OREGON STATE UNIVERSITY

college of public health and human sciences

Millions of people with metabolic syndrome may need more vitamin E

CORVALLIS, Ore. – New research has shown that people with metabolic syndrome need significantly more vitamin E – which could be a serious public health concern, in light of the millions of people who have this condition that’s often related to obesity.

A study just published in the American Journal of Clinical Nutrition also made it clear that conventional tests to measure vitamin E levels in the blood may have limited accuracy compared to tests made in research laboratories, to the point that conventional tests can actually mask an underlying problem.

Vitamin E – one of the more difficult micronutrients to obtain by dietary means – is an antioxidant important for cell protection. It also affects gene expression, immune function, aids in repair of wounds and the damage of atherosclerosis, is important for vision and neurologic function, and largely prevents fat from going rancid.

Nutrition surveys have estimated that 92 percent of men and 96 percent of women in the United States fail to get an adequate daily intake of vitamin E in their diet. It is found at high levels in almonds, wheat germ, various seeds and oils, and at much lower levels in some vegetables and salad greens, such as spinach and kale.

This study was done by researchers in the Linus Pauling Institute at Oregon State University and the Human Nutrition Program at The Ohio State University, as a double-blind, crossover clinical trial focusing on vitamin E levels in people with metabolic syndrome. It was supported by the National Institutes of Health, the National Dairy Council and DSM Nutrition.

“The research showed that people with metabolic syndrome need about 30-50 percent more vitamin E than those who are generally healthy,” said Maret Traber, a professor in the OSU College of Public Health and Human Sciences, and Ava Helen Pauling Professor in the Linus Pauling Institute.

“In previous work we showed that people with metabolic syndrome had lower bioavailability of vitamin E. Our current work uses a novel approach to measure how much vitamin E the body needs. This study clearly demonstrates that people with metabolic syndrome need a higher intake of this vitamin.”

More than 30 percent of the American public are obese, and more than 25 percent of the adults in the United States meet the criteria for metabolic syndrome, putting them at significantly increased risk for cardiovascular disease and type-2 diabetes – primary causes of death in the developed world.

That syndrome is defined by diagnosis of three or more of several conditions, including abdominal obesity, elevated lipids, high blood pressure, pro-inflammatory state, a pro-thrombotic state and insulin resistance or impaired glucose tolerance.

This research, for the first time, also clearly outlined a flaw with conventional approaches to measuring vitamin E.

By “labeling” vitamin E with deuterium, a stable isotope of hydrogen, scientists were able to measure the amount of the micronutrient that was eliminated by the body, compared to the intake. The advanced research laboratory tests, which are not available to the general public, showed that people with metabolic syndrome retained 30-50 percent more vitamin E than healthy people – showing that they needed it. When the body doesn’t need vitamin E, the excess is excreted.

But in the group with metabolic syndrome, even as their tissues were taking up and retaining the needed vitamin E, their blood levels by conventional measurement appeared about the same as those of a normal, healthy person.

“We’ve discovered that vitamin E levels often look normal in the blood, because this micronutrient is attracted to high cholesterol and fat,” Traber said. “So vitamin E can stay at higher levels in the circulatory system and give the illusion of adequate levels, even as tissues are deficient.

“This basically means that conventional vitamin E blood tests as they are now being done are useless.”

The findings support the conclusion that people with metabolic syndrome have higher levels of oxidative and inflammatory stress, scientists said in their conclusion, and require more antioxidants such as vitamins E as a result.

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Maret Traber, 541-737-7977

maret.traber@oregonstate.edu

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Air pollution and lack of physical activity pose competing threats to children in China

CORVALLIS, Ore. – Children and adolescents in mainland China are facing two serious and conflicting public health threats: ongoing exposure to air pollution and an increasingly sedentary lifestyle with little regular physical activity outside school.

Health workers and policymakers need to find ways to address both of these issues so that

children can be more physically active without suffering the health risks caused by exposure to air pollution, an Oregon State University researcher suggests in a new commentary published this month in The Journal of Pediatrics

“The question is how do we balance the virtues of physical activity with the hazards of air pollution?” said Brad Cardinal, a kinesiology professor in the College of Public Health and Human Sciences at Oregon State University and a national expert on the benefits of physical activity. “Ultimately, we have to find ways for people to stay active despite the air pollution.”

Many cities and countries around the world grapple with air pollution issues, but there is particular concern for children growing up in China in part because they tend to commute more on foot or bike and their playgrounds and sports fields are often found near busy streets or highways, Cardinal said. The impacts of air pollution contributed to 1.2 million deaths in 2010. 

