Low-Calorie Sweetened Beverages and Cardiometabolic Health: A Science Advisory From the American Heart Association.

In the United States, 32% of beverages consumed by adults and 19% of beverages consumed by children in 2007 to 2010 contained low-calorie sweeteners (LCSs). Among all foods and beverages containing LCSs, beverages represent the largest proportion of LCS consumption worldwide. The term LCS includes the 6 high-intensity sweeteners currently approved by the US Food and Drug Administration and 2 additional high-intensity sweeteners for which the US Food and Drug Administration has issued no objection letters. Because of a lack of data on specific LCSs, this advisory does not distinguish among these LCSs. Furthermore, the advisory does not address foods sweetened with LCSs. This advisory reviews evidence from observational studies and clinical trials assessing the cardiometabolic outcomes of LCS beverages. It summarizes the positions of government agencies and other health organizations on LCS beverages and identifies research needs on the effects of LCS beverages on energy balance and cardiometabolic health. The use of LCS beverages may be an effective strategy to help control energy intake and promote weight loss. Nonetheless, there is a dearth of evidence on the potential adverse effects of LCS beverages relative to potential benefits. On the basis of the available evidence, the writing group concluded that, at this time, it is prudent to advise against prolonged consumption of LCS beverages by children. (Although water is the optimal beverage choice, children with diabetes mellitus who consume a balanced diet and closely monitor their blood glucose may be able to prevent excessive glucose excursions by substituting LCS beverages for sugar-sweetened beverages [SSBs] when needed.) For adults who are habitually high consumers of SSBs, the writing group concluded that LCS beverages may be a useful replacement strategy to reduce intake of SSBs. This approach may be particularly helpful for persons who are habituated to a sweet-tasting beverage and for whom water, at least initially, is an undesirable option. Encouragingly, self-reported consumption of both SSBs and LCS beverages has been declining in the United States, suggesting that it is feasible to reduce SSB intake without necessarily substituting LCS beverages for SSBs. Thus, the use of other alternatives to SSBs, with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.

Quality Appraisal of Systematic Reviews for Behavioral Treatments of Attention Disorders in Traumatic Brain Injury.

OBJECTIVE: This review appraised the quality of systematic reviews (SRs) and meta-analyses (MAs) to summarize research on behavioral interventions for attention disorders in persons with traumatic brain injury. METHODS: A search of 7 databases revealed 15 MAs/SRs reporting outcomes for attention treatments in traumatic brain injury. Two examiners independently coded the quality of reviews with the Critical Appraisal of Systematic Review or Meta-Analysis and the Evidence in Augmentative and Alternative Communication Systematic Review Scale. RESULTS: The findings of both scales were highly correlated. Four reviews were conducted with high methodologic rigor indicated by a score of 60% or greater on both scales. No other study scored above 45%. Among the well-conducted SRs/MAs, evidence for direct attention training effects was limited to basic attention exercises, with little generalization to functional activities. Strategy training for activities and tasks requiring attentional abilities had a stronger evidence base in 1 rigorous MA. CONCLUSIONS: This appraisal provides valuable practice information. The conclusions of 4 rigorous reviews suggest that there is only limited positive scientific support for the effects of attention treatments for traumatic brain injury. Future SRs/MAs would benefit from adherence to review guidelines.

Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association.

BACKGROUND: Poor lifestyle behaviors are leading causes of preventable diseases globally. Added sugars contribute to a diet that is energy dense but nutrient poor and increase risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries. METHODS AND RESULTS: For this American Heart Association scientific statement, the writing group reviewed and graded the current scientific evidence for studies examining the cardiovascular health effects of added sugars on children. The available literature was subdivided into 5 broad subareas: effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. CONCLUSIONS: Associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels. Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. The committee found that it is reasonable to recommend that children consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age. Although added sugars most likely can be safely consumed in low amounts as part of a healthy diet, few children achieve such levels, making this an important public health target.

Critical appraisal of systematic reviews of executive function treatments in TBI.

