Radiological imaging is a major and increasing source of radiation exposure worldwide. Computed tomography (CT) is the largest contributor to medical radiation dose patients receive. Typically, CT scans impart doses to organs that are 100 times higher than doses imparted by other lower dose modalities such as chest X-rays. In general, CT examinations may involve doses (typically an average of 8 mSv) which may be equal to the dose received by several hundreds of chest X-rays (about 0.02 mSv/chest X-ray).
During an IAEA consultation on justification in 2007, it was estimated that up to 50% of examinations may not be necessary. It should be anticipated that part of the increase in global annual mean dose that has been observed recently is due to unjustified radiological procedures. Direct epidemiological data suggest that medical exposure to low doses of radiation even as low as 10-50 mSv might be associated with a small risk of cancer induction in the long term. The fact that a considerable percentage of people may undergo repeated high dose examinations , such as CT (sometimes exceeding 10 mSv per examination) dictates that caution should be used when referring a patient for radiological procedures. Health professionals need to make sure the patient benefits from the procedure and risk is kept minimal.
However, ensuring maximum benefit to risk ratio for the patient is not a trivial task. Referring medical practitioners, in a large part of the world, lack training in radiation protection and in risk estimation. 97% of practitioners who participated in a study underestimated the dose the patient would receive from diagnostic procedures. The average mean dose was about 6 times higher than the physicians had estimated. The fundamental principles of radiation protection in medicine are justification and optimization of radiological protection. Referring medical practitioners have a major role in justification. They are responsible in terms of weighing the benefit versus the risk of a given radiological procedure.
» What is justification and what is the framework?
Justification requires that the expected net benefit be positive. According to principles established by the International Commission on Radiological Protection (ICRP) and accepted by major international organizations, the principle of justification applies at three levels in the use of radiation in medicine.
» Is the referring medical practitioner responsible for justification of radiological procedures?
Yes, jointly with the radiological practitioner. As stated above, justification at the third level is the responsibility of the referring medical practitioner, as is the awareness about appropriateness criteria for justification at level 2. According to the BSS, the radiological exposure has to be justified through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, or be part of an approved health screening programme.
Since referring medical practitioners usually have the most complete picture of the patient’s health, they should be responsible for the guidance of the patient in undergoing only necessary procedures and benefitting from them. Particularly, this responsibility weighs more on generalists such as primary care providers. In order to facilitate justification in the case of radiological procedures, it is desirable that referring medical practitioners are knowledgeable about radiation effects in regard to the various dose ranges. The referring medical practitioners are responsible for keeping their knowledge about radiation up to date. In support of this, they should be provided education in radiation protection during their medical studies.
» How should justification be practiced and what knowledge is required for proper justification of a radiological procedure?
According to the BSS, the justification of medical exposure for an individual patient shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, with account taken, in particular for patients who are pregnant or breast-feeding or paediatric, of:
Justification should be patient specific. The referring medical practitioner should take into account all clinical aspects regarding the management of every patient separately. Other possible procedures with lower or no exposure, such as ultrasound or magnetic resonance imaging, should be considered, if and when appropriate, before proceeding to radiological procedures.
» Is the acquisition of patients’ consent important?
According to the BSS, in order for a symptomatic or asymptomatic patient to undergo a medical procedure that involves ionizing radiation, the patient or the patient’s legally authorized representative should be informed in a timely and clear fashion, of the expected diagnostic or therapeutic benefits of the radiological procedure as well as the radiation risks. Thus, the emphasis is on provision of information.
» When is an investigation useful and what are the reasons that cause unnecessary use of radiation?
According to the guidelines published by the Royal College of Radiologists (RCR), a useful investigation is one in which the result, either positive or negative, will alter a patient’s management or add confidence to the clinician’s diagnosis. According to the RCR guidelines, there are some reasons that lead to wasteful use of radiation. With emphasis on avoiding unjustified irradiation of patients, the RCR report has provided a check list for physicians referring patients for diagnostic radiological procedures:
» What are the reasons for over-investigating?