At the same time, very few Chinese children today are participating in moderate or vigorous physical activity outside of school, and the number of overweight and obese children in China has more than doubled in the last 25 years.

Children are particularly susceptible to adverse health impacts from both short- and long-term exposure to air pollution, in part because they have higher rates of respiration and tend to take shallower breaths. Air pollution has been associated with increases in asthma, chronic cough and other respiratory problems in children that are likely to be exacerbated by heavy breathing from vigorous exercise, Cardinal said. 

So how do public health officials approach these competing challenges? Cardinal and his co-author, Qi Si of Zhejiang University in China and a former visiting scholar at OSU, suggest the two problems should be addressed together.

They recommend four urgent steps for health officials and policymakers who are grappling with these issues: 

  • Increase awareness among parents, children, health workers, educators, and policymakers on the causes and impacts of air pollution on children and adolescents, as well as the potential harm when coupled with outdoor physical activity
  • Add air quality systems at school sites, so pollution can be measured when and where children are engaging in physical activity
  • Adjust the intensity of outdoor physical activity during the school day on the basis of air pollution monitoring results
  • Educate children about exercising in polluted environments, including instruction to stop activity when they notice problems such as coughing, chest tightness or wheezing

Since schools are the base for much of the physical activity of today’s children, they are a critical piece in addressing both issues, Cardinal said. Monitoring the micro-climate at a school would provide better, more localized information for school officials making decisions about whether children should be outside exercising or at what level of intensity. 

“Doing some kind of physical activity, even if it is not as vigorous, is still better than having no physical activity for the children,” he said.

Clothing accessories or fitness equipment could also be designed to help protect children from pollution during outdoor play activities on days when air quality levels were low, he said.

“The goal is to get people thinking about these complex problems and real-world solutions,” Cardinal said. “The hope is that someone will innovate appropriate solutions for addressing both of these problems.” 

The National Health and Fitness Technology Research Key Laboratory of Zhejiang Province provided support for this project.

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Brad Cardinal, 541-737-2506, brad.cardinal@oregonstate.edu

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Improving child-teacher interactions can reduce preschoolers’ stress levels

CORVALLIS, Ore. – A school-based intervention that promotes warm and caring interactions between a teacher and child can reduce the child’s stress in the classroom, a new study has found.

The intervention was designed for teachers of preschool-aged children and focused on fostering close teacher-child relationships through one-on-one play. Children who participated in the intervention showed reduced levels of the hormone cortisol, an indicator of stress, said Bridget Hatfield, an assistant professor in Oregon State University’s College of Public Health and Human Sciences and lead author of the study.

Researchers believe it is the first time a study has examined the relationship between a teacher-child intervention and a child’s cortisol levels in an early childhood education setting.

The findings highlight the importance of the relationship between child and teacher, and underscore the value of warm and caring interactions, including one-on-one play time between a child and his or her teacher, Hatfield said.

“The big message here is that positive relationships between teachers and students matter,” she said. “What a teacher does in the classroom, the way they behave, their positivity and supportiveness, has an enormous impact on the children and their health.”

The findings were published recently in the journal Prevention Science. The co-author of the paper is Amanda Williford of the University of Virginia. The research was supported in part by grants from the U.S. Department of Education’s Institute of Education Sciences and the American Psychological Association.

About 61 percent of children under the age of five spend time in formal childcare and education settings such as preschool. Past research has shown that this setting may increase children’s stress, which in turn can lead to disruptive classroom behavior.

Children who have frustrating or difficult relationships with their teachers also have shown decreased academic success in kindergarten and their challenging behaviors may increase in intensity as they get older.

“If a child can’t develop a healthy stress response system in early childhood, it limits their ability to develop strong school-readiness skills,” Hatfield said. “That’s why these early teacher-child relationships are so important.”

Hatfield and Williford wanted to see if an intervention designed to improve child-teacher interactions could reduce stress levels in children with challenging behaviors.

In all, 70 teachers and 113 children participated in the study. They were divided into three groups: one group was designated as “business as usual” and the children did not participate in any special activities; one group participated in a “child time” intervention; and one group participated in an intervention called “Banking Time.”

In the child time intervention, the child and teacher spent time playing one-on-one but the teacher was not given any specific guidance or instructions from a consultant for the play period.

Banking Time is a much more formal intervention, designed to foster sensitive, responsive interactions between a teacher and a child, creating a relationship the child and teacher can use as a resource during times of challenge in the classroom.

“When you ‘bank time’ with a child and that relationship, you’re building equity,” Hatfield said. “Then if a conflict arises, you can make a withdrawal.”

