Evaluation of mRNA-1273 Covid-19 Vaccine in Children 6 to 11 Years of Age.

BACKGROUND: Vaccination of children to prevent coronavirus disease 2019 (Covid-19) is an urgent public health need. The safety, immunogenicity, and efficacy of the mRNA-1273 vaccine in children 6 to 11 years of age are unknown. METHODS: Part 1 of this ongoing phase 2-3 trial was open label for dose selection; part 2 was an observer-blinded, placebo-controlled expansion evaluation of the selected dose. In part 2, we randomly assigned children (6 to 11 years of age) in a 3:1 ratio to receive two injections of mRNA-1273 (50 µg each) or placebo, administered 28 days apart. The primary objectives were evaluation of the safety of the vaccine in children and the noninferiority of the immune response in these children to that in young adults (18 to 25 years of age) in a related phase 3 trial. Secondary objectives included determination of the incidences of confirmed Covid-19 and severe acute respiratory syndrome coronavirus 2 infection, regardless of symptoms. Interim analysis results are reported. RESULTS: In part 1 of the trial, 751 children received 50-µg or 100-µg injections of the mRNA-1273 vaccine, and on the basis of safety and immunogenicity results, the 50-µg dose level was selected for part 2. In part 2 of the trial, 4016 children were randomly assigned to receive two injections of mRNA-1273 (50 µg each) or placebo and were followed for a median of 82 days (interquartile range, 14 to 94) after the first injection. This dose level was associated with mainly low-grade, transient adverse events, most commonly injection-site pain, headache, and fatigue. No vaccine-related serious adverse events, multisystem inflammatory syndrome in children, myocarditis, or pericarditis were reported as of the data-cutoff date. One month after the second injection (day 57), the neutralizing antibody titer in children who received mRNA-1273 at a 50-µg level was 1610 (95% confidence interval [CI], 1457 to 1780), as compared with 1300 (95% CI, 1171 to 1443) at the 100-µg level in young adults, with serologic responses in at least 99.0% of the participants in both age groups, findings that met the prespecified noninferiority success criterion. Estimated vaccine efficacy was 88.0% (95% CI, 70.0 to 95.8) against Covid-19 occurring 14 days or more after the first injection, at a time when B.1.617.2 (delta) was the dominant circulating variant. CONCLUSIONS: Two 50-µg doses of the mRNA-1273 vaccine were found to be safe and effective in inducing immune responses and preventing Covid-19 in children 6 to 11 years of age; these responses were noninferior to those in young adults. (Funded by the Biomedical Advanced Research and Development Authority and the National Institute of Allergy and Infectious Diseases; KidCOVE ClinicalTrials.gov number, NCT04796896.).

Promoting Children's Physical Activity in Low-Income Communities in Colorado: What Are the Barriers and Opportunities?

INTRODUCTION: Colorado has the highest rate of adult physical activity in the United States. However, children in Colorado have a lower rate of physical activity relative to other states, and the rate is lowest among children in low-income households. We conducted focus groups, surveys, and interviews with parents, youth, and stakeholders to understand barriers to physical activity among children in low-income households in Colorado and to identify opportunities to increase physical activity. METHODS: From April to July 2016, we recruited participants from 5 communities in Colorado with high rates of poverty, inactivity, and obesity; conducted 20 focus groups with 128 parents and 42 youth; and interviewed 8 stakeholders. All focus group participants completed intake surveys. We analyzed focus group and interviews by using constant comparison. RESULTS: We identified 12 themes that reflect barriers to children's physical activity. Within the family context, barriers included parents' work schedules, lack of interest, and competing commitments. At the community level, barriers included affordability, traffic safety, illicit activity in public spaces, access to high-quality facilities, transportation, neighborhood inequities, program availability, lack of information, and low community engagement. Survey respondents most commonly cited lack of affordable options and traffic safety as barriers. Study participants also identified recommendations for addressing these barriers. Providing subsidized transportation, improving parks and recreation centers, and making better use of existing facilities were all proposed as opportunities to improve children's physical activity levels. CONCLUSION: In this formative study of Colorado families, participants confirmed barriers to physical activity that previous research on low-income communities has documented, and these varied by geographic location. Participants proposed a set of solutions for addressing barriers and endorsed community input as an essential first step for planning community-level health initiatives.

Financial Burden of Cancer Clinical Trial Participation and the Impact of a Cancer Care Equity Program.