OBJECTIVE: To appraise the quality of systematic reviews (SRs) and meta-analyses (MAs) that summarize the treatment literature for executive function (EF) impairments following traumatic brain injury (TBI). METHODS: We used five data sources (PubMed; PsycINFO; ANCDS.org; Cochrane Collaboration; American Speech-Language-Hearing Association Compendium; Psychological Database for Brain Impairment Treatment Efficacy) and identified 19 reviews that met eligibility criteria (adults with TBI; behavioural treatments for EF impairments; no pharmacologic treatments). Two reviewers independently and reliably rated each paper using two appraisal tools (Critical Appraisal of Systematic Review or Meta-Analysis and Evidence in Augmentative and Alternative Communication systematic review scale). RESULTS: Five MAs received highest ratings. Four SRs also addressed the majority of SR criteria. Reviews were better at addressing SR criteria as outcome measures across studies varied considerably, posing a challenge to quantitatively synthesize TBI outcomes. The strongest research evidence favours compensatory treatments that train individuals with TBI to use strategies to circumvent EF impairments in daily activities. Smaller effects are reported for direct training approaches. CONCLUSIONS: Researchers need to identify core outcome measures to facilitate future rigorous MAs of the EF rehabilitation literature. SRs/MAs need to be conducted with thorough methods that are reported with detail.

Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association.

In 2013, the American Heart Association and American College of Cardiology published the "Guideline on Lifestyle Management to Reduce Cardiovascular Risk," which was based on a systematic review originally initiated by the National Heart, Lung, and Blood Institute. The guideline supports the American Heart Association's 2020 Strategic Impact Goals for cardiovascular health promotion and disease reduction by providing more specific details for adopting evidence-based diet and lifestyle behaviors to achieve those goals. In addition, the 2015-2020 Dietary Guidelines for Americans issued updated evidence relevant to reducing cardiovascular risk and provided additional recommendations for adopting healthy diet and lifestyle approaches. This scientific statement, intended for healthcare providers, summarizes relevant scientific and translational evidence and offers practical tips, tools, and dietary approaches to help patients/clients adapt these guidelines according to their sociocultural, economic, and taste preferences.

Stakeholder discussion to reduce population-wide sodium intake and decrease sodium in the food supply: a conference report from the American Heart Association Sodium Conference 2013 Planning Group.

BACKGROUND: A 2-day interactive forum was convened to discuss the current status and future implications of reducing sodium in the food supply and to identify opportunities for stakeholder collaboration. METHODS AND RESULTS: Participants included 128 stakeholders engaged in food research and development, food manufacturing and retail, restaurant and food service operations, regulatory and legislative activities, public health initiatives, healthcare, academia and scientific research, and data monitoring and surveillance. Presentation topics included scientific evidence for sodium reduction and public health policy recommendations; consumer sodium intakes, attitudes, and behaviors; food technologies and solutions for sodium reduction and sensory implications; experiences of the food and dining industries; and translation and implementation of sodium intake recommendations. Facilitated breakout sessions were conducted to allow for sharing of current practices, insights, and expertise. CONCLUSIONS: A well-established body of scientific research shows that there is a strong relationship between excess sodium intake and high blood pressure and other adverse health outcomes. With Americans getting >75% of their sodium from processed and restaurant food, this evidence creates mounting pressure for less sodium in the food supply. The reduction of sodium in the food supply is a complex issue that involves multiple stakeholders. The success of new technological approaches for reducing sodium will depend on product availability, health effects (both intended and unintended), research and development investments, quality and taste of reformulated foods, supply chain management, operational modifications, consumer acceptance, and cost. The conference facilitated an exchange of ideas and set the stage for potential collaboration opportunities among stakeholders with mutual interest in reducing sodium in the food supply and in Americans' diets. Population-wide sodium reduction remains a critically important component of public health efforts to promote cardiovascular health and prevent cardiovascular disease and will remain a priority for the American Heart Association.

The Unintended Consequences of Changes in Beverage Options and the Removal of Bottled Water on a University Campus.

OBJECTIVES: We investigated how the removal of bottled water along with a minimum healthy beverage requirement affected the purchasing behavior, healthiness of beverage choices, and consumption of calories and added sugars of university campus consumers. METHODS: With shipment data as a proxy, we estimated bottled beverage consumption over 3 consecutive semesters: baseline (spring 2012), when a 30% healthy beverage ratio was enacted (fall 2012), and when bottled water was removed (spring 2013) at the University of Vermont. We assessed changes in number and type of beverages and per capita calories, total sugars, and added sugars shipped. RESULTS: Per capita shipments of bottles, calories, sugars, and added sugars increased significantly when bottled water was removed. Shipments of healthy beverages declined significantly, whereas shipments of less healthy beverages increased significantly. As bottled water sales dropped to zero, sales of sugar-free beverages and sugar-sweetened beverages increased. CONCLUSIONS: The bottled water ban did not reduce the number of bottles entering the waste stream from the university campus, the ultimate goal of the ban. With the removal of bottled water, consumers increased their consumption of less healthy bottled beverages.

