Mind Your Heart: A Mindful Eating and Diet Education eHealth Program.

OBJECTIVE: Examine user perceptions of the Mind Your Heart (MYH) program, a mindful eating and nutrition education program delivered via an eHealth system. METHODS: Sixteen participants (41.5 ± 13.1 years) completed sample MYH lessons over 3 weeks. We examined changes in mindfulness from the State Mindfulness Scale via text messages sent 3 times per week. We assessed MYH user perceptions in a semistructured interview after 3 weeks. Analyses included Spearman's correlation, repeated measures ANOVA, and thematic analysis. RESULTS: State Mindfulness Scale scores were significantly improved (F[1,15] = 5.35, P = 0.01) from week 1 (M = 2.28 ± 0.80) to week 3 (M = 2.75 ± 1.04). Four themes emerged: (1) MYH is supportive of health goals, (2) text messages act as an intervention, (3) facilitators or inhibitors of use, and (4) enhancing engagement. CONCLUSIONS AND IMPLICATIONS: Based on participant feedback, the final version of MYH should include example-based learning to translate abstract concepts like mindful eating into action.

Meditation and Cognitive Outcomes: A Longitudinal Analysis Using Data From the Health and Retirement Study 2000-2016.

Objective: We aimed to assess the association between meditation practice and cognitive function over time among middle-aged and older adults. Method: We included Health and Retirement Study (HRS) participants assessed for meditation practice in the year 2000 as part of the HRS alternative medicine module (n = 1,160) and were followed up for outcomes over 2000-2016 period. We examined the association between meditation ≥ twice a week vs none/less frequent practice and changes in the outcomes of recall, global cognitive function, and quantitative reasoning using generalized linear regression models. Stratified analyses among persons with/without self-reported baseline depressive symptoms were conducted to assess the link between meditation and cognitive outcomes. Results: Among our full study sample, meditation ≥ twice a week was not significantly associated with total recall [ß; 95% CI: -0.97, 0.57; p = 0.61], global cognitive function [ß; 95% CI: -1.01, 1.12; p = 0.92], and quantitative reasoning [ß; 95% CI: -31.27, 8.32; p = 0.26]. However, among those who did not have self-reported depressive symptoms at baseline, meditation ≥ twice a week was associated with improvement in cognitive outcomes such as total recall [ß; 95% CI: 0.03, 0.18; p = 0.01] and global cognitive function [ß; 95% CI: 0.05, 0.40; p = 0.01] over time. Conclusions: Frequent meditation practice might have a protective effect on cognitive outcomes over time, but this protection could be limited to those without self-reported baseline depressive symptoms. Future studies could incorporate more precise meditation practice assessment, investigate the effect of meditation on cognitive outcomes over time, and include more rigorous study designs with randomized group assignment. Pre-registration: This study is not preregistered.

The association between serum folate and gestational diabetes mellitus: a large retrospective cohort study in Chinese population.

OBJECTIVE: To investigate the association between folate levels and the risk of gestational diabetes mellitus (GDM) risk during the whole pregnancy. DESIGN: In this retrospective cohort study of pregnant women, serum folate levels were measured before 24 gestational weeks (GW). GDM was diagnosed between 24th and 28th GW based on the criteria of the International Association of Diabetes and Pregnancy Study Groups. General linear models were performed to examine the association of serum folate with plasma glucose (i.e. linear regressions) and risk of GDM (i.e. log-binomial regressions) after controlling for confounders. Restricted cubic spline regression was conducted to test the dosage-response relationship between serum folate and the risk of GDM. SETTING: A sigle, urban hospital in Shanghai, China. PARTICIPANTS: A total of 42 478 women who received antenatal care from April 2013 to March 2017 were included. RESULTS: Consistent positive associations were observed between serum folate and plasma glucose levels (fasting, 1-h, 2-h). The adjusted relative risks (RR) and 95 % CI of GDM across serum folate quartiles were 1·00 (reference), 1·15 (95 % CI (1·04, 1·26)), 1·40 (95 % CI (1·27, 1·54)) and 1·54 (95 % CI (1·40, 1·69)), respectively (P-for-trend < 0·001). The positive association between serum folate and GDM remained when stratified by vitamin B12 (adequate v. deficient groups) and the GW of serum folate measurement (≤13 GW v. >13 GWs). CONCLUSIONS: The findings of this study may provide important evidence for the public health and clinical guidelines of pregnancy folate supplementation in terms of GDM prevention.