To build that relationship, the teachers and children participating in the study had one-on-one play sessions. Consultants directed the teachers in key elements of the program: allowing the child to lead the play sessions, carefully observing and narrating the child’s behavior, describing the child’s positive and negative emotions, and being available as an emotional resource.

Using saliva samples that were assayed for cortisol, researchers found that children whose teachers participated in the Banking Time intervention showed declines in cortisol levels during the school day compared to those in the business as usual group.

Children in the child time intervention also showed some benefits from the one-on-one time, but they were not as significant. Hatfield said additional research is needed to better understand the effects of the Banking Time intervention and what, in particular, is having the positive impact on the teacher-child relationship.

“Is it one thing, or a combination?” she asked. “We know there is something meaningful about that one-on-one time within Banking Time and we want to know more about how we may be able to incorporate that into classrooms every day.”

It may difficult for preschool teachers and early childhood educators to spend 15 minutes a week in one-on-one play with each child in their class, Hatfield said, but even small, positive, one-on-one interactions could have a valuable impact over time.

“Spending even five minutes, once a week in a one-on-one with a child can help you get to know them, what they think and what they might be interested in,” she said. “That investment could pay off during a challenging time later on. It’s the quality of the time that matters.”

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Bridget Hatfield, 541-737-6438, Bridget.hatfield@oregonstate.edu

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Parenting classes benefit all, especially lower-income families

CORVALLIS, Ore. – Parenting education can improve the skills of every mom and dad and the behavior of all children, and it particularly benefits families from low-income or otherwise underserved populations, a new study from Oregon State University suggests.

Researchers examined a sample of more than 2,300 mothers and fathers who participated in parenting education series in the Pacific Northwest between 2010 and 2012. The series, designed to support parents of children up to 6 years old, typically lasted nine to 12 weeks and consisted of one one-hour session per week led by a parent education facilitator. There was no fee for participants. 

The study, part of a growing partnership between the OSU College of Public Health and Human Sciences and the Oregon Parenting Education Collaborative to increase access to parenting education for all families, may remove some of the stigma attached to parenting education, which has historically been associated with court orders for parents who’ve run afoul of child-protective laws.

“Parenting education works across the board,” said John Geldhof, an OSU assistant professor of behavioral and health sciences. “All parents can benefit. The way people typically learn parenting is from their parents and from books, and often times what they’ve learned is out of date and not the best practices for today. All parents – high income, low income, mandated, not mandated – can benefit from evidence-based parenting education.”

Neglectful or otherwise ineffective parenting strategies, which can be heightened by economic strain, can put children in jeopardy. While many parenting practices can lead to favorable outcomes in children, research indicates that the optimal combination usually features high levels of support and monitoring and the avoidance of harsh punishment. Those positive outcomes include higher grades, fewer behavior problems, less substance use, better mental health and greater social competence.

Findings of the OSU research, recently published in Children and Youth Services Review, indicate that parent education series serving predominantly lower-income parents resulted in greater improvements in their skills and their children’s behaviors compared to series serving higher-income parents.

“The results provide preliminary evidence that parenting education may be most effective when it targets underserved populations,” said lead author Jennifer Finders, a graduate student in the College of Public Health and Human Sciences. “Another thing that’s exciting - the Oregon Parenting Education Collaborative classes that are offered are general in content, and we’re seeing evidence that they’re being adapted for diverse families. This suggests that the local parenting educators are implementing the programs with fidelity and also with flexibility.”

Finders called the results “really great preliminary findings.”

“Now we need to better understand the mechanisms that underlie the findings so we can tailor programs to specific families in exciting ways for research and for practice,” she said. “This highlights the need for future research that continues to involve the Oregon Parenting Education Collaborative and other researchers at OSU and elsewhere. We think parents are gaining knowledge of child development, tools for dealing with the stresses of parenting, and social networks.”

The collaborative includes among its leadership Shauna Tominey, assistant professor of practice and parenting education specialist at OSU’s Hallie E. Ford Center for Healthy Children & Families, part of the College of Public Health and Human Sciences. The parenting education series the collaborative offers are delivered at no cost to the parents.

“Given that the gap is widening between the white, middle-class population of children and children belonging to the growing low-income and Latino populations, examining the relative impact of parenting education programs across these diverse populations is essential,” Finders said. “We think parenting education can have the greatest impact by adapting existing curricula to be culturally relevant and sensitive to diverse children and families’ needs.”

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Steve Lundeberg, 541-737-4039

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Policy changes needed for promoting physical activity in group home settings

CORVALLIS, Ore. – Increased physical activity for group home residents and the potentially huge health care savings that could come with it hinge on people who run the homes making health-promoting behaviors a priority.