INTRODUCTION: Cancer clinical trial (CT) participation rates are low and financial barriers likely play a role. We implemented a cancer care equity program (CCEP) to address financial burden associated with trial participation. We sought to examine the impact of the CCEP on CT enrollment and to assess barriers to participation. METHODS: We used an interrupted time series design to determine trends in CT enrollment before and after CCEP implementation. Linear regression models compared trial enrollment before and after the CCEP. We also compared patient characteristics before and after the CCEP and between CCEP and non-CCEP participants. We surveyed CCEP and non-CCEP participants to compare pre-enrollment financial barriers. RESULTS: After accounting for increased trial availability and the trends in accrual for prior years, we found that enrollment increased after CCEP implementation (18.97 participants per month greater than expected; p < .001). A greater proportion of CCEP participants were younger, female, in phase I trials, lived farther away, had lower incomes, and had metastatic disease. Of 87 participants who completed the financial barriers survey, 49 CCEP and 38 matched, non-CCEP participants responded (63% response rate). CCEP participants were more likely to report concerns regarding finances (56% vs. 11%), medical costs (47% vs. 14%), travel (69% vs. 11%), lodging (60% vs. 9%), and insurance coverage (43% vs. 14%) related to trial participation (all p < .01). CONCLUSION: CT participation increased following implementation of the CCEP and the program enrolled patients experiencing greater financial burden. These findings highlight the need to address the financial burden associated with CT participation. IMPLICATIONS FOR PRACTICE: Financial barriers likely discourage patients from participating in clinical trials. Implementation of a cancer care equity program (CCEP) seeking to reduce financial barriers by assisting with travel and lodging costs was associated with increased trial accrual. The CCEP provided assistance to patients particularly in need, including those living farther away, those with lower incomes, and those reporting financial barriers related to trial participation. These findings suggest that financial concerns represent a major barrier to patient participation in clinical trials and underscore the importance of efforts to address these concerns.

A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis.

BACKGROUND & AIMS: Many hospitalized patients with cirrhosis are readmitted to the hospital within 30 days, particularly those with hepatic encephalopathy (HE). We performed a prospective study to assess the effects of a quality improvement protocol on readmission to a transplant center's liver unit within 30 days. METHODS: We studied the effects of a quality improvement program in 824 unique patients with decompensated cirrhosis or receiving liver transplants (mean Model for End-Stage Liver Disease score, 17.7 ± 7.4) admitted to an inpatient hepatology unit from 2010 through 2013. The study had a year-long control period (626 admissions receiving usual care) and 2 intervention phases: a hand-held checklist phase (470 admissions) and an electronic phase that incorporated the checklist items into the electronic provider order entry system (624 admissions). The intervention phases included goal-directed lactulose therapy and rifaximin for overt HE, and prompts for antibiotic prophylaxis of spontaneous bacterial peritonitis. The primary endpoint was the difference in 30-day readmissions between the control and intervention phases. Trends in 30-day readmissions were compared with those of patients with decompensated cirrhosis admitted at another center. RESULTS: During the electronic phase, study subjects had 40% lower adjusted odds of 30-day readmission than during the control period. The slope of the decline in readmissions over time was significantly greater than for patients at the other center (P < .0001). The proportion of patients with greater than grade 2 HE and 30-day readmission was 48.9% (66 of 135) in the control period versus 26.0% (27 of 104) in the electronic phase (P = .0003). Treatment of HE with rifaximin and secondary prophylaxis of spontaneous bacterial peritonitis with antibiotics (on discharge) were associated with lower adjusted odds of readmission (odds ratios, 0.39 and 0.40, respectively). The electronic phase was associated with 1.34 fewer hospital days for HE compared with the control period (P = .01). CONCLUSIONS: In a prospective study, a quality improvement initiative that included electronic decision support reduced readmissions of patients with cirrhosis to the hospital within 30 days.

Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis.

