Sharon Scarbro

Early Impact of the Federally Mandated Local Wellness Policy on Physical Activity in Rural, Low-Income Elementary Schools in Colorado

The Whats Working project described the initial impact of the United States’ federally mandated Local Wellness Policy in rural, low-income elementary schools located in Colorado. Before and after the Local Wellness Policy mandate went into effect, a survey about school features related to nutrition and physical activity was sent to a random sample of 45 rural elementary schools (i.e., schools located outside of urban areas), in which at least 40% of students qualified for free or reduced-cost lunch. Overall, opportunities for physical activity did not change after the policy went into effect: although time in physical education increased by 14 min per week (P=0.10), time for recess decreased by roughly 19 min per week (P=0.10). Policies supporting student participation in physical education and recess (an unstructured time during school hours when students are allowed to play outside) did not change. The researchers coded Local Wellness Policies and found them to have weak wording that produced minimal impact. Content analysis of key informant interviews suggested several barriers to the impact of the Local Wellness Policies: (1) competing pressures facing school districts, (2) lack of resources devoted to the Local Wellness Policy, (3) principals’ lack of knowledge about the policy, and (4) lack of accountability mechanisms to ensure policy implementation. Financial resources and more effective communication about Local Wellness Policies among school districts and principals are needed to elevate the importance of and increase opportunities for physical activity in rural, low-income Colorado elementary schools.

Coaching Process Outcomes of a Family Visit Nutrition and Physical Activity Intervention

The purpose of this article is to report the process outcomes of a coaching methodology used in a study designed to increase fruit and vegetable consumption and physical activity in families. Eighty-eight families with second graders were recruited from a rural, biethnic community in Colorado and randomized to intervention and delayed intervention conditions. This article reports on the 27 families in the delayed intervention group. Families received up to 10 home visits over 10 months from a family advisor and completed activities to improve their dietary and physical activity behaviors. Coaching conversations took place during each home visit. Coaching process outcomes were evaluated by analysis of visit documentation, participant survey, and qualitative interviews. Results indicated that coaching, in conjunction with family activities, engaged families in the process of change and facilitated movement toward the achievement of their weekly nutrition or physical activity goals. Coaching methodology may be particularly useful for participatory research.

Long-term student outcomes of the Integrated Nutrition and Physical Activity Program.

OBJECTIVE To examine the long-term effects of the Integrated Nutrition and Physical Activity Program (INPAP), a school-based nutrition education program. DESIGN Quasi-experimental design comparing intervention and comparison cohorts at 3-6 years after delivery of the INPAP intervention on nutrition- and physical activity-related outcomes. SETTING This study was conducted in 1 school district in a low-income rural county of ∼15,000 residents in south-central Colorado. PARTICIPANTS In second grade, intervention and comparison cohorts included 173 (fall 2000) and 190 (fall 1999) students, respectively. Approximately 60% of these students completed assessments in eighth grade. INTERVENTIONS INPAP is an experiential school-based nutrition education program, grounded in social cognitive theory and Piagets cognitive development theory and adapted for use in a rural setting. OUTCOMES Nutrition and physical activity knowledge, self-efficacy, attitudes and behaviors, body mass index. ANALYSIS Wilcoxon signed rank test, chi-square test for proportions, and t test for means. RESULTS Long-term effects were observed in nutrition-related knowledge and attitudes but not self-efficacy or behavior change. The effects that did occur were attenuated over time. CONCLUSION AND IMPLICATIONS This study found that INPAP implemented in elementary school had limited lasting effects by the end of middle school, a time when students have increased autonomy to make food choices.

Patterns of Rural Hispanic and Non-Hispanic White Health Care Use: The San Luis Valley Health and Aging Study

This cross-sectional study examines utilization of health care resources, including nursing homes, among 1,433 rural Hispanic and non-Hispanic White participants in the San Luis Valley Health and Aging Study. Results show substantially greater non-Hispanic White residence in nursing homes, greater Hispanic use of professional home nursing services, but little ethnic difference in outpatient care or hospitalization. Analyses based on the behavior model of utilization find health care use strongly associated with need factors. In particular, outpatient care correlated with disease and instrumental daily living activity dependence, home nursing care with basic daily living activity dependence, and nursing home use with daily living activity dependence and cognitive impairment. Predisposing characteristics (age, marital status, education) and enabling supports and barriers (insurance, availability of no-or low-cost care, transportation difficulties) also influenced utilization. The differential ethnic pattern of nursing home use persisted after controlling for these important characteristics.