Physical inactivity and high rates of chronic conditions are public health concerns for people with intellectual disabilities, said postdoctoral scholar Alicia Dixon-Ibarra of the Oregon State University College of Public Health and Human Sciences. Few health promotion programs, she added, target residential settings like group homes, where many individuals with intellectual disabilities live.

Obesity is rising steadily among people with intellectual disabilities, with prevalence at least 1.5 times higher than that of the general population. Addressing weight-related health issues through physical activity promotion is the focal point of multiple national initiatives, but despite that only 30 percent of adults with intellectual disabilities meet physical activity guidelines.

Dixon-Ibarra studied 18 residents, 22 staff members and 14 program coordinators from five different group homes in the Pacific Northwest. Each home was given a program designed to help residents and staff work together to set physical activity goals and include time in their schedules for trying to reach them.

The study showed that when a home’s top leadership allowed the program to be an option rather than a requirement, staff did not regularly make the effort to work with residents to create possibilities for physical activity.

Results were recently published in Evaluation and Program Planning.

In Dixon-Ibarra’s research, each group home was provided with a health-promotion program called “Menu-Choice,” designed to assist staff in including physical activity goals in residents’ schedules.

The program included weekly scheduling sheets, plus a calendar on which residents could display images depicting their activities. There was also a binder of resources for staff to learn about physical activity; to get examples of activities for residents with different abilities; to gather information about goal setting; and to gain knowledge about guidelines relating to specific disabilities.

“The overall intent of the program was to intervene at an environmental level,” Dixon-Ibarra said. “It’s evident that policy-level change in the group home setting is needed to promote active lifestyles.”

That’s because the staff members, who play a huge role in how residents spend their time, often looked at working with residents on Menu-Choice as an extra, optional duty. Staff turnover and lack of time were other barriers to Menu-Choice implementation, as was the fact that 79 percent of the program coordinators were themselves overweight or obese and not exercise oriented.

“One of the main goals is that health education can be part of staff orientation training,” Dixon-Ibarra said. “When you apply for the job you know that encouraging physical activity and nutrition is part of the job description, and you have that direction from the agency level and the coordinator level. I would also promote that group home agencies mandate the use of health-promotion programs and allocate resources to help staff and residents pursue physical activity and other health-promoting behaviors.” 

With that direction, staff turnover and/or indifference to physical activity won’t be able to negatively affect health-promotion programs nearly as much.

“Success definitely depends on staff involvement,” Dixon-Ibarra said. “Staff being motivated to pursue physical activity with residents is so important. Every staff member needs to be trained in how to incorporate activity in residents’ schedules and how to encourage residents. You can’t make someone be physically active, but you can make it a health-promoting environment where residents are encouraged to choose to be active if they want to be.”

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Steve Lundeberg, 541-737-4039

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Chronically ill women underusing online self-care resources, study shows

CORVALLIS, Ore. – Barriers to internet use may be preventing chronically ill middle-aged and older women from being as healthy as they otherwise could be, new research from Oregon State University suggests.

The study conducted by researchers from the OSU College of Public Health and Human Sciences and the University of Georgia analyzed data from hundreds of women age 44 and older with at least one chronic condition and found that 35 percent of them didn’t use the internet at all. Among those who did, fewer than half used it to learn from the experiences of other chronic-disease patients; fewer than 20 percent took part in online discussions regarding their conditions.

Self-care, including the use of online resources, is an important component in managing chronic illnesses such as heart disease, cancer, stroke, diabetes, arthritis, asthma, high blood pressure, emphysema, chronic bronchitis, depression and anxiety. Effective management of these types of conditions delays or prevents them from becoming debilitating, maintaining quality of life for the patient and saving health care dollars.

The research showed the potential for improved condition management by getting online resources into the hands of more patients.

“We want people to be able to optimize their health,” said researcher Carolyn Mendez-Luck, an assistant professor in the School of Social and Behavioral Health Sciences at OSU.

Among the 418 women participating in the study, internet use for self-care varied depending on factors that included age, the specific condition or conditions a patient had, education level and ethnic background.

“It really seemed to be the lower-resourced individuals who weren’t using the internet and thus online resources,” Mendez-Luck said. “If you’re older, if you’re a member of a minority group, if you’re less educated, if you’re not working, all of those things work against you and impede your use of the internet; that’s what this research suggests.”