How does domestic migration pose a challenge in achieving equitable social health insurance benefits in China? A national cross-sectional study.

OBJECTIVES: To evaluate the benefit distribution of social health insurance among domestic migrants in China. DESIGN: A national cross-sectional survey. SETTING: 348 cities from 32 provincial units in China. PARTICIPANTS: 1165 domestic migrants who used inpatient care services in the city of a new residence and had social health insurance. PRIMARY AND SECONDARY OUTCOME MEASURES: The probability of receiving reimbursements from social health insurance, the amounts and ratio of reimbursement received. RESULTS: Among migrants who used inpatient care in 2013, only 67% received reimbursements from social health insurance, and the reimbursement amount only accounted for 47% of the inpatient care expenditure. The broader the geographical scope of migration, the lower the probability of receiving reimbursement and the reimbursement ratio, but the higher the reimbursement amount. Specifically, the probability of receiving reimbursements for those who migrated across cities or provinces was significantly lower by 14.7% or 26.0%, respectively, than those who migrated within a city. However, they received significantly higher reimbursement amounts by 33.4% or 27.2%, respectively, than those who migrated within a city. And those who migrated across provinces had the lowest reimbursement ratio, although not reaching significance level. CONCLUSIONS: The unequal benefit distribution among domestic migrants may be attributed to the fragmented health insurance design that relies on localised administration, and later reimbursement approach that migrating patients pay for health services up-front and get reimbursement later from health insurance. To improve the equity in social health insurance benefits, China has been promoting the portability of social health insurance, immediate reimbursement for inpatient care used across regions, and a more integrated health insurance system. Efforts should also be made to control inflation of healthcare expenditures and prevent inverse government subsidies from out-migration regions to in-migration regions. This study has policy implications for China and other low/middle-income countries that experience rapid urbanisation and domestic migration.

The Association Between Stroke Mortality and Time of Admission and Participation in a Telestroke Network.

OBJECTIVES: Acute ischemic stroke is one of the leading causes of death. Patient outcomes, such as in-patient mortality, may be impacted by the time of arrival to the hospital. Telestroke networks have been found to be effective and safe at treating acute ischemic strokes. This paper investigated the association between mortality and time of arrival and hospital's participation in a telestroke network. METHODS: Data were collected on ischemic stroke patients who arrived at 15 nonteaching hospitals in Georgia's Paul Coverdell Acute stroke registry from 2009 to 2016. After controlling for patient and hospital characteristics, multivariate logistic regression was conducted to assess whether time of arrival and telestroke participation was associated with in-hospital mortality. Subgroup analysis was conducted based on hospital bed size. RESULTS: Overall, a total of 19,759 admissions for acute ischemic stroke were included in this analysis. The odds of dying in the hospital when arriving during the nighttime are 1.22 times the odds of dying when arriving during the day (95% CI: 1.04-1.45) and the odds of dying at a telestroke hospital are 53% lower than at a nontelestroke hospital (OR .47, 95% CI .31-.71). The associations were more prominent in large hospitals. CONCLUSIONS: Our study found that the hour of arrival for acute ischemic stroke is linked with in-hospital mortality in large hospitals, with patients more likely to die if they arrive during the nighttime hours as compared to the daytime hours. Telestroke participation is linked with lower odds of hospital mortality in all hospitals.

Impact of Participation in a Telestroke Network on Clinical Outcomes.