UNLABELLED: The risk of morbidity and mortality for hospitalized patients with cirrhosis is high and incompletely captured by conventional indices. We sought to evaluate the predictive role of frailty in an observational cohort study of inpatients with decompensated cirrhosis between 2010 and 2013. The primary outcome was 90-day mortality. Secondary outcomes included discharge to a rehabilitation hospital, 30-day readmission, and length of stay. Frailty was assessed with three metrics: activities of daily living (ADL), the Braden Scale, and the Morse fall risk score. A predictive model was validated by randomly dividing the population into training and validation cohorts: 734 patients were admitted 1358 times in the study period. The overall 90-day mortality was 18.3%. The 30-day readmission rate was 26.6%, and the rate of discharge to a rehabilitation facility was 14.3%. Adjusting for sex, age, Model for End-Stage Liver Disease, sodium, and Charlson index, the odds ratio for the effect of an ADL score of less than 12 of 15 on mortality is 1.83 (95% confidence interval [CI] 1.05-3.20). A predictive model for 90-day mortality including ADL and Braden Scale yielded C statistics of 0.83 (95% CI 0.80-0.86) and 0.77 (95% CI 0.71-0.83) in the derivation and validation cohorts, respectively. Discharge to a rehabilitation hospital is predicted by both the ADL (<12) and Braden Scale (<16), with respective adjusted odds ratios of 3.78 (95% CI 1.97-7.29) and 6.23 (95% CI 2.53-15.4). Length of stay was associated with the Braden Scale (<16) (hazard ratio = 0.63, 95% CI 0.44-0.91). No frailty measure was associated with 30-day readmission. CONCLUSIONS: Readily available, standardized measures of frailty predict 90-day mortality, length of stay, and rehabilitation needs for hospitalized patients with cirrhosis.

A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents.

OBJECTIVE: To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents. METHODS: Forty-six adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT). TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT01019252. RESULTS: Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: -1.39, -.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report. CONCLUSIONS: This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.

Obesity and food insecurity at the same table: how head start programs respond.

INTRODUCTION: Head Start is a federally funded early childhood education program that serves just over 900,000 US children, many of whom are at risk for obesity, are living in food insecure households, or both. The objective of this study was to describe Head Start practices related to assessing body mass index (BMI), addressing food insecurity, and determining portion sizes at meals. METHODS: A survey was mailed in 2008 to all eligible Head Start programs (N = 1,810) as part of the Study of Healthy Activity and Eating Practices and Environments in Head Start. We describe program directors' responses to questions about BMI, food insecurity, and portion sizes. RESULTS: The response rate was 87% (N = 1,583). Nearly all programs (99.5%) reported obtaining height and weight data, 78% of programs calculated BMI for all children, and 50% of programs discussed height and weight measurements with all families. In 14% of programs, directors reported that staff often or very often saw children who did not seem to be getting enough to eat at home; 55% saw this sometimes, 26% rarely, and 5% never. Fifty-four percent of programs addressed perceived food insecurity by giving extra food to children and families. In 39% of programs, staff primarily decided what portion sizes children received at meals, and in 55% the children primarily decided on their own portions. CONCLUSION: Head Start programs should consider moving resources from assessing BMI to assessing household food security and providing training and technical assistance to help staff manage children's portion sizes.

Economic Well-Being And Health: The Role Of Income Support Programs In Promoting Health And Advancing Health Equity.

People with low incomes have poorer health outcomes, including greater risk for disease and shorter lifespans. This pattern has the least favorable outcomes for those living in poverty but is present at every level of the income ladder. Income support programs that provide a social safety net for families-including the Earned Income Tax Credit and Temporary Assistance for Needy Families-can influence health by meeting families' basic needs and supporting participation in economic development. However, families face inequitable access to income support programs. States vary in whether they offer the Earned Income Tax Credit, and this can lead to unequal access and participation across groups. Critical challenges for policy makers are identifying barriers to access to and participation in income supports as well as developing strategies to increase equitable access to income supports. This article synthesizes evidence on income and health and its relevance to income supports.

Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008.

INTRODUCTION: Lowering the prevalence of childhood obesity requires a multilevel approach that targets the home, school, and community. Head Start, the largest federally funded early childhood education program in the United States, reaches nearly 1 million low-income children, and it provides an ideal opportunity for implementing such an approach. Our objective was to describe obesity prevention activities in Head Start that are directed at staff, parents, and community partners. METHODS: We mailed a survey in 2008 to all 1,810 Head Start programs in the United States. RESULTS: Among the 1,583 (87%) responding programs, 60% held workshops to train new staff about children's feeding and 63% held workshops to train new staff about children's gross motor activity. Parent workshops on preparing or shopping for healthy foods were offered by 84% of programs and on encouraging children's gross motor activity by 43% of programs. Ninety-seven percent of programs reported having at least 1 community partnership to encourage children's healthy eating, and 75% reported at least 1 to encourage children's gross motor activity. CONCLUSION: Head Start programs reported using a multilevel approach to childhood obesity prevention that included staff, parents, and community partners. More information is needed about the content and effectiveness of these efforts.

Reliability and validity of YRBS physical activity items among middle school students.