New School Meal Regulations and Consumption of Flavored Milk in Ten US Elementary Schools, 2010 and 2013.

Milk is a source of shortfall nutrients in children's diets, but most children do not consume recommended amounts. We measured consumption of milk by elementary-schoolchildren (grades 3-5) in a diverse sample of schools before and after implementation of the US Department of Agriculture's updated meal regulations requiring flavored milk to be fat-free. Flavored milk consumption did not change from 2010 to 2013; 52.2% of students in 2010 and 49.7% in 2013 consumed 7 ounces or more of an 8-ounce container. Updated regulations succeeded in lowering the amount of fat, added sugars, and calories in school milk but did not change overall milk consumption, thus improving children's diet quality.

Effectiveness of Transcranial Direct Current Stimulation as an Adjuvant to Aphasia Treatment Following Stroke: Evidence From Systematic Reviews and Meta-Analyses.

PURPOSE: Transcranial direct current stimulation (tDCS) is a neuromodulation tool to amplify neural excitability and enhance outcomes associated with speech-language therapy (SLT). Stimulation currents to the left and right hemispheres vary in applying anodal (excitatory), cathodal (inhibitory), or bihemispheric signals. Several systematic reviews (SRs) and meta-analyses (MAs) have summarized the large literature examining tDCS for aphasia rehabilitation. The purpose of this project was to appraise the quality of SRs and MAs of tDCS for aphasia and examine the weight of the evidence for language outcomes in individuals with aphasia beyond SLT alone. METHOD: We searched four databases for SRs/MAs examining effects of tDCS for poststroke aphasia. We identified 16 reviews, with nine that incorporated MA to quantify results. Two reviewers reliably coded articles for methodological rigor using the AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews, Version 2). We then summarized findings of the 16 reviews. RESULTS: The AMSTAR 2 appraisal criteria suggest that critical weaknesses were noted among all reviews except those by Elsner et al. (2015, 2019). Reviews summarized three to 48 studies, as some included only randomized crossover trials and others included all trial designs. All SRs and one MA reported improvements following tDCS stimulation for general aphasia abilities and measures of repetition and speech fluency. Five recent MAs reported significant naming improvements following tDCS using all stimulation arrays. No tDCS effects were noted for comprehension measures. CONCLUSIONS: As the tDCS literature matured, the conclusions of MAs merged with earlier SRs reporting statistically positive benefits over SLT alone. Most consistent results are reported for naming measures, leaving some to question the clinical significance of tDCS effects for functional measures of aphasia recovery. Although the tDCS literature is expansive, important questions remain before the technique can be confidently recommended for clinical practice.

Predictors for Augmentative and Alternative Communication Clinical Service Provision: Closing the Gap.

PURPOSE: At the core of the clinical services provided by a speech-language pathologist (SLP) is upholding the human right to communicate. Augmentative and alternative communication (AAC) modalities support communication across environments by offering temporary or permanent solutions. Barriers to AAC service provision include translation of knowledge into clinical practice, which remains problematic despite changes to AAC preservice training addressing the knowledge barrier. This study aims to understand the importance of factors impacting the provision of AAC clinical services. METHOD: From the survey data of SLPs (N = 530) regarding current AAC service delivery practices, barriers, and professional development preferences in the United States, a hierarchical multiple regression identified the importance between individual and clinical practice variables of knowledge and current use of AAC modalities. A binomial logistic regression predicted the probability of one or more independent variables for barriers to AAC service delivery and learning preferences for AAC-related professional development. RESULTS: The factors impacting SLPs' knowledge and barriers to practice are related to clinical practicum experiences. Engagement in AAC-related continuing education (CE) is the primary contributor to the use of AAC service provision. Predictors for barriers to AAC clinical provision are associated with clinical practicum experiences, the average number of patients seen weekly, and geographic region. Preference for CE topics and frequency depend on the work setting. CONCLUSIONS: Hands-on clinical practicum experience addresses opportunity barriers in AAC service provision, contributing explicitly to the value of collaboration in AAC service delivery and highlights the importance of evidence-based professional development content. The findings from this study are reassuring in that clinicians are using AAC and suggest that high-quality professional development is an effective means to address the gap between knowledge generation and translation in the field. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.23202170.