BACKGROUND: A telestroke program, known as the Remote Evaluation for Acute Ischemic Stroke program, has been implemented in Georgia since 2003. This study examined whether a hospital's participation in a telestroke network was associated with improvement in clinical outcomes and quality indicators. METHODS AND RESULTS: An observational study was conducted using data from the Georgia Coverdell Acute Stroke Registry between September 2005 and September 2016 for patients aged ≥18 years with ischemic stroke. We use a difference-in-differences approach to compare the following clinical outcomes and quality indicators among those admitted at hospitals within and outside of the Remote Evaluation for Acute Ischemic Stroke network: tPA (tissue-type plasminogen activator) use, complications related to tPA use, door-to-needle time, ambulation at discharge, discharge status, and destination. Logistic regression models and a propensity score weighting approach were performed to adjust for patients' age, sex, race, insurance coverage, arrival mode, ambulatory status before the current stroke, stroke severity, medical history, admission time, and hospital bed size. A total of 25 494 patients with ischemic stroke admitted at 15 nonteaching hospitals located outside of the Atlanta metropolitan area were included in the analysis. After propensity score weighting, hospitals participated in a telestroke network was not associated with a significant increase in the rate of tPA use, while it was significantly associated with a modest decline in the rate of complications related to tPA (-5.9%; 95% CI, -9.2% to -2.6%). Telestroke participation showed no significant difference in other clinical outcomes and quality measures except for a marginally significant decrease in in-hospital mortality (-1.1%; 95% CI, -2.2% to -0.1%). CONCLUSIONS: Although a slight decrease in tPA complication was observed among hospitals participating in the telestroke network, overall the impact of telestroke participation on a hospital's stroke care quality was not statistically significant based on our observational study.

Modeling the Impact of Transcendental Meditation on Stroke Incidence and Mortality.

OBJECTIVES: Meditation has shown promise in clinical trials in reducing systolic blood pressure, one of the main risk factors for stroke. We aim to estimate the potential benefits of popularizing meditation on stroke incidence and mortality in the United States (U.S.). METHODS: We developed a dynamic population-based microsimulation model to simulate the disease progression of each individual and compute disease burden. We calibrated the microsimulation model for stroke incidence and further validated it by comparing the stroke-related mortality for each age group generated by the model with that observed in the U.S. We used the population simulation model to estimate the effects of meditation intervention on the number of stroke cases and deaths over a course of 15 years. RESULTS: Our results show that we could avert nearly 200,000 stroke cases and 50,000 stroke-related deaths over the course of 15 years. Our sensitivity analysis reveals that most of the benefits come from applying the intervention for individuals older than 60 years. In addition, meditation acceptance and adherence rate play a critical role in its effectiveness. CONCLUSIONS: The practice of meditation, if properly utilized along with the regular antihypertensive medication, could substantially alleviate the burden of stroke in the U.S. In order to design an effective meditation program, policymakers may prioritize funding to the programs that aim to encourage older individuals to practice meditation.

Integrated care reform in urban China: a qualitative study on design, supporting environment and implementation.

BACKGROUND: Initiatives on integrated care between hospitals and community health centers (CHCs) have been introduced to transform the current fragmented health care delivery system into an integrated system in China. Up to date no research has analyzed in-depth the experiences of these initiatives based on perspectives from various stakeholders. This study analyzed the integrated care pilot in Hangzhou City by investigating stakeholders' perspectives on its design features and supporting environment, their acceptability of this pilot, and further identifying the enabling and constraining factors that may influence the implementation of the integrated care reform. METHODS: The qualitative study was carried out based on in-depth interviews and focus group discussions with 50 key informants who were involved in the policy-making process and implementation. Relevant policy documents were also collected for analysis. RESULTS: The pilot in Hangzhou was established as a CHC-led delivery system based on cooperation agreement between CHCs and hospitals to deliver primary and specialty care together for patients with chronic diseases. An innovative learning-from-practice mentorship system between specialists and general practitioners was also introduced to solve the poor capacity of general practitioners. The design of the pilot, its governance and organizational structure and human resources were enabling factors, which facilitated the integrated care reform. However, the main constraining factors were a lack of an integrated payment mechanism from health insurance and a lack of tailored information system to ensure its sustainability. CONCLUSIONS: The integrated care pilot in Hangzhou enabled CHCs to play as gate-keeper and care coordinator for the full continuum of services across the health care providers. The government put integrated care a priority, and constructed an efficient design, governance and organizational structure to enable its implementation. Health insurance should play a proactive role, and adopt a shared financial incentive system to support integrated care across providers in the future.

