger men, may be primarily associated with better health and healthcare access. The lack of differences in bladder or kidney cancer incidence among 50-59-year-old men between the populations might result from multifactorial effects, such as the possible effects of cumulative military-related exposures offset by healthier status and better medical care.

Effects of upper thoracic Mulligan mobilization on pain, range of motion and function in patients with mechanical neck pain: A randomized placebo-controlled trial

OBJECTIVE

This study aimed to assess the impact of Mulligan Reverse Natural Apophyseal Glides (RNAGS) applied to the upper thoracic region on pain, movement limitation, and function in individuals with mechanical neck pain.

METHODS

Conducted between January 2021 and May 2021, the study involved 69 participants randomly assigned to a sham group, physiotherapy group, and Mulligan group. A two-week, 11-session treatment program was administered with shared physiotherapy interventions and stretching exercises to all groups. The Mulligan group received additional mobilization with the Mulligan RNAGS technique. The sham group received sub-standard Mulligan mobilization. Outcome measures included Range of Motion (ROM), Visual Analogue Scale (VAS), and Neck Disability Index (NDI).

RESULTS

No baseline differences were found in measurements among the groups. After the intervention, all groups showed increased ROM and decreased VAS and NDI scores (p<0.001). The Mulligan group exhibited significantly greater improvement in VAS, ROM, and NDI compared to other groups (p<0.001). The sham group demonstrated greater improvement in NDI and extension ROM compared to the physiotherapy group (p<0.001).

CONCLUSION

Mulligan RNAGS technique in the upper thoracic region proved beneficial for pain relief, range of motion, and functionality in mechanical neck pain. Long-term effects warrant further exploration through population-based studies.

An unbiased, sustainable, evidence-informed Universal Food Guide: a timely template for national food guides

BACKGROUND

Although national food guides are designed, ostensibly, to translate scientific evidence with respect to food, dietary patterns, and health, their development has increasingly become a corporate/political process as well as scientific one; often with corporate/political influences overriding science. Our aim was to construct an unbiased, sustainable, evidence-informed Universal Food Guide to serve as a template for countries to develop their unique guides, thereby, provide a valid resource for health professionals, health authorities, and the public.

METHODS

To address our aim, we conducted an integrative review of multiple evidence-informed sources (e.g., established databases, evidence syntheses, scholarly treatises, and policy documents) related to four areas: 1. Food guides' utility and conflicts of interest; 2. The evidence-based healthiest diet; 3. Constituents of the Universal Food Guide template; and 4. Implications for population health; regulation/governance; environment/climate/planetary health; and ethics.

RESULTS

The eating pattern that is healthiest for humans (i.e., most natural, and associated with maximal health across the life cycle; reduced non-communicable disease (NCD) risk; and minimal end-of-life illness) is whole food, low fat, plant-based, especially vegan, with the absence of ultra-processed food. Disparities in national food guide recommendations can be explained by factors other than science, specifically, corporate/political interests reflected in heavily government-subsidized, animal-sourced products; and trends toward dominance of daily consumption of processed/ultra-processed foods. Both trends have well-documented adverse consequences, i.e., NCDs and endangered environmental/planetary health. Commitment to an evidence-informed plant-based eating pattern, particularly vegan, will reduce risks/manifestations of NCDs; inform healthy food and nutrition policy regulation/governance; support sustainable environment/climate and planetary health; and is ethical with respect to 'best' evidence-based practice, and human and animal welfare.

CONCLUSION

The Universal Food Guide that serves as a template for national food guides is both urgent and timely given the well-documented health-harming influences that corporate stakeholders/politicians and advisory committees with conflicts of interest, exert on national food guides. Such influence contributes to the largely-preventable NCDs and environmental issues. Policy makers, health professionals, and the public need unbiased, scientific evidence as informed by the Universal Food Guide, to inform their recommendations and choices.

Virtual Reality-Based Food and Beverage Marketing: Potential Implications for Young People of Color, Knowledge Gaps, and Future Research Directions

Unlabelled

Exposure to unhealthy food and beverage marketing is a major contributor to excessive weight gain among young people and it may disproportionately affect Black and Latinx communities. Appropriate and comprehensive regulations on food and beverage companies are essential, particularly as companies expand their reach and leverage the latest technologies to create marketing experiences using immersive virtual reality (VR). Although immersive VR technology is in its infancy, the potential effects of immersive VR food and beverage marketing on consumption, coupled with the history of racially targeted marketing by food and beverage corporations toward Black and Latinx communities, and the heightened burden of diet-related illnesses in Black and Latinx communities underscore a critical need to investigate immersive VR marketing targeting young people of color. This viewpoint will provide a brief description of VR food and beverage marketing as the newest food and beverage marketing frontier, highlight key concerns and knowledge gaps, and underscore future directions in research.

Addressing the Urgent Need For Clinical Nutrition Education in Post-Graduate Medical Training: New Programs and Credentialling

The importance of nutrition in the development of disease, and in the recovery from illness, is among the most fundamental tenets in human biology and optimal health. Nutrition was fundamental in many traditional forms of medicine, until its role in medical care experienced a rapid decline over the last century. We believe a key cause of the decline in nutrition's essential role in healthcare and preventative medicine is the escalating crisis of inadequate nutrition education in medical training. Recent data shows 75% of US medical schools have no required clinical nutrition classes and only 14% of residency programs have required nutrition curriculum. More troubling, only 14% of current healthcare providers feel comfortable discussing nutrition with their patients. The purpose of this paper is to present the evidence illustrating the distinct lack of nutrition education in medical training. Further, we will present key examples of existing formal nutrition curricula to incorporate nutritional science into all healthcare providers' education and practices. We will discuss existing nutrition fellowships and training programs, including the new Duke Online Clinical Nutrition Fellowship. We will also cover a physician nutrition certification allowing for physicians to pursue clinical nutrition as a career path. Finally, recent financial incentives and quality measures incentivizing healthcare provider nutrition education will be discussed. Thus, in conclusion, we advocate inclusion of nutrition education curricula must be a priority in medical schools, graduate medical education and continuing medical education. Formal clinical nutrition training should be required by hospital leadership and administrators for all Parenteral Nutrition and Nutrition Team Physician Directors in hospitals worldwide, and this key clinical role must become an essential position in all hospitals. In addition, we desperately need to address the critical shortage in physician nutrition specialists who will serve as the next generation of leaders in clinical nutrition care and research.

The association between dietary carbohydrate intake and the risk of hyperlipidemia among reproductive-aged women in the US: A cross-sectional study

BACKGROUND

The association between dietary carbohydrate intake and hyperlipidemia remained incompletely understood. This study aimed to explore the association between dietary carbohydrate intake and the risk of hyperlipidemia among reproductive-aged women in the US.

METHODS

The study utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted from 2005 to 2020. Dietary intake information was assessed via interviews using 24-hour dietary recall interviews, and hyperlipidemia diagnosis adhered to the National Cholesterol Education Program guidelines. Univariate and multivariate logistic regression analyses, along with restricted cubic splines (RCS) and stratified analyses, were conducted to investigate the association between dietary carbohydrate intake and the risk of hyperlipidemia.