The women in the study all completed, via telephone, the National Council on Aging Chronic Care Survey and all had one or more chronic conditions. Support for the research also came from Atlantic Philanthropies, the California Healthcare Foundation, and the Center for Community Health Development. Results were recently published in the Journal of Women’s Health.

The study featured two parts. The first analyzed data in terms of sociodemographics, disease types and healthcare management associated with internet use, and the second focused on the 251 internet-using women to identify the online self- care resources they use and for what purposes.

About 31 percent of the women in the study were 65 and older; 30 percent had three or more chronic conditions; and 65 percent said they used the internet.

“A significantly larger proportion of older women reported multiple chronic conditions, and a significantly smaller proportion of older women reported using the internet or relying on it for help or support,” Mendez-Luck said. “A significantly larger proportion of non-internet users reported needing help learning what to do to manage their health conditions and needing help learning how to care for their health conditions.”

Mendez-Luck says understanding how women with chronic conditions use the internet, or why they don’t, can inform targeted efforts to increase internet availability, to educate patients about online resources, and to tailor internet-based materials to self-care needs. Women tend to live longer than men and also tend to be particularly affected by chronic diseases.

“The number of people living with chronic conditions for longer durations is growing,” Mendez-Luck said. “Complex patients, especially individuals with multiple chronic conditions, present enormous challenges to healthcare providers and a significant financial burden to the healthcare system. This situation is likely to become more critical as the number of Americans living to advanced ages increases in the next few decades.”

Self-care behaviors are important in managing chronic disease, Mendez-Luck noted. Without effective management, chronic conditions can diminish individuals’ capacity to care for themselves as well as thwart caregivers’ efforts.

“We discovered that a significantly larger proportion of internet-using women with diabetes and depression reported needing help in both learning what to do to manage their health conditions and how to better care for their health, compared with women with other health conditions,” Mendez-Luck said. “This finding highlights the notion that internet resources are not a one size fits all situation; it really does depend on the condition.”

Older women represent the chronic-conditions group with the most potential for gains in using online resources for disease self-management.

“There’s an opportunity for sure,” Mendez-Luck said, noting that one method for improvement might be as simple as a physician, nurse or dietitian taking a moment to talk to patients about using the internet and how it can benefit them.

“The fact that older women in general use the internet at lower rates, I think that’s not surprising,” Mendez-Luck said. “We need to give them a chance to get connected to community resources like libraries and senior centers that try to do education to dispel that fear or discomfort older women might have regarding technology. And more research needs to be done to determine how to tailor that online information in a way that meets their needs.”

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Repeatedly thinking about work-family conflict linked to health problems

CORVALLIS, Ore. – Thinking over and over again about conflicts between your job and personal life is likely to damage both your mental and physical health, research from Oregon State University suggests.

The study included more than 200 people, with results showing that “repetitive thought” was a pathway between work-family conflict and negative outcomes in six different health categories.

As the term suggests, repetitive thought regarding work-family conflict refers to thinking repeatedly and attentively about the parts of your job and your personal life that clash with each other: for example, that late-afternoon meeting that prevents you from attending your son’s baseball game. It’s a maladaptive coping strategy that impedes daily recovery from stress.

Kelly D. Davis of OSU’s College of Public Health and Human Sciences was the lead author on the project funded by Pennsylvania State University’s Social Science Research Institute and Penn State’s Center for Healthy Aging.

The journal Stress & Health recently published the results.

Davis, an assistant professor in the CPHHS School of Social and Behavioral Health Sciences, says repetitive thought over work-family conflict keeps the stressor active and thus gets in the way of recovery.

The study involved 203 adults ages 24 to 76. Each was in a romantic relationship, and roughly two-thirds had at least one child at home.

Results showed a link between repetitive thought and negative outcomes in the health categories of life satisfaction, positive affect, negative affect, fatigue, perceived health, and health conditions.

Positive affect is the extent to which a person subjectively experiences positive moods, and negative affect is the extent to which someone experiences negative moods. In this study, health conditions referred to a list of 22 conditions or problems, such as stroke or diabetes. Participants were scored based on how many times they answered yes.

In the category of perceived health, participants were asked to rate their health on a five-point scale. 

“The main objective of this study was to test a conceptual model in which repetitive thought explained the association between work-family conflict and health,” Davis said. “There was support for repetitive thought as a mediator in the association between work-family conflict and all six health outcomes.”

Repetitive thought is related to two other types of cognition that also can have adverse effects on health: rumination and worry. Rumination is persistent, redundant thinking that usually looks backward and is associated with depression; worry is also persistent, redundant thinking but tends to look forward and is typically more associated with anxious apprehension.

“Practitioners can assist individuals facing the dual demands of work and family by reducing repetitive thought, and the related issues of worry and rumination,” Davis said.