Evidence of Dietary Improvement and Preventable Costs of Cardiovascular Disease.

We conducted a review to summarize preventable medical costs of cardiovascular disease (CVD) associated with improved diet, as defined by the 2020 Strategic Impact Goal of the American Heart Association. We searched databases of PubMed, Embase, CINAHL and ABI/INFORM to identify population-based studies published from January 1995 to December 2015 on CVD medical costs related to excess intake of salt/sodium or sugar-sweetened beverages, and inadequate intake of fruits and vegetables, fish/fish oils/omega-3 fatty acids, or whole grains/fiber/dietary fiber. Based on the American Heart Association's secondary dietary metrics, we also searched the literature on inadequate intake of nuts and excess intake of processed meat and saturated fat. For each component, we evaluated the CVD cost savings if consumption levels were changed. The cost savings were adjusted into 2013 US dollars. Among 330 studies focusing on diet and economic consequences, 16 studies evaluated CVD costs associated with 1 or more dietary components: salt/sodium (n = 13), fruits and vegetables (n = 1), meat (n = 1), and saturated fat (n = 3). In the United States, reducing individual sodium intake to 2,300 mg/day from the current level could potentially save $1,990.9/person per year for hypertension treatment, based on a simulation study. Increasing consumption of fruits and vegetables from <0.5 cup/day to >1.5 cups/day could save $1,568.0/person per year in treatment costs for CVD, based on a cohort study. Potential CVD cost savings associated with diet improvement are substantial. Interventions for reducing sodium intake and increasing fruit and vegetable consumption could be viable means to alleviate the increasing national medical expenditures.

Meditation and blood pressure: a meta-analysis of randomized clinical trials.

OBJECTIVES: We meta-analyzed the effect of meditation on blood pressure (BP), including both transcendental meditation and non-transcendental meditation interventions. METHODS: We identified randomized controlled trials (RCTs) that examined the BP responses to meditation interventions through a systematic literature search of the PubMed, ABI/INFORM, MEDLINE, EMBASE, PsycINFO, and CINAHL databases (from January 1980 to October 2015). We meta-analyzed the change in SBP and DBP, stratified by type of meditation (transcendental meditation vs. non-transcendental meditation intervention) and by type of BP measurement [ambulatory BP monitoring (ABPM) vs. non-ABPM measurement]. RESULTS: Nineteen studies met the eligibility criteria. Among the studies using the ABPM measurement, the pooled SBP effect estimate was -2.49 mmHg [95% confidence interval (CI): -7.51, 2.53] for transcendental meditation intervention (statistically insignificant) and -3.77 mmHg (95% CI: -5.33, -2.21) for non-transcendental meditation interventions, whereas the pooled DBP effect estimate was -4.26 mmHg (95% CI: -6.21, -2.31) for transcendental meditation interventions and -2.18 mmHg (95% CI: -4.28, -0.09) for non-transcendental meditation interventions. Among the studies using the non-ABPM measurement, the pooled SBP effect estimate from transcendental meditation interventions was -5.57 mmHg (95% CI: -7.41, -3.73) and was -5.09 mmHg with non-transcendental meditation intervention (95% CI: -6.34, -3.85), whereas the pooled effect size in DBP change for transcendental meditation interventions was -2.86 mmHg (95% CI: -4.27, -1.44) and was -2.57 mmHg (95% CI: -3.36, -1.79) for non-transcendental meditation interventions. CONCLUSION: Non-transcendental meditation may serve as a promising alternative approach for lowering both SBP and DBP. More ABPM-measured transcendental meditation interventions might be needed to examine the benefit of transcendental meditation intervention on SBP reduction.