PURPOSE: To assess test-retest reliability and validity of the Youth Risk Behavior Survey (YRBS) items for moderate and vigorous physical activity in middle school students. METHODS: Students (N = 125; 12.7 +/- 0.6 yr) wore Actigraph accelerometers for 6.1 +/- 1.0 d and twice completed surveys that included YRBS moderate and vigorous physical activity items. Accelerometer counts were transformed into minutes of moderate (3-6 METs) and vigorous (> 6 METs) physical activity. Days per week meeting moderate and vigorous physical activity recommendations were estimated using four summary methods. Reliability was assessed using intraclass correlation coefficients (ICC) from the two surveys. Validity was assessed as percent concordance, kappa coefficients, and sensitivity and specificity using binary YRBS and Actigraph outcomes. RESULTS: Test-retest ICC for the moderate and vigorous physical activity items were 0.51 and 0.46, respectively. Twenty-two percent of students met the recommended level of moderate physical activity (>or= 30 min.d(-1), >or= 5 d.wk(-1)) according to self-reports, whereas 90.4 and 66.4% met the recommendation according to accumulated accelerometer minutes and 5-min-bout criteria, respectively. Concordance between YRBS and Actigraph moderate physical activity measures was highest using accumulated accelerometer minutes. Sensitivity of the moderate YRBS item ranged from 0.19 to 0.23 for four comparisons, and specificity was 0.74-0.92. More than two thirds of students reported vigorous physical activity at recommended levels (>or= 20 min.d(-1), >or= 3 d.wk(-1)), whereas the highest prevalence according to Actigraph monitoring was 22.4%. Sensitivity of the YRBS vigorous item was high (0.75-0.92) compared with the four Actigraph measures; specificity was low (0.23-0.26). CONCLUSION: YRBS questions underestimate the proportion of students attaining recommended levels of moderate physical activity and overestimate the proportion meeting vigorous recommendations. Use of accelerometry for physical activity surveillance seems to be indicated. At the minimum, new questions demonstrating greater validity are needed.

School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth.

OBJECTIVE: To examine associations between use of school vending machines and fast-food restaurants and youth intake of sugar-sweetened beverages. DESIGN: A cross-sectional observational study. SUBJECTS/SETTING: From a group randomized obesity intervention, we analyzed baseline data from 1,474 students in 10 Massachusetts middle schools with vending machines that sold soda and/or other sweetened drinks. MAIN OUTCOME MEASURES: Daily sugar-sweetened beverage consumption (regular soda, fruit drinks, and iced tea), purchases from school vending machines, and visits to fast-food restaurants in the preceding 7 days were estimated by self-report. STATISTICAL ANALYSES PERFORMED: Chi(2) and nonparametric tests were performed on unadjusted data; multivariable models adjusted for sex, grade, body mass index, and race/ethnicity, and accounted for clustering within schools. RESULTS: Among 646 students who reported using school vending machines, 456 (71%) reported purchasing sugar-sweetened beverages. Overall, 977 students (66%) reported eating at a fast-food restaurant. Sugar-sweetened beverage intakes averaged 1.2 servings per day. In adjusted models, relative to no vending machine purchases, servings per day increased by 0.21 for one to three purchases per week (P=0.0057), and 0.71 with four or more purchases (P<0.0001). Relative to no fast-food restaurant visits, sugar-sweetened beverage servings per day increased by 0.13 with one visit per week (P=0.07), 0.49 with two to three visits (P=0.0013), and by 1.64 with four or more visits (P=0.0016). CONCLUSIONS: Among students who use school vending machines, more report buying sugar-sweetened beverages than any other product category examined. Both school vending machine and fast-food restaurant use are associated with overall sugar-sweetened beverage intake. Reduction in added dietary sugars may be attainable by reducing use of these sources or changing product availability.

A tool to predict suicidal ideation and behavior in bipolar disorder: The Concise Health Risk Tracking Self-Report.