There are various reasons that may lead medical practitioners to refer patients for more procedures than needed. Practitioners should be aware of that and take action to avoid such situations. Some of the reasons that lead to over-investigation are the following:
» Is there any guidance available?
During the last 20 years international and national organizations published guidelines for proper justification of radiological procedures. The UK Royal College of Radiologists (RCR) publication "Making the best use of clinical radiology services " has been in print since 1989. The American College of Radiology (ACR) published its guidelines as Appropriateness Criteria. Similar efforts have been undertaken by the Department of Health of Western Australia in Diagnostic Imaging Pathways.
For references of publications from national societies in Europe, Oceania, and other regions please see publication from Remedios. These publications constitute guidelines and aim to guide referring medical practitioners in the selection of the optimum procedure for a certain clinical problem. In case there are alternative procedures that do not utilize radiation but yield results of similar clinical value, these guidelines encourage the avoidance of radiological procedures.
The cited publications give very specific guidance to help practitioners perform justification properly.
» What is the role of radiation protection experts?
A medical physicist with experience and expertise in radiation protection will be able to provide information and guidance on radiation doses and risks in radiological procedures. In case you do not have an access to the help of radiation protection experts, referring medical practitioners may address their questions to their colleagues who work in radiology departments. However, staff specialized in radiation protection is more likely to provide complete, responsible and up-to-date information for the specific clinical problem. Radiation protection experts are comfortable with dose measurements and quantities which come from the domain of natural sciences and are usually hard to conceive for people outside the field.
» Which procedures are responsible for the highest doses to the patient?
The referring medical practitioner should be aware about procedures which impart high radiation dose to patients in order to be more cautious in such cases. This does not mean that other procedures should be written without proper justification. A quantitative knowledge of doses of various procedures is useful for the referring medical practitioner. Data given below will help the practitioner in that direction. In diagnostic radiological procedures, dose depends on the modality used. Computed tomography (CT) exposes patients to relatively high doses in comparison to other diagnostic imaging modalities.
Interventional diagnostic and therapeutic procedures that utilize fluoroscopy may also be a source of high radiation doses. Such procedures carry the risk of causing erythema to patients that receive high dose in single or repeated procedures. Some nuclear medicine procedures are also responsible for high radiation doses to patients.
» What if the patient whom I refer for a radiological procedure is pregnant?
The responsibility to identify patients that might be pregnant and are unaware of it is shared by the patient, referring medical practitioner and the imaging service providers. Safeguards to avoid inadvertent exposures of the foetus should be observed at all times.
The “ten day rule” was postulated by ICRP for women of reproductive age. The more exact “28-day rule” allows radiological procedures throughout the complete menstrual cycle unless there is a missed period. When a woman has a missed period, she is considered pregnant unless proven otherwise.
Even if safeguards are observed, sometimes a pregnant patient may be exposed to radiation. Depending on the radiation dose and the gestation age of the foetus, radiation effects may differ. Radiation risks are most significant during organogenesis in the early foetal period, somewhat less in the second trimester, and least in the third trimester.
As a rule of thumb one can assume that properly carried out diagnostic radiological procedures to any part of the body other than the pelvic region or when the primary X-ray beam is not passing through the foetus can be performed throughout pregnancy without significant foetal risk, if clinically necessary and justified. For radiological procedures where the primary beam intercepts the foetus, advice from the medical physicist should be obtained, who will calculate radiation dose to the foetus and, based on that, the practitioner and patient should make a decision. However, doses associated with radiotherapy procedures and interventional procedures are high and they require the attention of experts (including medical or health physicists, practitioners, and sometimes engineers and epidemiologists). In the case when a practitioner is responsible for a patient who has undergone a radiological procedure inadvertently and has subsequently been found to be pregnant, advice from the individuals listed above is needed. For more information, please click here where comprehensive information is provided not only for diagnostic radiology but also for nuclear medicine and radiotherapy.