RESULTS

A total of 6,791 women of reproductive age, with a mean age of 34.87 (±8.57) years, were included in the final analysis. In the multivariate logistic regression model adjusting for covariates, a higher percentage of energy from carbohydrate was positively correlated with the risk of hyperlipidemia (adjusted odds ratio (AOR): 1.014, 95% CI: 1.004-1.024). Analyzing the percentage of energy from carbohydrate as a categorical variable, compared to the lowest quartile, the third quartile (AOR: 1.263, 95% CI: 1.031-1.546) and the highest quartile (AOR: 1.411, 95% CI: 1.083-1.839) were associated with increased hyperlipidemia risk. Additionally, a linear relationship (P for nonlinearity = 0.088) existed between the percentage of energy from carbohydrate and the risk of hyperlipidemia, with an inflection point identified at 49.64.

CONCLUSIONS

This study found that elevated dietary carbohydrate intake was associated with an increased the risk of hyperlipidemia in reproductive-aged women. These findings implied that reproductive-aged women should pay closer attention to reducing their carbohydrate intake.

Restaurants as Environments for Healthy Eating: Factors That Contribute to Restaurant-Based Healthy Eating Program Adoption

Purpose. This study identified restaurant manager/owner factors that may contribute to adoption of a restaurant-based healthy eating program, Eat Fit. Findings may be used to engage restaurants in efforts to increase access to and availability of healthy foods, promote healthy food choices, and work toward improving diet and lowering obesity and chronic disease risk in the community. Methods. Cross-sectional survey data were collected from restaurant managers/owners interested in partnering with Eat Fit. Variables included restaurant manager/owner beliefs, perceived staff knowledge/skills, support, self-efficacy, outcome expectancies, and barriers and facilitators to implementation. Results. Forty-nine managers/owners participated. Most managers/owners held positive beliefs about offering healthy food items in restaurants (83.7%). Most agreed that restaurants could influence eating behaviors (83.7%) and that restaurants have a responsibility to offer healthy options (77.6%). Most managers/owners perceived high levels of support (83.7%) and were confident in their ability (95.9%) to implement the Eat Fit program. The most cited barriers were customer preference, ingredient availability, staff knowledge, and operational challenges. The most common reasons for involvement in the program were a desire to increase access to healthy food, to entice customers looking for healthier food, a belief that restaurants should offer healthy food, and opportunities to market through Eat Fit. Conclusions. This research contributes to knowledge about beliefs and perceptions of restaurant manager/owners. Efforts to engage restaurants should focus on benefits of offering healthy food and the role restaurants can play in promoting health. Furthermore, programs may benefit from enhanced restaurant staff training, customer-targeted marketing, and educational efforts.

Prevalence and risk factors of low back pain in military personnel: a systematic review

Purpose

Low back pain (LBP) has a significant impact on the general population, especially on military personnel. This study aimed to systematically review the relevant literature to determine the prevalence and risk factors of low back pain among military personnel from different military occupational categories.

Methods

For this systematic review, we searched Embase, PubMed, and Cochrane. We performed study selection, data extraction, and assessed the quality of the evidence using the adapted risk of bias assessment tool by Hoy et al. This review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This study is registered on the Center for Open Science, registration DOI: 10.17605/OSF.IO/HRGE8.

Results

Out of 860 papers, 19 studies met the inclusion criteria. More than 360 000 military people with lumbar pain situation were considered for inclusion in this systematic review. The 1-year prevalence of LBP could be up to 81.7% in the Army, 5.2% in the Marines, and 48.1% in the Air Force. Age (OR = 0.494-2.89), history of LBP (OR = 2.2-8.91), and sedentary position (OR = 0.55-3.63) were the most common physical, sociodemographic, and occupational risk factors, respectively.

Conclusions

Low back pain was prevalent among military personnel. There was heterogeneity in studies and a significant difference in prevalence and incidence across various occupational categories. Physical, sociodemographic, and occupational risk factors were researched more than psychological risk factors in the military.

Lumbar spine marker placement errors and soft tissue artifact during dynamic flexion/extension and lateral bending in individuals with chronic low back pain

Quantitative in vivo biomechanical assessments are typically performed with optoelectronic motion capture (MoCap) using retroreflective markers attached to skin. This technique inherently contains measurement errors from both marker placement on palpated bony landmarks and skin motion relative to the underlying bone (i.e., soft tissue artifact (STA)). Research on lumbar spine STA is scarce and limited to young, healthy participants in static positions. This study aimed to evaluate static placement errors, lumbar spine STA from MoCap marker clusters (MMC), and linear relationships between STA and patient characteristics. Thirty-nine participants with cLBP performed three trials each of flexion/extension and lateral bending while imaged simultaneously by MoCap (120 Hz) and dynamic biplane radiography DBR (20 Hz). MMCs were placed 29.5 ± 18.0 mm and 27.1 ± 13.4 mm superior to the most prominent aspect of the L1 and L5 spinous process, respectively. L1 relative to L5 STA was larger during flexion/extension (8.6 ± 5.7°) than lateral bending (4.5 ± 2.1°) (p < 0.001). After correcting for marker placement errors, components of the L1 and L5 STA averaged as much as 16.3 mm and 11.4° during flexion/extension, but only 4.0 mm and 4.8° or less during lateral bending. On average, STA for individual L1 and L5 vertebrae increased as participants moved away from the upright neutral position. STA was participant-dependent, however, age and BMI did not model STA well. Given the inaccuracy in marker placement and wide range of patterns of STA, caution is urged when making clinical decisions or when using computational models to estimate spine tissue loading based upon lumbar spine kinematics obtained from skin-mounted markers.

Racial and ethnic disparities in the natural history of alcohol-associated liver disease in the United States

BACKGROUND

Outcomes in alcohol-associated liver disease (ALD) are influenced by several race and ethnic factors, yet its natural history across the continuum of patients in different stages of the disease is unknown.

METHODS

We conducted a retrospective cohort study of U.S. adults from 2011 to 2018, using three nationally representative databases to examine potential disparities in relevant outcomes among racial and ethnic groups. Our analysis included logistic and linear regressions, along with competing risk analysis.

RESULTS

Black individuals had the highest daily alcohol consumption (12.6 g/day) while Hispanic participants had the largest prevalence of heavy episodic drinking (33.5%). In a multivariable-adjusted model, Hispanic and Asian participants were independently associated with a higher ALD prevalence compared to Non-Hispanic White interviewees (OR: 1.4, 95% CI: 1.1-1.8 and OR: 1.5 95% CI:1.1-2.0, respectively), while Blacks participants had a lower ALD prevalence (OR: .7 95% CI: .6-.9), and a lower risk of mortality during hospitalization due to ALD (OR: .83 95% CI: .73-.94). Finally, a multivariate competing-risk analysis showed that Hispanic ethnicity had a decreased probability of liver transplantation if waitlisted for ALD (SHR: .7, 95% CI: .6-.8) along with female Asian population (HR: .40, 95% CI: .26-.62).

CONCLUSIONS

After accounting for key social and biological health determinants, the Hispanic population showed an increased risk of ALD prevalence, even with lower alcohol consumption. Additionally, Hispanic and Asian female patients had reduced access to liver transplantation compared to other enlisted patients.

Improving Hypertension and Diabetes Mellitus Control with a Dedicated Patient Navigator

OBJECTIVES

Hypertension and diabetes mellitus (DM) are the leading causes of cardiovascular, cerebrovascular, and chronic kidney diseases. They affect an estimated 47% and 11% of Americans, respectively. In this study, we assessed whether a dedicated patient navigator embedded within a patient-centered medical home (PCMH) using a structured panel management and patient outreach strategy could improve blood pressure and glycemic control in primary care patients with uncontrolled hypertension and DM.