Reported Barriers to Augmentative and Alternative Communication Service Delivery and Learning Preferences Among Speech-Language Pathologists.

PURPOSE: Speech-language pathologists (SLPs) report extensive barriers to delivering augmentative and alternative communication (AAC) services, including the knowledge and skills necessary for AAC service delivery. Although nearly all graduate programs report the inclusion of preservice training for SLPs to provide AAC services, existing research on SLPs' characteristics of AAC service provision does not reflect these changes. This study aimed to identify current AAC service delivery characteristics, barriers, and learning preferences reported by SLPs. METHOD: A survey invitation was distributed to SLPs with American Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence through social media and the ASHA Community discussion groups. RESULTS: Participants were 530 SLPs who predominantly identified as general practice SLPs. Participants reported 1%-25% of their weekly patient caseload has AAC needs for communication or receives AAC intervention. SLPs reported feeling at least "knowledgeable" in more than half of the targeted competency areas. The reported primary barriers to AAC service provision are knowledge, caseload, and time. Preferences for topic, format, and frequency and duration for AAC-related continuing education were highly variable among SLPs. CONCLUSIONS: SLPs' barriers to AAC service delivery are consistent with research from the last 15 years, revealing a lack of systematic, organizational, and informational mechanisms to support SLPs as vital members of the AAC team. Those involved in post-service instruction and training must consider the training needs of SLPs with varying competence and their experience with AAC modalities, clinical practice backgrounds, and learning preferences. AAC-related training and continuing education must reflect SLP's daily practice, learning needs, and preferences. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.23503809.

Translation and implementation of added sugars consumption recommendations: a conference report from the American Heart Association Added Sugars Conference 2010.

BACKGROUND: A 2-day forum was convened to (1) discuss ways to translate the 2009 American Heart Association added sugars recommendations into actions in areas such as regulation, food labeling, nutrient content claims, and practical application in the American diet; (2) review surveillance methodology and metrics for tracking and understanding the impact of reducing added sugars in the diet; and (3) initiate the development of a framework for future collaboration to help Americans implement science-based guidance relative to added sugars. METHODS AND RESULTS: More than 100 multinational participants representing scientists from academia and government and stakeholders engaged in food production, development, and processing, food manufacturing and servicing, food and nutrition policy, and nutrition recommendations for the public attended the conference. Presentations included definitions and examples of added sugars, current US and international added sugars perspectives, added sugars in diets of individuals and in the food supply, food technology behind added sugars, added sugars and health, food manufacturer perspectives, added sugars food-labeling considerations, and examples of positive approaches to improve eating behaviors and the food environment. Facilitated breakout sessions were conducted after the plenary sessions to allow participants to contribute their expertise and thoughts. CONCLUSION: The American Heart Association Added Sugars Conference is the first step in an important process that facilitates collaboration across science, public health, and industry to foster innovation, partnerships, policy, and implementation of new products and services for the benefit of the health and well-being of the American public. Science has advanced in the area of added sugars and health, creating mounting pressure to use better methods for translation and dissemination of the science for consumer education and for food companies to respond by producing foods and beverages with fewer added sugars. The new science also reinforces the importance of preventing, rather than simply treating diseases, especially overweight and obesity, diabetes mellitus, high blood pressure, heart disease, and stroke. Reducing added sugars consumption is a good target for addressing obesity, along with other sources of excess calories. However, the potential unintended consequences of substituting added sugars with ingredients that may not reduce calories and of increasing other macronutrients or food groups that may not result in a net health gain must be considered. Although there are many challenges to incorporating added sugars to the food label as was discussed during the conference, disclosure of added sugars content on food and beverage labels is an essential element in consumer education and can provide the information and motivation for making healthier food choices. This conference demonstrated the value of interactive dialogue among multiple sectors and disciplines. More disciplines should be at the table to bring expertise to discuss cross-cutting issues related to public policies and offer diverse insights to finding a solution.

Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association.