One technique that can help is mindfulness: intentionally paying attention to the present-moment experience, such as physical sensations, perceptions, affective states, thoughts and imagery, in a nonjudgmental way.

“You stay in the moment and acknowledge what you are feeling, recognize that those are real feelings, and process them, putting things in perspective,” Davis said. “In the hypothetical baseball game example, the person could acknowledge the disappointment and frustration he was feeling as legitimate, honest feelings, and then also think in terms of ‘these meeting conflicts don’t happen that often, there are lots of games left for me to watch my child play, etc.’”

Davis also points out that the burden for coping with work-family conflict shouldn’t fall solely on the employee.

“There needs to be strategies at the organizational level as well as the individual level,” she said. “For example, a business could implement mindfulness training or other strategies in the workplace that make it a more supportive culture, one that recognizes employees have a life outside of work and that sometimes there’s conflict. There can be a good return on investment for businesses for managing work-family stress, because positive experiences and feelings at home can carry over to work and vice versa.”

Work-family conflict is not just a women’s issue or even just a parent’s issue, Davis notes, given the number of workers who are caring for their own mother and/or father.

“Planning ahead and having a backup plan, having a network to support one another, those things make you better able to reduce work-family conflict,” Davis said. “But it shouldn’t just rest on the shoulders of the individual. We need changes in the ways in which organizations treat their employees. We can’t deny the fact that work and family influence one another, so by improving the lives of employees, you get that return on investment with positive work and family lives spilling over onto one another.”

Policy changes are particularly important to lower-income workers, Davis says.

“Not all of us are so fortunate to have backup plans for our family responsibilities to stop us from repetitively thinking about work-family conflict,” she said. “It’s the organizational support and culture that matter most. Knowing there’s a policy you can use without backlash maybe is almost as beneficial as actually using the policy. It’s also important for managers and executives to be modeling that too, going to family events and scheduling time to fit all of their roles.”

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Mental health spending nets return by reducing jail population

CORVALLIS, Ore. – Each dollar a state spends on mental health care cuts roughly 25 cents off its jail expenditures by reducing its inmate population, a new study shows.

The findings, published in the journal Social Science & Medicine, suggest that 35 of the 44 states analyzed could reduce jail populations by spending more on public inpatient mental health care while maintaining their current level of community mental health care. The U.S. average cost for housing a jail inmate is $60 a day.

Jangho Yoon and Jeff Luck, professors in the College of Public Health and Human Sciences at Oregon State University, looked at data from 44 states plus the District of Columbia over a nine-year period, examining the relationships among government spending on community mental health care, spending on inpatient mental health care and jail population.

Community care, which traces its roots to President Kennedy’s signing of the 1963 Community Mental Health Act, evolved as an alternative to institutionalization. It involves a mix of public and private organizations that work with patients as they continue to live in their home city or town. Inpatient care, meanwhile, refers to facilities such as state mental hospitals.

People with mental illness make up a significant portion of jail populations, and many of those inmates could be safely supervised and more effectively treated somewhere other than jail. Effects of the treatment could include being less likely to behave in a way that results in being jailed.

While emphasizing their work does not support cutting spending for community mental health services, the researchers note that from a strict intersystem return on investment perspective, inpatient spending has a greater effect on lowering jail spending.

“Everyone has a right to treatment in the most safe and humane environment possible,” Yoon said. “Our findings show that if per-capita public inpatient mental health spending is increased by 10 percent, the jail population shrinks by 1.5 percent. The positive spill-over effect of increased inpatient spending is greater at lower levels of community spending, which shows the principle of diminishing marginal return applies here.”

Likewise, Yoon noted, the positive spill-over effect of community spending is greater at lower levels of inpatient spending, “although a change in per-capita community mental health expenditure on average does not have a statistically significant effect on jail population size.

“An increase in public inpatient spending would decrease jail populations in the 35 states that spend less than $134 per capita on community mental health care, and the District of Columbia, which also spends less than $134 per capita,” Yoon said.

Below that $134-per-capita level, he added, “the associated benefit-cost ratio is 26 cents, which indicates a positive intersystem return on investment of 26 percent. Every dollar spent annually on inpatient mental health by a state would yield a positive spillover benefit of a quarter dollar for the jail system by reducing the number of inmates.”

The research showed that spending on community mental health care loses its ability to reduce jail populations once spending levels rise to greater than $16 per capita. Forty-two of the 44 states analyzed, as well as the District of Columbia, are below that threshold; thus, those states’ jail populations would likely decline with an increase in community mental health spending while maintaining the current level of inpatient funding.