METHODS

We performed a prospective study comparing blood pressure and glycemic control in primary care patients before and after implementation of a patient navigator executing a hypertension and DM-focused panel management plan.

RESULTS

From January 2014 to October 2019, inclusion criteria were met 5164 times, which comprised 1958 unique patients within a PCMH. Multivariate regression analysis reveals a significant decrease in uncontrolled systolic blood pressure (SBP) over time, with an actual decrease of roughly 40% of uncontrolled episodes of SBP becoming controlled by 12 months. Multivariate regression analysis reveals a significant decrease in uncontrolled hemoglobin A1c (HbA1c) over time for each plot (P < 0.0001), with an actual decrease of roughly 30% of uncontrolled episodes of HbA1c becoming controlled by 12 months.

CONCLUSIONS

This study demonstrated the benefit of a dedicated patient navigator embedded within a PCMH on improving BP and glycemic control in primary care patients with uncontrolled hypertension and DM. Glycemic control was achieved, with 30% of episodes reaching an HbA1c of <8% and BP control achieved for 40% of episodes with SBP <140 mm Hg at 12 months. There were no differences by the social determinants of race and poverty.

Burden and social distribution of occupational psychosocial exposures in the United States workforce, 2022

OBJECTIVE

To characterize the burden and social distribution of occupational psychosocial exposures in the United States (US).

METHODS

We merged 2022 US employment and demographic data from the Current Population Survey (CPS) with occupational characteristic data from the Occupational Information Network (O*NET), wage data from the Occupational Employment and Wage Statistics Survey, and hours worked from the CPS, to estimate the number and proportion of US workers at risk of exposure to 19 psychosocial hazards. We additionally estimated the number and proportion of US workers over- or underrepresented in exposure burden.

RESULTS

Of the exposures examined, US workers were most commonly employed in occupations with high time pressure (67.5 million US workers exposed; 43.2% US workers exposed), high emotional labor (57.1 million; 36.6%), and low wages (47.8 million; 30.6%). The burden of exposures was uneven across sociodemographic strata, attributable to occupational segregation. The full data set is available online at https://deohs.washington.edu/us-exposure-burden.

CONCLUSIONS

Work-related psychosocial exposures are ubiquitous and should be considered in occupational and public health research, policy, and interventions to reduce the burden of disease and health inequities in the United States.

Association Between Opioid and Benzodiazepine Use and All-Cause Mortality in Individuals with Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study

Background

Opioids and benzodiazepines are frequently prescribed for managing pain and anxiety in chronic obstructive pulmonary disease (COPD) patients. This study aimed to determine whether opioid use, with or without benzodiazepine use, is associated with increased all-cause mortality in COPD patients.

Methods

This prospective cohort study included adults aged ≥20 years with COPD from the US National Health and Nutrition Examination Survey 2007-2012. The primary outcome was all-cause mortality, which were obtained through linkage to registries. Weighted Cox proportional hazards regression models were used to evaluate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Additionally, subgroup and sensitivity analyses were used to evaluate the robustness of our findings.

Results

This study enrolled 811 participants, representing 10.84 million COPD individuals in the United States (mean [standard error] age, 58.7 [0.6] years). During a median follow-up of 9.6 years, mortality rates were 57.8 per 1000 person-years in patients using only opioids, 41.3 per 1000 person-years in patients using only benzodiazepines, 45.7 per 1000 person-years in patients using both opioids and benzodiazepines, and 27.0 per 1000 person-years in patients using neither. In the fully adjusted model, COPD patients prescribed both opioids and benzodiazepines (HR: 1.76; 95% CI: 1.11-2.78) and those prescribed opioids only (HR: 1.68; 95% CI: 1.13-2.49) had significantly higher all-cause mortality compared to non-users. After adjusting for propensity scores, the mortality risk for opioid-only users slightly increased (HR: 1.87; 95% CI: 1.25-2.81). Further, subgroup analysis revealed an elevated mortality risk in patients over 60 years receiving coprescriptions or opioids only, but not in younger participants. In contrast, benzodiazepine-only users aged 60 or younger showed increased mortality risk.

Conclusion

Opioid use, with or without benzodiazepine use, was associated with higher mortality in COPD patients over 60, while benzodiazepine-only use was associated with higher mortality aged 60 or younger.

Digital Education on Hospital Nutrition Diets: What Do Patients Want to Know?

INTRODUCTION

Therapeutic nutrition plays an imperative role during a patient's hospital course. There is a tremendous body of literature that emphasizes the systematic delivery of information regarding hospital nutrition diets. A major component of delivering healthcare information is the principle of providing quality healthcare information, but this has not yet been investigated on hospital nutrition diets. This study aimed to evaluate the comprehension and readability of patient education materials regarding therapeutic hospital diets.

METHODOLOGY

The methodology employed the use of publicly available questions regarding hospital nutrition diets and categorized them per Rothwell's Classification of Questions. Additionally, the questions were extracted online and have an associated digital article linked to the question. These articles underwent analysis for readability scores.

RESULTS

This study's findings reveal that most hospital diets do not meet the recommended grade-reading levels.

CONCLUSIONS

This underscores the need for healthcare providers to enhance patient education regarding hospital diets. The prevalence of "Fact" questions showcases the importance of clearly explaining diets and dietary restrictions to patients.

Individual- and environmental-level determinants of fruit and vegetable intakes in rural Georgia

OBJECTIVE

To investigate the ways in which food insecurity, food acquisition behaviors, and perceived and objective food access influence fruit and vegetable intakes among rural Georgians.

DESIGN

A population-based survey was merged with USDA's Food Access Research Atlas, and multilevel modeling was used to determine individual-level (eg, food insecurity, food acquisition behaviors, perceived access) and environmental-level (eg, census tract food access) predictors of fruit and vegetable intakes.

SETTING

Twenty-four rural census tracts in 6 counties in Georgia, USA.

PARTICIPANTS

One thousand four hundred and seventy-four adults.

RESULTS

Residing in a low food access census tract was not associated with fruit or vegetable intake. Food insecurity had negative effects on both fruit and vegetable intakes. Perceived access to fresh fruits and vegetables was positively associated with fruit intake, and obtaining fresh fruits and vegetables from community or home gardens was positively associated with both fruit and vegetable intakes.

CONCLUSIONS

Findings are unique from previous research on census tract-level fruit and vegetable determinants, underscoring the need for a better understanding of influences on fruit and vegetable intakes among rural populations. Interventions to increase fruit and vegetable consumption in rural areas should prioritize food security.

Insulin resistance assessed by estimated glucose disposal rate and risk of atherosclerotic cardiovascular diseases incidence: the multi-ethnic study of atherosclerosis

BACKGROUND

To investigate the relationship between estimated glucose disposal rate (eGDR), a surrogate indicator of insulin resistance, and atherosclerotic cardiovascular diseases (ASCVD) incidence risk.

METHODS

This prospective cohort study utilized data from the 6026 participants from the Multi-Ethnic Study of Atherosclerosis. The eGDR (mg/kg/min) was computed as 21.158 - (0.09 × waist circumference [cm]) - (3.407 × hypertension [yes/no]) - (0.551 × HbA1c [%]). The population was categorized into four subgroups according to the quartiles (Q) of eGDR. Cox proportional hazard models were applied to assess the associations between eGDR and ASCVD incidence, and restricted cubic spine (RCS) was employed to examine the dose-response relationship.