BACKGROUND: Few brief, self-report measures exist that can reliably predict adverse suicidality outcomes in patients with BD. This study utilized the Concise Health Risk Tracking Self-Report (CHRT) to assess suicidality in patients with BD and examined its psychometric performance, clinical correlates, and prospective value in predicting adverse events related to suicidality. METHODS: The CHRT was administered at baseline and follow-up to 482 adult patients in Bipolar CHOICE, a 6-month randomized comparative effectiveness trial. The Columbia Suicide Severity Rating Scale (CSSRS) was used at baseline to assess lifetime history of suicide attempts and related behaviors. Clinician-rated measures of mood (Bipolar Inventory of Symptoms Scale) and bipolar symptoms (Clinical Global Impressions-Bipolar Version) were conducted at baseline and follow-up. RESULTS: The CHRT showed excellent internal consistency and construct validity and was highly correlated with clinician ratings of depression, anxiety, and overall functioning at baseline and throughout the study. Baseline CHRT scores significantly predicted risk of subsequent suicidality-related Serious Adverse Events (sSAEs), after controlling for mood and comorbidity. Specifically, the hazard of a sSAE increased by 76% for every 10-point increase in baseline CHRT score. Past history of suicide attempts and related behaviors, as assessed by the CSSRS, did not predict subsequent sSAEs. LIMITATIONS: The CSSRS was used to assess static risk factors in terms of past suicidal behaviors and may have been a more powerful predictor over longer-term follow-up. CONCLUSIONS: The CHRT offers a quick and robust self-report tool for assessing suicidal risk and has important implications for future research and clinical practice.

Quantitatively determined survivin expression levels are of prognostic value in human gliomas.

PURPOSE: Survivin is a novel antiapoptotic gene that has been recently cloned and characterized. Its expression has been found to be of prognostic significance in several tumor types. This is the first study on the prognostic significance of survivin expression in human gliomas. MATERIALS AND METHODS: We used quantitative Western blot analysis with densitometry to determine survivin protein expression levels in 92 glioma cases for which frozen tissue was available for analysis. Survivin positivity and expression levels were correlated with histopathologic features of the tumors, apoptosis (as measured by cleaved, or activated, caspase 3 levels), and clinical outcome. RESULTS: Survivin expression has clear prognostic value in human gliomas. Patients with detectable survivin expression had significantly shorter overall survival times (P <.0001) compared with those without detectable expression when all glioma patients were considered. Although glioblastoma multiforme (GBM) patients had significantly higher rates of survivin positivity and higher levels of survivin expression (P <.0001) than their non-GBM counterparts, the prognostic value of survivin expression seemed to be independent of histology alone. Survivin-positive GBM patients had significantly shorter overall survival times compared with survivin-negative GBM patients (P <.0001). Likewise, survivin-positive non-GBM patients had shorter survival times compared with survivin-negative non-GBM patients (P =.029). Furthermore, increasing levels of survivin expression significantly correlated with reduced survival times when all glioma patients were considered, and markedly so for GBM patients (P <.0001). Increasing survivin levels significantly correlated with reduced expression of cleaved caspase 3, indicating its association with antiapoptotic activity. CONCLUSION: Survivin positivity and protein expression levels, as determined quantitatively, are of significant prognostic value in human gliomas and seem to be associated with reduced apoptotic capacity of these tumors.

Barriers to obesity prevention in Head Start.

Head Start provides early childhood education to nearly one million low-income children, through federal grants to more than 2,000 local programs. About one-third of children who enter Head Start are overweight or obese. But program directors face difficulty in implementing policies and practices to address obesity-and in our national survey, they identified the key barriers as lack of time, money, and knowledge. Also, parents and staff sometimes shared cultural beliefs that were inconsistent with preventing obesity, such as the belief that heavier children are healthier. Minimizing those barriers will require federal resources to increase staff training and technical assistance, develop staff wellness programs, and provide healthy meals and snacks.

A national survey of obesity prevention practices in Head Start.

OBJECTIVE: To describe obesity prevention practices and environments in Head Start, the largest federally funded early childhood education program in the United States. DESIGN: Self-administered survey as part of the Study of Healthy Activity and Eating Practices and Environments in Head Start (SHAPES). SETTING: Head Start, 2008. PARTICIPANTS: Directors of all 1810 Head Start programs, excluding those in US territories. OUTCOME MEASURES: Descriptive measures of reported practices and environments related to healthy eating and gross motor activity. RESULTS: The 1583 (87%) programs responding to the survey enrolled 828 707 preschool children. Of these programs, 70% reported serving only nonfat or 1% fat milk. Ninety-four percent of programs reported that each day they served children some fruit other than 100% fruit juice; 97% reported serving some vegetable other than fried potatoes; and 91% reported both of these daily practices. Sixty-six percent of programs said they celebrated special events with healthy foods or nonfood treats, and 54% did not allow vending machines for staff. Having an on-site outdoor play area at every center was reported by 89% of programs. Seventy-four percent of programs reported that children were given structured (adult-led or -guided) gross motor activity for at least 30 minutes each day; 73% reported that children were given unstructured gross motor activity for at least 30 minutes each day, and 56% reported both of these daily practices. CONCLUSION: Most Head Start programs report doing more to support healthy eating and gross motor activity than required by federal performance standards in these areas.