Fear of injury with physical activity is greater in adults with diabetes than in adults without diabetes.

OBJECTIVE Physical activity is a cornerstone of treatment for diabetes, yet people with diabetes perform less moderate and vigorous physical activity (MVPA) than people without diabetes. In contrast, whether differences in walking activity exist has been understudied. Diabetes-specific barriers to physical activity are one possible explanation for lower MVPA in diabetes. We hypothesized that people with diabetes would perform less walking and combined MVPA and would be less likely to anticipate increasing physical activity if barriers were theoretically absent, compared with people without diabetes. RESEARCH DESIGN AND METHODS We surveyed 1,848 randomly selected rural Colorado adult residents by telephone from 2002 to 2004. Respondents reported weekly walking and MVPA duration and their likelihood of increasing physical activity if each of seven barriers was theoretically absent. RESULTS People with diabetes (n = 129) had lower odds of walking and MVPA than people without diabetes (walking: adjusted odds ratio 0.62 [95% CI 0.40–0.95]; MVPA: adjusted odds ratio 0.60 [0.36–0.99]; ≥10 vs. <10 min/week, adjusted for age, sex, BMI, and ethnicity). Respondents with diabetes reported fear of injury as a barrier to physical activity more often than respondents without diabetes (56 vs. 39%; P = 0.0002), although this relationship was attenuated after adjusting for age and BMI (adjusted odds ratio 1.36 [0.93–1.99]). CONCLUSIONS Although walking is a preferred form of activity in diabetes, people with diabetes walk less than people without diabetes. Reducing fear of injury may potentially increase physical activity for people with diabetes, particularly in older and more overweight individuals.

Local Wellness Policy 5 Years Later: Is It Making a Difference for Students in Low-Income, Rural Colorado Elementary Schools?

Introduction The federally mandated Local Wellness Policy (LWP) was intended to promote student health in schools. This study assesses the 5-year effects of the LWP on the health practices of rural elementary schools in Colorado. Methods One year before and 5 years after the LWP mandate, a survey was administered to a random sample of principals, physical education (PE) teachers, and food-service managers in 45 rural, low-income elementary schools in Colorado. Response rates were 71% in 2005 and 89% in 2011. Results Minutes for PE and recess did not increase, nor did offerings of fresh fruits and vegetables. More schools adopted policies prohibiting teachers from taking recess away as punishment (9.7% in 2005 vs 38.5% in 2011, P = .02) or for making up missed instructional time, class work, or tests in other subjects (3.2% in 2005 vs 28.2% in 2011, P = .03). More schools scheduled recess before lunch (22.6% in 2005 vs 46.2% in 2011, P = .04) and developed policies for vending machines (42.9% in 2005 vs 85.7% in 2011, P = .01) and parties (21.4% in 2005 vs 57.9% in 2011, P = .004). Conclusion Changes in school practices are modest, and arguably the important school practices such as increased PE and recess time and increased offerings of fruits and vegetables in the lunch line have not changed in the 5 years since the mandate went into effect. Further investigation is needed to identify the knowledge, skills, and attitudes as well as financial and physical resources required for school administrators to make changes in school practices.

A Community-Engaged Approach to Collecting Rural Health Surveillance Data.

PURPOSE In order for communities to make health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities, they need an accurate picture of the health status of residents. While state and national health surveillance systems exist to help local communities make data-driven health decisions, rural communities face unique challenges including: (1) limited county-level data; (2) underrepresented segments of the population; and (3) a lack of survey items to address local health concerns. The purpose of this study was to take a community-engaged approach to collecting population-based health status data in a rural area in an effort to address some of these unique challenges. METHODS Using a community-based participatory research (CBPR) approach, over 1,500 residents from 6 rural and frontier counties were randomly selected with a stratified, multistage cluster study design. Surveys were primarily completed over the phone. FINDINGS Response rates by county ranged from 59% to 80% (overall = 66%). Males and younger adults (18-24 year olds) were underrepresented in the sample, but Hispanics, low-income residents, and cell phone-only users were adequately represented. Prevalence rates for chronic disease and health behavior varied by county. CONCLUSIONS The implications of this project are that engaging stakeholders in community surveillance efforts increases the quality, relevance and utility of the information collected and can help reach otherwise difficult-to-reach populations. This can result in a more accurate picture of the health status of residents, which can lead to making health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities.