RESULTS

The mean age of participants was 63.6 ± 10.1 years, comprising 3163 (52.5%) women. Over a median follow-up duration of 14.1 years, 565 (9.4%) developed ASCVD, including 256 (4.2%) myocardial infarctions, 234 (3.9%) strokes, and 358 (5.9%) fatal coronary heart disease. Compared to the lowest quartile, the adjusted hazard ratios (95% confidence intervals) for incident ASCVD for Q2-Q4 were 0.87 (0.68-1.10), 0.63 (0.47-0.84), and 0.43 (0.30-0.64), respectively. Per 1 standard deviation increase in eGDR was associated with a 30% (HR: 0.70, 95% CI 0.60-0.80) risk reduction of ASCVD, with the subgroup analyses indicating that age and hypertension modified the association (P for interaction < 0.05). RCS analysis indicated a significant and linear relationship between eGDR and ASCVD incidence risk.

CONCLUSION

eGDR level was negatively associated with incident ASCVD risk in a linear fashion among the general population. Our findings may contribute to preventive measures by improving ASCVD risk assessment.

Chronic Use of Artificial Sweeteners: Pros and Cons

Over the past few decades, the scientific community has been highly concerned about the obesity epidemic. Artificial sweeteners are compounds that mimic the sweet taste of sugar but have no calories or carbohydrates; hence, they are very popular among patients suffering from diabetes or obesity, aiming to achieve glycemic and/or weight control. There are four different types of sweeteners: artificial, natural, rare sugars, and polyols. Artificial and natural sweeteners are characterized as non-nutritional sweeteners (NNSs) since they do not contain calories. The extended use of sweeteners has been reported to have a favorable impact on body weight and glycemic control in patients with type 2 diabetes (T2DM) and on tooth decay prevention. However, there is concern regarding their side effects. Several studies have associated artificial sweeteners' consumption with the development of insulin resistance, nonalcoholic fatty liver disease (NAFLD), gastrointestinal symptoms, and certain types of cancer. The present review focuses on the description of different types of sweeteners and the benefits and possible deleterious effects of the chronic consumption of NNSs on children's health. Additionally, possible underlying mechanisms of the unfavorable effects of NNSs on human health are described.

Adaptation and Validation of the Psychological Consequences of Screening Questionnaire (PCQ) for Cognitive Screening in Primary Care

BACKGROUND

Context-specific measures with adequate external validity are needed to appropriately determine psychosocial effects related to screening for cognitive impairment.

METHODS

Two-hundred adults aged ≥65 y recently completing routine, standardized cognitive screening as part of their Medicare annual wellness visit were administered an adapted version of the Psychological Consequences of Screening Questionnaire (PCQ), composed of negative (PCQ-Neg) and positive (PCQ-Pos) scales. Measure distribution, acceptability, internal consistency, factor structure, and external validity (construct, discriminative, criterion) were analyzed.

RESULTS

Participants had a mean age of 73.3 y and were primarily female and socioeconomically advantaged. Most had a normal cognitive screening result (99.5%, n = 199). Overall PCQ scores were low (PCQ-Neg: x ¯ = 1.27, possible range 0-36; PCQ-Pos: x ¯ = 7.63, possible range 0-30). Both scales demonstrated floor effects. Acceptability was satisfactory, although the PCQ-Pos had slightly more item missingness. Both scales had Cronbach alphas >0.80 and a single-factor structure. Spearman correlations between the PCQ-Neg with general measures of psychological distress (Impacts of Events Scale-Revised, Perceived Stress Scale, Kessler Distress Scale) ranged from 0.26 to 0.37 (P's < 0.001); the correlation with the World Health Organization-Five Well-Being Index was -0.19 (P < 0.01). The PCQ-Neg discriminated between those with and without a self-reported subjective cognitive complaint (x ¯ = 2.73 v. 0.89, P < 0.001) and was associated with medical visit satisfaction (r = -0.24, P < 0.001) on the Patient Satisfaction Questionnaire. The PCQ-Pos predicted self-reported willingness to engage in future screening (x ¯ = 8.00 v. 3.00, P = 0.03).

CONCLUSIONS

The adapted PCQ-Neg is an overall valid measure of negative psychological consequences of cognitive screening; findings for the PCQ-Pos were more variable. Future studies should address measure performance among diverse samples and those with abnormal screening results.

HIGHLIGHTS

The PCQ scale is an overall valid measure of psychological dysfunction related to cognitive screening in older adults receiving normal screen results.PCQ scale performance should be further validated in diverse populations and those with abnormal cognitive screening results.The adapted PCQ may be useful to both health research and policy stakeholders seeking improved assessment of psychological impacts of cognitive screening.

Medical financial hardship in the Southern United States: the struggle continues across generations pre- and post- the Affordable Care Act

INTRODUCTION

Medical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations - Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA).

METHODS

This observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre-ACA (2011-2013), ii) post ACA (2015-2018), and iii) COVID-19 pandemic (2021-2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage.

RESULTS

Adults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage.

CONCLUSIONS

The problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage.

Exploring transfer effects on memory and its neural mechanisms through a computerized cognitive training in mild cognitive impairment: randomized controlled trial

BACKGROUND

Computerized cognitive training (CCT) has been proposed as a potential therapy for cognitive decline. One of the benefits of CCT is a transfer effect, but its mechanism on the memory domain is unclear. This study aimed to investigate the transfer effect of non-memory multidomain CCT on the memory domain and its neural basis in patients with mild cognitive impairment (MCI) through a randomized controlled trial.

METHODS

Patients with MCI recruited from memory clinics were randomly assigned to either the CCT or the control group. The CCT group received multidomain CCT training excluding memory training, while the control group read educational books with learning-based quizzes twice a week for 8 weeks. Participants underwent memory tests yielding a composite score, other cognitive domain tests, non-cognitive scales, and resting-state functional magnetic resonance imaging (rsfMRI), at baseline and after intervention. Within- and between-group comparisons, group × time interactions, and seed-to-voxel analyses in memory-involving brain networks were performed.

RESULTS

The CCT group showed improvement over the control group in memory domain (Group × time, F = 5.87, P = 0.03, η2 = 0.31), which was related with the increased connectivity in the hippocampal-frontal and fusiform-occipital network. No other cognitive and non-cognitive symptoms differed between groups after adjusting for covariates.

CONCLUSION

Eight weeks of multidomain CCT without memory training improved memory function and restored functional network in the hippocampal and medial temporal region in MCI patients. These results can provide evidence for the transferring ability of CCT on memory functioning with its neural basis.

The Role of Social Determinants of Health in Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

This review seeks to provide important information on each of the major domains of social determinants of health (SDOH) in the context of atherosclerotic cardiovascular disease.

RECENT FINDINGS

SDOH can be classified into five domains: social and community context, health care access and quality, neighborhood and built environment, economic stability, and education access and quality. SDOH are major drivers for cardiovascular health outcomes that exceed the impact from traditional risk factors, and explain inequities in health outcomes observed across different groups of individuals. SDOH profoundly impacts healthcare's receipt, delivery, and outcomes. Many patients fall within various disenfranchised groups (e.g., identify with minority race, low socioeconomic status, low educational attainment, LGBTQ+), which impact overall health status and care. Learning to understand, recognize, and address SDOH as the driving force of disparities are critical for achieving health equity in the prevention and adequate treatment of ASCVD.