» Should pregnant patients undergo radiological procedures?
Sometimes it is imperative that pregnant women should undergo radiological procedures. The referring medical practitioner and the imaging provider have to be mindful of risk and benefit and decide whether a radiological procedure should be asked for or if the medical problem may be solved by other non-radiological procedures. Generally, it is preferable that non-radiological procedures, or at least those that do not provide exposure to ionizing radiation, are used whenever possible. However, the use of radiological procedures is not prohibited and, when properly justified, they may be optimized so that these procedures may help to achieve the desired result for the patient while keeping dose to the foetus at low levels. The patient should be made aware about the possible impact of radiation exposure to the foetus. The need for consent must be determined based on individual practice standards, guided by more global professional or regulatory/legislative requirements.
» Can radiological procedures cause acute radiation injury?
Acute injuries such as skin erythema, blistering and hair loss have been recognized as a rare side effect of procedures guided by fluoroscopy. Similar injuries have been long recognized in radiation oncology, which uses much higher doses of radiation than diagnostic imaging. While radiation therapy is administered in fractions and the radiation-inflicted cells may recover in between sessions, fluoroscopy usually imparts a high dose to the skin in a short amount of time and with no dose fractionation. Referring medical practitioners could miss recognizing acute radiation injury resulting from interventional procedures. Such injuries may appear weeks after the interventional procedure and patients may not think of the procedure as being the cause unless they have been instructed accordingly by the interventional facility. Practitioners have often tended to attribute injury to many other causes, including insect bite and allergic reactions, but not to radiation exposure. Awareness about radiation through fluoroscopy being a possible cause can avoid mis-diagnosis and patient suffering.
The intent is admirable: give doctors guidelines so they can be sure to cover what needs to be discussed with patients and help select options. Let’s talk about your diet and any problems you might have sleeping. Are you getting enough exercise? If not, here is some advice. You are due for colon cancer screening. Do you prefer a colonoscopy or a fecal test? Here are the pros and cons of each.
But there is a problem. There are just not enough hours in a workday to discuss and act on all the guidelines.
Suppose an American doctor wanted a gold star when seeing patients and followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups. That could require nearly 27 hours per day, a team of doctors wrote in a study last year for the Journal of General Internal Medicine.
No one could actually do that, so imagine a doctor shrugged off the chronic and acute care, as well as administrative work, and merely followed the preventive care checklist recommended by the U.S. Preventive Services Task Force, an independent panel of health experts. That would be 8.6 of the doctor’s hours each day, according to a study in the American Journal of Public Health.
As anyone who has been sped through a 15-minute annual wellness visit knows, doctors cannot be so exacting. That the guidelines are so thorough yet so often glossed over prompts questions about their usefulness. At the same time, doctors’ pay often depends on checking off guideline boxes.
“Is this an issue? Absolutely,” said Dr. Michael Pignone, a former member of the Preventive Services Task Force and chairman of the department of internal medicine at the University of Texas at Austin’s Dell Medical School.
“Suffice it to say that what has been incentivized isn’t always what delivers the most health or benefit,” Dr. Pignone said.
Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. She worked with doctors in other countries on an analysis of the issue that was published last month in BMJ. “A lot of guidelines may seem reasonable when considered in isolation,” Dr. Johansson said. “But the cumulative burden of all guideline recommendations combined is absurd.”
Dr. Johansson was inspired to study the issue working in a small town on Sweden’s west coast.
“I have a yearly visit with my patients,” she said. Spending that precious time discussing a lifestyle prescription that, however well meaning, is unlikely to change a patient’s habits, is of dubious value, she said. And, she added, it “crowds out more important discussions.”
“Maybe the patient smokes or has suicidal thoughts,” she said.
And, she added, many guidelines, like those for extensive discussions about improving exercise habits or diet, have not been shown to result in important health benefits.