“Although there is significant cross-state variation, the ROI overall is much greater for inpatient spending,” Yoon said. “Our results suggest that states whose policy aim is to reduce jail populations direct increased spending toward inpatient mental health rather than outpatient-based community mental health.”

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System changes improve prenatal care for Oregon Medicaid beneficiaries

CORVALLIS, Ore. – Oregon’s 2012 shift to an incentivized, accountable-care system for Medicaid beneficiaries led to positive changes for expectant mothers and their babies, research at Oregon State University shows.

The research found Oregon’s implementation of “coordinated care organizations” resulted in more expectant moms starting prenatal care on time. It also showed a small narrowing of the gap in prenatal care quality between Medicaid beneficiaries and those with private insurance.

Late-starting or inadequate prenatal care is connected to a number of adverse outcomes, including low birth weight, preterm birth, stillbirth and infant death.

“Improving women’s access to adequate prenatal care — typically defined as initiating prenatal care within the first trimester of pregnancy and adhering to recommended prenatal care visits — can facilitate the identification and subsequent management of high-risk pregnancies,” said Ifeoma Muoto, who was a doctoral student working with Associate Professor Jeff Luck in OSU’s College of Public Health and Human Sciences at the time of the study.

Muoto, now an administrative fellow at Kaiser Permanente Southern California, looked at more than a half-million pregnancies in a six-year period in Oregon and Washington, including 2013, the first year for Oregon’s 16 coordinated care organizations, or CCOs. Washington served as the control group.

The study’s objective was to assess the impact of the CCOs on the quality of prenatal care among Oregon Medicaid beneficiaries. The results were recently published in the journal Health Affairs.

The study also showed a narrowing, albeit a small one, of the gap in prenatal care quality between Medicaid beneficiaries and those with private insurance.

“Prenatal care was one of the performance measures for the new CCOs and you can’t disentangle the measures from the CCO startup, but it’s promising that just in the first year there were significant improvements,” Luck said.

Luck is a member of the Oregon Health Authority’s Metrics and Scoring Committee, which is charged with determining whether CCOs are “effectively and adequately improving care, making quality care accessible, eliminating health disparities, and controlling costs.”

The committee picked which types of care would be incentivized – meaning which types of care would serve as benchmarks that CCOs could meet to earn more funding. Other types of care that are incentivized include chronic diseases, substance abuse and mental health.

“We hypothesized that the CCOs would have the benefit for prenatal care that they did,” Luck said. “This is early evidence that some of the care delivery improvements we hoped for really are occurring.”

The federal Office of Disease Prevention and Health Promotion’s HealthyPeople 2020 initiative includes increasing the percentage of women who initiate prenatal care in the first trimester of pregnancy from 70.8 percent to 77.9 percent.

In Oregon, the rate of pregnant Medicaid beneficiaries starting care in the first trimester climbed from 73.1 percent in the pre-CCO period to 77.3 percent in the first year of the CCOs. In Washington, the rate for women on Medicaid rose from 71.7 to 73.6 percent, a smaller percentage increase than Oregon’s. Although women covered by private insurance in Oregon had higher levels of timely prenatal care initiation and prenatal care adequacy, the rates among that group were stable during the time period studied.

For prenatal care adequacy – initiating care in the first trimester and having at least nine doctor visits during a pregnancy – there was an increase from 65.9 to 70.5 percent for Medicaid-covered women in Oregon. That increase, though, was not statistically significant relative to the increase observed among Medicaid-covered women in Washington, where the improvement was 58.5 to 62.2 percent.

Luck noted the results indicated care adequacy was “going in the right direction but wasn’t yet statistically significant.”

“It’s possible when we have more years of data we’ll be able to make a more precise estimate,” he said. “We also have a parallel project funded by the Centers for Disease Control using a larger pool of data from Oregon – not only birth certificates but Medicaid claims data, claims data from the Oregon Health Plan, which is Oregon’s Medicaid program, and hospital discharge data.”

Luck noted the research is particularly important given the percentage of births to Medicaid beneficiaries. Medicaid births made up roughly 45 percent of total U.S. births even prior to an expansion of the Medicaid program that began in January 2014.

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Steve Lundeberg, 541-737-4039

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Prenatal care

Expectant mother

Want to optimize those 10,000 (or fewer) steps? Walk faster, sit less

CORVALLIS, Ore. -- That popular daily target of 10,000 steps is a worthwhile goal, but a new study at Oregon State University suggests that if you find that unattainable, don’t despair - a smaller number, especially at moderate or greater intensity, can lead to health benefits too.