Food Is Medicine: The Time Is Now

Virtually every professional society globally now endorses a plant-forward diet that is lower in fat and processed foods as key components of disease prevention and health promotion. It is characterized by whole grain foods, and predominantly made of fresh foods. With healthcare expenditures at record levels across the globe, implementing a treatment plan that has larger magnitude health improvements than nearly any known medicine, that is extremely inexpensive, and has the power to not only improve human health but also planetary health is critical. That plan is Food is Medicine (FIM) which will be explored in this manuscript.

Association of life's essential 8 with mortality among the individuals with cardiovascular disease

This study explores the association between LE8 scores and mortality risks among individuals diagnosed with cardiovascular disease (CVD). Utilizing data from the NHANES conducted between 2005 and 2018, survey-weighted multivariable Cox proportional hazards regression models were utilized. Life's Essential 8 (LE8) scores dose-response associations were assessed using restricted cubic spline regression. Sub-analyses were performed for different categories of CVD. The study consisted of 2164 participants diagnosed with CVD, ranging in age from 20 to 80 years (weighted mean [SE] age, 61.47 [0.34] years; The average total LE8 was 64.97 [0.54]. 499 participants experienced mortality, with 350 deaths attributed to CVD. After accounting for potential covariates, LE8 score was found to be associated with a decreased both all-cause mortality (OR 0.34, CI 0.22-0.51) and CVD mortality (OR 0.40, CI 0.23-0.68). A survey-weighted multivariable Cox model with restricted cubic splines identified the lowest all-cause mortality (P < 0.001) and CVD mortality (P < 0.001) risk when LE8 reach at 63.75 (P < 0.001). The results highlight the association between LE8 scores and reduced mortality in CVD patient population. The implementation of comprehensive initiatives that prioritize healthy dietary patterns, will play a crucial role in alleviating the impact of cardiovascular disease and improving cardiovascular health outcomes.

Piloting Home Produce Delivery to Improve Food Security, Budget, and Diet in Families with Children: A Mixed-Methods Study

BACKGROUND

Few children in food insecure (FI) households meet dietary recommendations for fruit and vegetables ("produce"). Barriers include affordability, accessibility, and desirability. Home produce delivery may reduce FI, increase produce consumption, and decrease budget tradeoffs.

OBJECTIVE

Evaluate the acceptability and potential impact of delivering produce through home visiting programs on FI, diet, and budget tradeoffs.

METHODS

In this prospective pre/post mixed methods study, 51 parents engaged in home visiting programs were enrolled. Participants completed pre- and post-program surveys on FI (18-item Food Security Scale), produce consumption, and budget tradeoffs. Pre- and post-surveys were compared using McNemar's test and weighted kappas. Interview guides were based on Social Cognitive Theory and a previously published framework. Interviews were conducted in English or Spanish; thematic analysis was completed.

RESULTS

Twenty-nine (56.9%) participants completed both surveys. Most were female (96.3%) and Hispanic (79.3%) (Table 1). Food security improved in the post-period, with more participants reporting high food security (pre: 6.9%, post: 31.0%) and fewer reporting very low food security (pre: 20.7%, post: 6.9%, p<0.01) (Table 2). Budgetary tradeoffs decreased in the post-program period (pre: 71.4%, post: 48.1%, p=0.03). Fifteen participants were interviewed. Themes included 1) saved money, 2) increased fruit and vegetable consumption, and 3) interest in future participation.

CONCLUSION

This pilot study found that an intervention for delivery of produce through home visiting programs was acceptable to participants and resulted in potential improvements in FI and household budgets. This supports future studies to further explore the impact of this novel intervention.

WHAT'S NEW

In this prospective mixed-methods pilot, home delivered produce was acceptable and feasible with potentially improved food security and household budgets; evidence of potential change in produce consumption was mixed. Changes in budget tradeoffs is a novel outcome in food programs.

Association of back pain with all-cause and cause-specific mortality among older men: a cohort study

OBJECTIVE

We evaluated whether more severe back pain phenotypes-persistent, frequent, or disabling back pain-are associated with higher mortality rate among older men.

METHODS

In this secondary analysis of a prospective cohort, the Osteoporotic Fractures in Men (MrOS) study, we evaluated mortality rates by back pain phenotype among 5215 older community-dwelling men (mean age, 73 years, SD = 5.6) from 6 sites in the United States. The primary back pain measure used baseline and Year 5 back pain questionnaire data to characterize participants as having no back pain, nonpersistent back pain, infrequent persistent back pain, or frequent persistent back pain. Secondary measures of back pain from the Year 5 questionnaire included disabling back pain phenotypes. The main outcomes measured were all-cause and cause-specific death.

RESULTS

After the Year 5 exam, during up to 18 years of follow-up (mean follow-up = 10.3 years), there were 3513 deaths (1218 cardiovascular, 764 cancer, 1531 other). A higher proportion of men with frequent persistent back pain versus no back pain died (78% versus 69%; sociodemographic-adjusted HR = 1.27, 95% CI = 1.11-1.45). No association was evident after further adjustment for health-related factors, such as self-reported general health and comorbid chronic health conditions (fully adjusted HR = 1.00; 95% CI = 0.86-1.15). Results were similar for cardiovascular deaths and other deaths, but we observed no association of back pain with cancer deaths. Secondary back pain measures, including back-related disability, were associated with increased mortality risk that remained statistically significant in fully adjusted models.

CONCLUSION

Although frequent persistent back pain was not independently associated with risk of death in older men, additional secondary disabling back pain phenotypes were independently associated with increased mortality rate. Future investigations should evaluate whether improvements in disabling back pain affect general health and well-being or risk of death.

Evaluation of the Effect of Nutrition Education on Osteopathic Medical Students' Personal Nutrition Choices and Incorporation Into Future Medical Practice

CONTEXT

Our current research project evaluates the impact of nutrition education on the medical student's personal nutrition goals and the likelihood of incorporating nutrition needs into patient evaluation and treatment plans in future practice. The growing popularity of lifestyle medicine has further emphasized the importance of nutrition in the treatment of all patients, especially those suffering from chronic diseases. The paucity of formal medical nutrition education in medical school curricula leaves a significant gap in the knowledge base of physicians in practice.

OBJECTIVE

In an attempt to close the gap, we increased nutrition education in first-year osteopathic medical students by establishing a nutrition course emphasizing modern competencies and their importance in clinical practice.  Methods: The course evaluation utilized a two-group quasi-experimental pre-test/post-test study design. The intervention group consisted of medical students participating in the newly established course, and the control group consisted of second-year medical students who had not taken the course as part of their curriculum. Information was collected about students' knowledge, attitudes, behaviors around nutrition, their plans to pursue a residency with a focus on culinary medicine and incorporate medical nutrition into their medical practice in the future, and their intention to incorporate culinary medicine into future treatment plans. Participation rates within a voluntary culinary medicine interest group were also tracked.

RESULTS

 Students in the intervention group were 26% more likely to report that proper nutrition for patient care had been addressed in coursework. This suggests that medical students exposed to the medical nutrition course have received more training that is critical in proper patient care than students in the control group. Students in the intervention group were 93% more likely to believe that proper nutrition can be used to prevent disease. Lastly, significantly more students in the intervention group (33% more) intend to explore residency programs with a focus on culinary medicine than those students in the control group.