High intakes of dietary sugars in the setting of a worldwide pandemic of obesity and cardiovascular disease have heightened concerns about the adverse effects of excessive consumption of sugars. In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day (355 calories per day). Between 1970 and 2005, average annual availability of sugars/added sugars increased by 19%, which added 76 calories to Americans' average daily energy intake. Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans' diets. Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients. Although trial data are limited, evidence from observational studies indicates that a higher intake of soft drinks is associated with greater energy intake, higher body weight, and lower intake of essential nutrients. National survey data also indicate that excessive consumption of added sugars is contributing to overconsumption of discretionary calories by Americans. On the basis of the 2005 US Dietary Guidelines, intake of added sugars greatly exceeds discretionary calorie allowances, regardless of energy needs. In view of these considerations, the American Heart Association recommends reductions in the intake of added sugars. A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.

Survey of male college students' perceptions and knowledge of speech-language pathology.

When considering the paucity of males in the speech-language pathology field and the continued interest to increase the diversity within the profession, the current study seeks to identify variables that may deter male students from choosing communication sciences and disorders as a major. Survey responses from 290 males from two universities were analyzed. Findings indicated male undergraduate students have minimal awareness of the speech-language-pathology profession. This was seen in overall knowledge as well as the scope of the practice. Overall, despite the limited awareness and knowledge of the profession, the students' perceptions were positive towards the profession (e.g. intellectually challenging and requires independent thinking). Further reported perceptions and implications for future research are discussed.

Update on Preservice Training in Augmentative and Alternative Communication for Speech-Language Pathologists.

Purpose This is a report of the data from a current survey of academic programs in the United States, which provide preservice training in augmentative and alternative communication (AAC) for speech-language pathologists in the United States. A comparison of these findings to the last reported survey was made to identify changes and areas in need of further improvement following implementation of the recent changes to the American Speech-Language-Hearing Association Certification Standards of Clinical Practice. Method A survey was distributed to 279 speech-language pathology graduate training programs in the United States identified from the Council on Academic Accreditation program list. Results A total of 79 survey responses were received for a 28.4% response rate. There was a statistically significant increase in the percentage of programs reported to provide at least 1 course with primary content in AAC compared to the last survey performed. The reported inclusion of AAC content in other courses has also increased, and several programs report multiple AAC courses are now offered for specialized training. The majority of the programs report that less than half of the students graduate with clinical hours in AAC. The number of training grants and doctoral training remains limited to a few programs. Conclusion Academic programs have increased the preservice training in AAC over the past decade. Data indicate a critical need for clinical experience and doctoral training to meet the growing demands of speech-language pathologists.

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents.

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in US children and adolescents.

OBJECTIVE: Little research has been conducted on health effects associated with consumption of flavored milk. The purposes of this study were to compare nutrient intakes and body measures among children and adolescents drinking flavored milk (with or without plain milk), exclusively plain milk, and no milk. DESIGN: Data used in the study included intakes reported in 24-hour dietary recalls and height and weight measurements collected during a physical examination in the 1999--2002 National Health and Nutrition Examination Surveys. The milk drinking status of each person was identified, and nutrient intakes and body mass index (BMI) measures were determined by milk drinking status. SUBJECTS: The study population included 7,557 children and adolescents aged 2 to 18 years. STATISTICAL ANALYSIS: Comparisons among mean milk intakes, energy and nutrient intakes, and BMI measures by milk drinking status were completed using linear regression analysis. RESULTS: Children and adolescents who included flavored milk in their diets reported higher total milk intakes than consumers of exclusively plain milk (P<0.05). Intakes of vitamin A, calcium, phosphorus, magnesium, potassium, and saturated fat (adjusted for energy intake and age) were generally comparable among milk drinking groups, whereas intakes by milk nondrinkers were significantly lower (P<0.05). Among females aged 12 to 18 years, calcium intakes by flavored and exclusively plain milk drinkers were 992+/-41.5 and 1,038+/-22.5 mg/day, respectively, whereas intake by nondrinkers was 576+/-11.7 mg/day. Intake of added sugars did not differ between flavored milk drinkers and milk nondrinkers. BMI measures of milk drinkers were comparable to or lower than measures of nondrinkers (P<0.05). CONCLUSIONS: Findings from this study suggest that consumption of either flavored or plain milk is associated with a positive influence on nutrient intakes by children and adolescents and is not associated with adverse effects on BMI measures.