It’s especially helpful if 3,000 of the steps come at a brisk pace, and limiting sedentary time also plays a role in healthy readings for cholesterol and other risk factors.

The average American takes between 5,000 and 7,000 steps per day, researchers say.

“Some physical activity is better than none, and typically more is better than less,” said John Schuna Jr., assistant professor of kinesiology in OSU’s College of Public Health and Human Sciences.

“When it comes to steps, more is better than fewer, and steps at higher cadences for a significant amount of time are beneficial. A good target for healthy adults is 150 minutes per week spent at 100 or more steps per minute. And in terms of time spent sedentary, less is better – you want to spend as little time not moving as possible within reason.”

Schuna, lead author Catrine Tudor-Locke of the University of Massachusetts and six other researchers analyzed data from 3,388 participants age 20 and older in a National Health and Nutrition Examination Survey.

Their findings were recently published in the journal Medicine & Science in Sports & Exercise.

The research builds on earlier studies, many of which relied on self-reported estimates of activity levels, which tend to run high, or accelerometer data using proprietary output measures (e.g., activity counts/minute), and also failed to take cadence – steps per minute – into account. A cadence of 100 steps per minute or greater is widely accepted as the threshold for moderate-intensity activity in adults.

In addition to minute-by-minute step data, the researchers looked at relationships between step-defined physical activity and various cardiometabolic risk factors for the survey participants – such as waist circumference, blood pressure, fasting glucose, insulin, and cholesterol levels, as well as body mass index.

Among male participants, only the highest quintile – the top one-fifth – had a median of more than 10,000 steps per day, checking in at 12,334. Among women, the top quintile’s median was 9,824.

Beyond just total step counts, the research looked at daily “peak 30-minute cadence” – the average number of steps in a participant’s most vigorous 30 minutes, which weren’t necessarily consecutive minutes. To measure sedentary time, researchers used the percentage of accelerometer time per day that showed no step-based movement.

Among all survey participants, only the top quintile had a median peak cadence – 96 steps per minute – that was in line with accepted physical activity guidelines of 30 minutes a day at 100 steps per minute.

Nevertheless, analysis across all quintiles showed a strong relationship between higher cadences – walking more briskly as opposed to less briskly – and favorable numbers in the cardiometabolic risk categories.

The same held true for number of steps, whether above or below the 10,000-step threshold. And higher percentages of sedentary time were linked to less-favorable values in several risk factors.

While FitBit, Garmin and other fitness trackers might be responsible for the current 10,000-step fixation, Schuna notes that the magic number’s roots trace to 1960s Japan. From a fitness craze inspired by the 1964 Tokyo Olympics sprang the first commercial pedometer, the manpo-kei. In Japanese, manpo-kei literally means “10,000 steps meter.”

“One of the questions has always been, what if one person with 10,000 steps per day accumulates nearly all of them in a two-hour time block, and another stretches them over 15 hours – does it matter in terms of health effects?” Schuna said.

“This is a big debate in the field, with a couple of intertwined questions. Current evidence does suggest that moderate to vigorous activity and sedentary time have a certain amount of independence from each other in terms of health effects. But if you’re getting two or three hours of moderate to vigorous activity every day, even if you’re relatively sedentary the rest of the time, it’s hard to imagine the sedentary time would completely ameliorate or wipe out the health benefits associated with that level of activity.”

A person who averages 10,000 or more steps/day typically accumulates at least 150 minutes a week of moderate to vigorous activity, Schuna said.

“Now there is an additional caveat regarding the manner in which physical activity is accumulated to meet current physical activity guidelines, which states that aerobic activity should be accumulated in bouts of at least 10 minutes in duration.,” he said. “If we take this into consideration, it becomes more difficult to determine whether or not someone is meeting the physical activity guidelines using step counts alone. That aside, averaging 10,000 or more steps/day puts you in the top 15 percent of adults in terms of step-defined physical activity.”   

Schuna envisions a future in which wearable fitness trackers will feature apps that make minute-by-minute data available to the user, as research-grade accelerometers now do to scientists.

“That’s along this paradigm of personalized medicine,” he said. “In the future, everyone will have his or her genome sequenced, and from that we’ll be looking for specific markers that predispose people to higher risks for certain conditions. The physical activity and sleep data we collect from wearable devices will be used to track compliance to individualized behavior prescriptions while attempting to optimize each individual’s health.”

Media Contact: 

Steve Lundeberg, 541-737-4039

Source: 

John Schuna, 541-737-1536
john.schuna@oregonstate.edu

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Health Extension Run 2014
Walking steps