CONCLUSION

These results demonstrate that nutritional education promotes an awareness of the effectiveness of nutritional counseling in disease prevention and management. Furthermore, it will hopefully prompt future physicians to consider nutritional counseling during their clinical rotations, through residency, and into their independent practice. The presentation of nutrition in the first year of medical school is critical to develop increasing numbers of primary care physicians that promote the importance of nutrition and a healthy lifestyle for patients.

High-Impact Pain Is Associated With Epigenetic Aging Among Middle-Aged and Older Adults: Findings From the Health and Retirement Study

BACKGROUND

Chronic pain has been associated with accelerated biological aging, which may be related to epigenetic alterations. We evaluated the association of high-impact pain (ie, pain that limits activities and function) with epigenetic aging, a measure of biological aging, in a nationally representative sample of middle-aged and older adults in the United States.

METHODS

Cross-sectional analysis of adults 50 years of age and older from the 2016 Health and Retirement Study. Epigenetic aging was derived from 13 epigenetic clocks based on DNA methylation patterns that predict aging correlates of morbidity and mortality. Ordinary least squares regressions were performed to test for differences in the epigenetic clocks, adjusting for the complex survey design, as well as biological, social, and behavioral factors.

RESULTS

The analysis consisted of 3 855 adults with mean age of 68.5 years, including 59.8% with no pain and 25.8% with high-impact pain. Consistent with its operational definition, high-impact pain was associated with greater functional and activity limitations. High-impact pain was associated with accelerated epigenetic aging compared to no pain, as measured via second (Zhang, PhenoAge, GrimAge) and third (DunedinPoAm) generation epigenetic clocks. Additionally, GrimAge was accelerated in high-impact pain as compared to low-impact pain.

CONCLUSIONS

High-impact pain is associated with accelerated epigenetic aging among middle-aged and older adults in the United States. These findings highlight aging-associated epigenetic alterations in high-impact chronic pain and suggest a potential for epigenetic therapeutic approaches for pain management and the preservation of physical function in older adults.

Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions

OBJECTIVE

Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set.

METHODS

We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups.

RESULTS

Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category.

CONCLUSIONS

Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Goals, Barriers, and Facilitators of Caregivers Who Participated in an In-Home Intervention to Improve Food Parenting Practices and Child Diet Quality

OBJECTIVE

To explore the goals, barriers, and facilitators set by caregivers of preschool-aged children to improve food parenting practices and household food environments.

DESIGN

Secondary qualitative analysis of collaborative goal sheets completed during in-home and telephone visits as part of a home-based pilot intervention.

PARTICIPANTS

Thirty-three Hispanic/Latinx caregivers, predominantly of low income.

PHENOMENON OF INTEREST

Patterns in goal content and anticipated barriers and facilitators.

ANALYSIS

Thematic analysis of goal sheets with a mixed inductive-deductive approach.

RESULTS

Almost half of the goals were to support a healthy environment (40.7%) by increasing the availability of healthy foods through food shopping and meal planning. Other goals were to increase structure (33.7%) by establishing food-related routines and decreasing distractions. Goals related to autonomy support (25.4%) included involving their children (eg, cooking together). Caregivers' perceived barriers encompass individual (eg, stress, lack of time), interpersonal (eg, other family members' eating behaviors), and environmental-level (eg, food availability) factors. Caregivers only identified facilitators at the individual and interpersonal levels (eg, motivation).

CONCLUSIONS AND IMPLICATIONS

Understanding goals, barriers, and facilitators can be used to tailor key messages to improve food parenting practices and children's diets. Future interventions can target broader environmental barriers while increasing awareness of individual, interpersonal, and environmental-level facilitators.

Chrononutrition and Cardiometabolic Health: An Overview of Epidemiological Evidence and Key Future Research Directions

Chrononutrition is a rapidly evolving field of nutritional epidemiology that addresses the complex relationship between temporal eating patterns, circadian rhythms, and metabolic health, but most prior research has focused on the cardiometabolic consequences of time-restricted feeding and intermittent fasting. The purpose of this topical review is to summarize epidemiological evidence from observational and intervention studies regarding the role of chrononutrition metrics related to eating timing and regularity in cardiometabolic health preservation and cardiovascular disease prevention. Observational studies are limited due to the lack of time-stamped diet data in most population-based studies. Findings from cohort studies generally indicate that breakfast skipping or the later timing of the first eating occasion, a later lunch and dinner, and a greater proportion of caloric intake consumed in the evening are associated with adverse cardiometabolic outcomes, including higher risk for coronary heart disease, hypertension, type 2 diabetes, obesity, dyslipidemia, and systemic inflammation. Randomized controlled trials are also limited, as most in the field of chrononutrition focus on the cardiometabolic consequences of time-restricted feeding. Overall, interventions that shift eating timing patterns to earlier in the day and that restrict evening caloric intake tend to have protective effects on cardiometabolic health, but small sample sizes and short follow-up are notable limitations. Innovation in dietary assessment approaches, to develop low-cost validated tools with acceptable participant burden that reliably capture chrononutrition metrics, is needed for advancing observational evidence. Culturally responsive pragmatic intervention studies with sufficiently large and representative samples are needed to understand the impact of fixed and earlier eating timing schedules on cardiometabolic health. Additional research is warranted to understand the modifiable determinants of temporal eating patterns, to investigate the role of chrononutrition in the context of other dimensions of diet (quantity, quality, and food and nutrition security) in achieving cardiometabolic health equity, and to elucidate underlying physiological mechanisms.

Oral citrate supplementation mitigates age-associated pathological intervertebral disc calcification in LG/J mice

Despite the high prevalence of age-dependent intervertebral disc calcification, there is a glaring lack of treatment options for this debilitating pathology. Here, we investigate the efficacy of long-term oral K3Citrate supplementation in ameliorating disc calcification in LG/J mice, a model of spontaneous age-associated disc calcification. K3Citrate successfully reduced the incidence of disc calcification in LG/J mice without deleterious effects on vertebral bone structure, plasma chemistry, and locomotion. Notably, a positive effect on grip strength was evident in treated mice. Spectroscopic investigation of the persisting calcified nodules indicated K3Citrate did not alter the mineral composition and revealed that reactivation of an endochondral differentiation program in endplates may drive LG/J disc calcification. Importantly, K3Citrate reduced calcification incidence without altering the pathological endplate chondrocyte hypertrophy, suggesting mitigation of disc calcification primarily occurred through Ca2+ chelation, a conclusion supported by chondrogenic differentiation and Seahorse metabolic assays. Overall, this study underscores the therapeutic potential of K3Citrate as a systemic intervention strategy for disc calcification.

Association between oxidative balance score and 10-year atherosclerotic cardiovascular disease risk: results from the NHANES database

Introduction

The oxidative balance score (OBS) is a holistic measure that represents the overall equilibrium between prooxidants and antioxidants in one's diet and lifestyle. Little research has been conducted on the correlation between OBS and 10-year atherosclerotic cardiovascular disease risk (ASCVD). Therefore, the objective of this investigation was to examine the potential correlation between OBS and 10-year risk.