Ophthalmology patients' religious and spiritual beliefs: an opportunity to build trust in the patient-physician relationship.

OBJECTIVE: To assess the prevalence of religion and spirituality as a component of ophthalmology patients' value systems. METHODS: A brief questionnaire distributed to 124 consecutive patients was self-administered by the patient and was collected without identifier so that participants could be assured that answers would not affect their care. The main outcome measure was the prevalence of religious and spiritual beliefs and behaviors in ophthalmology patients. RESULTS: The sample was predominantly Christian (76.6%). Of the participants, 82.3% reported that prayer was important (69.4% "very important" and 12.9% "moderately important") to their sense of well-being, and 45.2% reported weekly attendance at religious services. The prevalence of positive religious and spiritual interpretations of God's role in illness was higher than that of negative religious appraisals of God's role in illness. CONCLUSIONS: The prevalence and importance of religious and spiritual beliefs in this sample of ophthalmology patients suggests that, like other medical patient populations, religion and spirituality are significant, and often positive, components of patients' value systems. Attention to religion and spirituality is one aspect of acknowledging and respecting a patient's value system and of establishing a relationship that promotes trust for making joint therapeutic decisions.

School food environments and policies in US public schools.

OBJECTIVE: The purpose of this study was to describe school food environments and policies in US public schools and how they vary according to school characteristics. METHODS: We analyzed cross-sectional data from the third School Nutrition and Dietary Assessment study by using a nationally representative sample of 395 US public schools in 129 school districts in 38 states. These 2005 data included school reports of foods and beverages offered in the National School Lunch Program and on-site observations, in a subsample of schools, of competitive foods and beverages (those sold in vending machines and a la carte and that are not part of the National School Lunch Program). Seventeen factors were used to characterize school lunches, competitive foods, and other food-related policies and practices. These factors were used to compute the food environment summary score (0 [least healthy] to 17 [most healthy]) of each school. RESULTS: There were vending machines in 17%, 82%, and 97% of elementary, middle, and high schools, respectively, and a la carte items were sold in 71%, 92%, and 93% of schools, respectively. Among secondary schools with vending and a la carte sales, these sources were free of low-nutrient energy-dense foods or beverages in 15% and 21% of middle and high schools, respectively. The food environment summary score was significantly higher (healthier) in the lower grade levels. The summary score was not associated with the percentage of students that was certified for free or reduced-price lunches or the percentage of students that was a racial/ethnic minority. CONCLUSIONS: As children move to higher grade levels, their school food environments become less healthy. The great majority of US secondary schools sell items a la carte in the cafeteria and through vending machines, and these 2 sources often contain low-nutrient, energy-dense foods and beverages, commonly referred to as junk food.

Socioeconomic differences in adolescent stress: the role of psychological resources.

PURPOSE: To investigate whether psychological resources influenced the association between parent education (PE), a marker of socioeconomic status (SES), and perceived stress. METHODS: Cross-sectional analyses were conducted in a sample of 1167 non-Hispanic black and white junior and senior high school students from a Midwestern public school district in 2002-2003. Hierarchical multivariable regression analyses examined relationships between PE (high school graduate or less = E1, > high school, < college = E2, college graduate = E3, and professional degree = E4), and psychological resources (optimism and coping style) on teens' perceived stress. Greater optimism and adaptive coping were hypothesized to influence (i.e., mediate or moderate) the relationship between higher PE and lower stress. RESULTS: Relative to adolescents from families with a professionally educated parent, adolescents with lower parent education had higher perceived stress (E3 beta = 1.70, p < .01, E2 beta = 1.94, p < .01, E1 beta = 3.19, p < .0001). Both psychological resources were associated with stress: higher optimism (beta = -.58, p < .0001) and engagement coping (beta = -.19, p < .0001) were associated with less stress and higher disengagement coping was associated with more stress (beta = .09, p < .01). Adding optimism to the regression model attenuated the effect of SES by nearly 30%, suggesting that optimism partially mediates the inverse SES-stress relationship. Mediation was confirmed using a Sobel test (p < .01). CONCLUSIONS: Adolescents from families with lower parent education are less optimistic than teens from more educated families. This pessimism may be a mechanism through which lower SES increases stress in adolescence.