Growth and endocrine function in children with Dravet syndrome

PURPOSE Dravet syndrome is an intractable childhood epilepsy syndrome most often associated with an SCN1A mutation. In our clinical practice, several patients with Dravet syndrome were noted to have short stature and endocrine dysfunction. This has not been reported in the literature. Our study aim was to describe growth measurements and endocrine abnormalities in children with Dravet syndrome. METHOD A retrospective chart review was performed at a single institution. Eligibility criteria included clinical and genetic (SCN1A) diagnosis of Dravet syndrome. Records were reviewed for height and weight measurements and serologic evidence of endocrine abnormality, as well as patient demographics, anti-seizure medication, and family history. Age and gender specific trend of height and weight measurements, using z-scores, were compared to CDC growth curves (Centers for Disease Control and Prevention [1]). RESULTS Sixty-eight children were identified, 46% male, age 1-21 years, taking an average of 2.9 anti-seizure medications per patient. Mean growth parameter measurements were significant for decrease in height z-score of 0.10 (p=<0.001) and decrease in weight z-score of 0.09 (p=<0.01) for every year increase in age, such that with increasing age the cohort moved farther away from the mean. The average group height and weight z-score, at age 8, was -0.45 and -0.09, respectively. After adjusting for age, neither gender, family history, or anti-seizure medication was associated with height or weight z-score. Serologic endocrine results were available for 26 children (38%). This identified low insulin-like growth factor 1 (IGF-1) in 7/15 and low testosterone in 2/10. Two children received growth hormone supplementation. TSH testing was abnormal <10% of the time. CONCLUSIONS Comorbidities in children with Dravet syndrome may involve more systems than previously reported. We report a cohort of children with Dravet syndrome with reduced height and weight growth trend, as well as a subset with endocrine dysfunction evidenced by low IGF-1 and testosterone levels. Additional prospective research is needed to further define the significance of this relationship.

Parental Perception of Comorbidities in Children With Dravet Syndrome

BACKGROUND We hypothesized that children with Dravet syndrome may have additional common features beyond seizures and cognitive impairment. To address this gap in knowledge, we conducted a survey of caregivers of children with Dravet syndrome to identify and quantify their perception of associated symptoms in this population. METHODS An electronic survey was developed in REDcap (Research Electronic Data Capture) and sent via e-mail to the participants on the Dravet Syndrome Foundation e-mail list. Questions focused on eating, sleep, behavior, and other symptoms that might be related to Dravet syndrome. The questions were assessed using a four-point Likert scale (e.g., strongly agree to strongly disagree). Results were later dichotomized for analysis. Logistic regression was used to calculate odds ratios of various demographic factors potentially associated with symptoms. Multivariable models were constructed using backward elimination to assess the relationship among a variety of symptoms. RESULTS There were 202 respondents, 96% were parents of a child with Dravet syndrome (the remainder were grandparents or guardians); 90.5% were female. The median age of the affected child was eight years (interquartile range five to 14), 50% were male, and 90.5% were reported to have a known SCN1A mutation. At least one symptom associated with appetite was reported in 99% of respondents, 82% reported a disturbance of sleep, one third reported autonomic symptoms, and 75% reported problems with gait. Inattention and perseveration were reported more commonly than other behavioral disturbances. SIGNIFICANCE Caregivers have the perception of many symptoms in children with Dravet syndrome in addition to those that have been previously reported, including appetite, sleep, gait, and behavior. Many of these can significantly affect quality of life for both the child and the caregiver.

Clinical outcomes in U.S. infants with cystic fibrosis from 2001 to 2012

All 50 United States implemented newborn screening (NBS) for cystic fibrosis (CF) by 2010. The purpose of this study was to evaluate trends over the decade when NBS became universal to determine current rates of malnutrition, stunting, and infection rates in U.S. infants with CF.