Methods

A total of 11,936 participants from the NHANES conducted between 2001 and 2016 were chosen for the study and their dietary and lifestyle factors were used to assess the OBS score. Logistic regression and restricted cubic splines (RCS) were employed in the cross-sectional study to evaluate the correlation between OBS and the 10-year ASCVD risk. The cohort study utilized Cox proportional hazards models and RCS to assess the correlation between OBS and all-causes and cardiovascular disease (CVD) mortality in individuals with high ASCVD risk.

Results

The cross-sectional study found that the OBS (OR = 0.94, 95% CI = 0.93-0.98), as well as the dietary OBS (OR = 0.96, 95% CI = 0.92-0.96) and lifestyle OBS (OR = 0.74, 95% CI = 0.69-0.79), were inversely associated with the 10-year ASCVD risk. A significant linear relationship was observed between OBS, dietary OBS, lifestyle OBS, and the 10-year ASCVD risk. The cohort study found that the OBS was inversely associated with all-cause (aHRs = 0.97, 95% CI = 0.96-0.99) and CVD (aHRs = 0.95, 95% CI = 0.93-0.98) mortality in individuals with high ASCVD risk. A significant linear correlation was observed between OBS, dietary OBS, lifestyle OBS, and all-cause and CVD mortality in participants with high ASCVD risk.

Conclusion

The findings indicate that OBS, OBS related to diet, and OBS related to lifestyle were significantly inversely correlated with the 10-year ASCVD risk. Adopting a healthy eating plan and making positive lifestyle choices that result in increased OBS levels can help lower the likelihood of all-cause and CVD mortality in individuals with high ASCVD risk.

Machine learning for detection of heterogeneous effects of Medicaid coverage on depression

In 2008, Oregon expanded its Medicaid program using a lottery, creating a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design (Oregon Health Insurance Experiment). Analysis showed that Medicaid coverage lowered the risk of depression. However, this effect may vary between individuals, and the identification of individuals likely to benefit the most has the potential to improve the effectiveness and efficiency of the Medicaid program. By applying the machine learning causal forest to data from this experiment, we found substantial heterogeneity in the effect of Medicaid coverage on depression; individuals with high predicted benefit were older and had more physical or mental health conditions at baseline. Expanding coverage to individuals with high predicted benefit generated greater reduction in depression prevalence than expanding to all eligible individuals (21.5 vs 8.8 percentage-point reduction; adjusted difference = +12.7 [95% CI, +4.6 to +20.8]; P = 0.003), at substantially lower cost per case prevented ($16 627 vs $36 048; adjusted difference = -$18 598 [95% CI, -156 953 to -3120]; P = 0.04). Medicaid coverage reduces depression substantially more in a subset of the population than others, in ways that are predictable in advance. Targeting coverage on those most likely to benefit could improve the effectiveness and efficiency of insurance expansion. This article is part of a Special Collection on Mental Health.

Sugar-sweetened beverage intake and chronic low back pain

Background

The consumption of sugar-sweetened beverages (SSBs) has become a major public health problem globally. However, no studies have specifically examined the relationship between SSB intake and chronic low back pain (CLBP). Therefore, the present study aimed to investigate the relationship between SSB intake and the risk of CLBP.

Methods

This cross-sectional study enrolled participants aged 20 to 69 from the National Health and Nutrition Examination Survey. CLBP was defined as persistent LBP for a consecutive three-month period. Furthermore, SSB intake was assessed and calculated based on dietary recall interviews. Moreover, survey-weighted logistic regression models were employed to evaluate the association between SSB intake and the risk of CLBP, while the restricted cubic spline (RCS) analysis was used to determine whether there were nonlinear associations between SSB intake and CLBP risk. In addition, subgroup analysis was performed using stratification and interaction analysis for all covariates.

Results

A total of 4,146 participants (mean age: 43.405 years) were enrolled in the final analysis. The results of survey-weighted logistic regression models showed that SSB consumption was significantly associated with an increased risk of CLBP among individuals aged 20 to 69 years. Moreover, the results of subgroup analysis and interaction analysis demonstrated that the association between SSB intake and the risk of CLBP was modified by smoking status and hypertension. Specifically, the SSB intake-associated CLBP risk was more pronounced among current smokers or individuals with hypertension.

Conclusion

Reduction of SSB consumption might contribute to the prevention of CLBP for individuals aged 20 to 69 years. Moreover, current smokers or individuals with hypertension should be more vigilant about the SSB intake-associated CLBP risk. Nevertheless, caution should be exercised when interpreting the results of this study, as further research is necessary to explore the association between SSB consumption and CLBP, given the limitations of the current study.

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Augmenting the National Nutrition Data System to Promote Diet Sustainability Analyses

Research on sustainable diets has become an important and growing area of the nutrition field, but recent studies have pointed to a lack of sustainability metrics and methods that are hindering research and policy progress. To fill this gap, the White House National Strategy on Hunger, Nutrition, and Health calls for increased funding to improve metrics, data collection, and research to address all domains of sustainability, which include nutrition/health, economic, environmental, and social domains. Commodity recipe databases, such as the Food Commodity Intake Database (FCID), are important tools for conducting diet sustainability analyses because they translate mixed dishes from dietary surveys, such as the National Health and Nutrition Examination Survey (NHANES), into commodity ingredients. These ingredients have been linked to data on environmental impacts and economic costs from other databases, thus facilitating collaboration between nutrition researchers, environmental scientists, economists, and others. These linkages cannot be made with other components of the national nutrition data system, such as the Food Patterns Equivalents Database (FPED), because the disaggregated food groups from them are not relevant for examining environmental impacts. Although the NHANES is conducted on an ongoing basis, and FPED is continually updated, the FCID has not been officially updated since 2010. This severely limits advancements in sustainability research and related policy analyses. In this commentary, we argue that the federal government should promote this diet sustainability work by integrating a commodity recipe database into the national nutrition data system, and updating it on a regular basis, as it does with other component databases.

Primary Care Models and Depression Outcomes in Rural Adult Populations: A Systematic Review

Rural populations rely on primary care services for depression care due to shortages and maldistributions of specialty mental health care favoring urban areas. Yet, it is unknown which primary care models are effective at reducing depressive symptoms and emergency department (ED) use for depression among rural populations. The purpose of this systematic review is to synthesize the effectiveness of primary care models on depressive symptoms and ED utilization for depression in rural populations. PubMed, PsycINFO, CINAHL, and reference lists of included studies were searched. Eligible articles focused on the impact of primary care models on depressive symptoms or ED utilization for depression among rural populations in the United States. Seventeen studies met the inclusion criteria. Three care models were identified in the studies, including collaborative care (i.e., team-based integrated care that tracks patient populations with a registry; n = 7), tele-psychotherapy (i.e., identification of patients in primary care and referral to virtual psychotherapy; n = 6), or self-management support (i.e., identification of patients in primary care and referral to community support for depression self-management; n = 4). These care models were associated with improved patient-reported depressive symptoms such as Patient-Health Questionnaire reported remission of depression (score < 5). No studies assessed depression ED utilization as an outcome. Collaborative care, tele-psychotherapy, and self-management support may be effective at reducing depressive symptoms, specifically in rural populations and should be implemented at the practice level. Research focused on primary care models and ED utilization for depression among rural populations is needed.

'Everywhere I call, there's nothing available': Understanding the alcohol treatment landscape and needs among unstably housed people who use alcohol in Rhode Island

INTRODUCTION

Alcohol is a leading cause of morbidity and mortality in the United States and people who are unstably housed are disproportionately impacted by adverse alcohol-related health outcomes. Addressing the needs of unstably housed people with high-intensity alcohol use (i.e., heavy episodic use or binge drinking), including those whose goal is not abstinence, is critical to reducing harms among this population. This study explores the alcohol-related treatment and support needs among unstably housed people who use alcohol.

METHODS

Data collection included participant observation and semi-structured interviews (n = 25) with unstably housed people with high-intensity alcohol use. Data were analysed thematically, with attention to structural vulnerability and social-structural forces at shaping perceptions of and experiences with alcohol treatment.

RESULTS

Participants underscored how housing instability was critical in precipitating and maintaining heavy alcohol use, with alcohol often used to manage the stress and anxiety related to housing instability. While participants regularly engaged with alcohol treatment programs, program design and barriers to access undermined the effectiveness of these services for participants. Participants described the need for a range of program and service options across a continuum of care to be implemented to support participants in meeting their diverse needs and identified goals regarding alcohol use.

DISCUSSION AND CONCLUSIONS

Alcohol treatment and supports need to be modified so that they include a range of harm reduction and abstinence-based models to better meet people's diverse needs. Furthermore, treatment must be paired with permanent and affordable housing to address underlying drivers of alcohol-related harm for unstably housed people.

Dietary Counseling Documentation Among Patients Recently Hospitalized for Cardiovascular Disease

BACKGROUND

Diet intervention forms the cornerstone for cardiovascular disease (CVD) management.

OBJECTIVE

The objective was to measure the frequency of dietary counseling documentation for patients recently hospitalized with CVD.

DESIGN

This was an observational study.

PARTICIPANTS AND SETTING

Patients were included from the Michigan Value Collaborative Multipayer Claims Registry from October 2015 to February 2020.

MAIN OUTCOME MEASURE

The study measured the frequency of medical claims that document dietary counseling ≤90 days after hospitalization (ie, an episode of care) for CVD events (coronary artery bypass grafting, acute myocardial infarction, congestive heart failure, and percutaneous coronary intervention). Dietary counseling documentation was defined as having an encounter-level International Classification of Diseases 10th Revision code for dietary counseling or current procedural terminology code for medical nutrition therapy or cardiac rehabilitation.

STATISTICAL ANALYSES PERFORMED

Multivariable logistic regression was used to measure variation in documentation across gender, age, comorbidities, hospital geography, CVD event, and insurer.

RESULTS

There were 175,631 episodes of care (congesitve heart failure 47.1%, acute myocardial infarction 28.7%, percutaneous coronary intervention 17.0%, and coronary artery bypass grafting 7.3%) among 146,185 individuals. Most episodes occurred among men (55.8%) and those older than age 65 years (71.9%). Dietary counseling was documented for 22.8% of episodes and was more common as cardiac rehabilitation (18.6%) than other encounter types (5.1%). In multivariable analysis, there was lower odds for dietary counseling documentation among those older than age 65 years (odds ratio [OR] 0.77; P < .001), women (OR 0.83; P < .001), with chronic kidney disease (OR 0.74; P < .001), or diabetes (OR 0.95; P < .001), but greater odds for those with obesity (OR 1.28; P < .001) and nonmetropolitan hospitals (OR 1.31; P < .001). Compared with coronary artery bypass grafting, acute myocardial infarction (OR 0.29; P < .001), confestive heart failure (OR 0.12; P < .001), and percutaneous coronary intervention (OR 0.36; P < .001) episodes had lower odds to have dietary counseling coded. Compared with Traditional Medicare, Medicaid and Medicare Advantage health maintenance organization plans had lower odds, whereas Commercial or Medicare Advantage preferred provider organization and Commercial health maintenance organization plans had higher odds to have dietary counseling documented. Results were mostly similar when evaluated by race.

CONCLUSIONS

Dietary counseling was infrequently documented after hospitalization for CVD episodes in medical claims in a Michigan-based multipayer claims database with large variation by reason for hospitalization and patient factors.

From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

Increasing Trainee Comfort with Nutrition

OBJECTIVES

Nutrition counseling is necessary for the prevention and treatment of many chronic diseases. US survey data demonstrate that 61% of Internal Medicine (IM) residents receive little to no nutrition training. The objective of our study was to develop a curriculum to increase IM resident comfort and ability in conducting a nutritional assessment.

METHODS

Categorical IM residents at a large academic medical center participated in a curriculum that included a lecture, a small-group discussion, and a skills exercise. Residents completed pre- and posttest surveys that evaluated their attitudes and comfort level with nutritional assessment.

RESULTS

Eighty percent (84/105) of the residents participated in the curriculum and 48% (40/84) of them completed both pre- and postsession surveys. Residents who considered themselves moderately to extremely comfortable completing a nutritional assessment increased after the program (27.5% to 87.5%, P < 0.0001). The proportion of those who agreed or strongly agreed with the statement, "Nutritional counseling should be included in any routine appointment, just like diagnosis and treatment," increased from 62.50% to 80.00% (P = 0.012). The proportion of residents who considered lack of individual knowledge to be a barrier for nutrition counseling decreased from 65.79% to 42.11% (P = 0.0126).

CONCLUSIONS

This curriculum was successful in increasing IM resident comfort with conducting a nutritional assessment.

Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review

BACKGROUND

Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP.

OBJECTIVE

The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research.

METHODS

Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles.

RESULTS

A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results.

CONCLUSIONS

Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.

A Look Into How the "Blue Zone" Lifestyle May Affect Patients' Lives Before and After Hip Fracture: A Propensity-Matched Cohort Study

INTRODUCTION

Hip fractures are life-changing injuries with associated one-year mortality up to 30%. Five locations in the world have been termed "blue zones," where the longevity of the population is markedly higher than that of surrounding areas and there are 10 times more centenarians. The United States has one blue zone (Loma Linda, California), which is believed to be because of the lifestyle of the Seventh-day Adventist population living there. We hypothesized that patients from the blue zone experience low-energy, frailty-driven, osteoporotic hip fractures later in life and an increased postinjury longevity relative to non-blue zone control subjects.

METHODS

A review of patients treated for hip fracture between January 2010 and August 2020 from a single institution was conducted. Demographic data were collected, and the end point of mortality was assessed using death registry information, queried in April 2024. Groups were divided into blue zone and non-blue zone. Statistical analysis was conducted with P < 0.05 considered significant.

RESULTS

Complete data were available for 1,032 patients. The blue zone cohort sustained low-energy hip fractures 12 years later in life (83.2 versus 71.1, P < 0.01). Propensity score matching was used to account for this difference. After propensity score matching, age, body mass index, American Society of Anesthesiologists score, surgery performed, sex, mechanism, ethnicity, diabetes, chronic obstructive pulmonary disease, CHF, chronic kidney disease grade, dementia, surgical time, and drug/tobacco/marijuana use were similar between groups. Blue zone patients had lower mortality at both 1 and 2 years postoperatively (12% versus 24%, P = 0.03 and 20% versus 33%, P = 0.03, respectively), had more hypertension (76% versus 62%, P = 0.03), reported lower alcohol use (7% versus 20%, P < 0.01), and included more Seventh-day Adventists (64% versus 15%, P < 0.01).

CONCLUSION

The blue zone lifestyle affected the onset of frailty and delayed osteoporotic hip fracture by 12 years in this propensity-matched cohort study. Postoperative mortality was also markedly lower in the blue zone cohort.