Dr. Johansson worked with Dr. Gordon Guyatt of McMaster University in Hamilton, Ontario, and Dr. Victor Montori of the Mayo Clinic in Rochester, Minn. They argue that this problem affects medical systems throughout North America and Western Europe.
In Norway, for example, guidelines for assessing and treating high blood pressure apply to the nearly three-quarters of adults with pressures above the goal of 120/80. If the guidelines were strictly adhered to, patients would need so many regular follow-up visits that accommodating them would require more general practitioners than are currently working in Norway.
And implementing all the British guidelines for improving patients’ lifestyles could require more doctors and nurses than are practicing in the entirety of Britain.
The researchers say that guideline makers should consider what the study calls “the time needed to treat” — how much time it takes to implement a guideline.
For example, they say, the British guideline on assessing a patient’s physical activity would take 15 percent of a doctor’s visit to implement, but there is no evidence it would Strengthen long-term health. That, they say, might suggest the guideline should be jettisoned.
Dr. Carol Mangione, chair of the U.S. Preventive Services Task Force, said the task force considered the time guidelines take. And nowhere is it suggested that doctors try to tick off each guideline recommendation in a single visit.
“Clinicians do not — and would never be expected to — implement all of the suggested screenings, counseling services, and preventive medications in a single patient visit,” Dr. Mangione wrote in an email. “When caring for patients, clinicians use both their judgment and the information obtained during conversations with each patient to prioritize which preventive services should be offered during each visit.”
Even that is not easy, said Dr. Daniel Jonas, director of the division of general internal medicine at Ohio State University.
Guidelines can serve a purpose, Dr. Jonas said. “I think they’re incredibly helpful,” he added. But, he said, “deciding what to prioritize in a busy primary care practice is a big challenge.”
Dr. Montori added another complication.
“To assume that patients and clinicians can sort and prioritize recommendations over multiple visits,” he said, “wishes away the fundamental problem that many patients cannot get primary care, see the same clinician or have unhurried consultations.”
Dr. Pignone said that some of the burden should be shared with other professionals, like nutritionists, who can talk to patients about healthy diets. But, he said, that is only a partial solution. He’d like to see current recommendations prioritized by their impact on health and on their cost effectiveness. As examples, he said, childhood immunizations would rank high but existing guidelines to give tetanus boosters to adults who already had tetanus shots would rank lower.
Dr. Guyatt said guidelines should be held to the same standard as new drugs. Before they are implemented, there should be evidence that they are helpful.
“Somebody might say, ‘Oh, a new drug has side effects but what harm is there in this guideline?’” he said. “But yes, there is real harm. There is a trade-off between doing things that are actually useful and spending time on things that are useless.”
Often nurse practitioners (NPs) are great at taking care of everyone but themselves. In fact, Medscape’s Nurse Practitioner Burnout & Depression Report 2022 found that six out of 10 NPs are burned out, and close to four in 10 are depressed.
"Nurse practitioners inherently are wired to be caregivers and put self-care on the back burner," says Arlene Wright, DNP, a nurse practitioner for 22 years and director of advanced practice for Millennium Physician Group in Fort Myers, Forida. "In many ways, the mindset of prioritizing our well-being is almost a contradiction to the caring and curing model we embrace."
Medscape’s report found that some NPs rely on maladaptive coping skills such as isolation, drinking, and binge eating to manage burnout. Others turn to healthier coping strategies like exercise, meditation, or talking to family members and friends. But less than 20% seek help from an outside source.
Americans, in general, don’t seek mental health help for a wide range of reasons. A study from the Mental Health Million Project identified some deterrents in the general population including uncertainty about treatment, preference for self-help, stigma, cost, and access.
Danielle McCamey, DNP, a nurse practitioner for 11 years and founder and chief executive officer of DNPs of Color, a nonprofit that works to increase diversity in nursing doctoral studies, says that belief in self-help is at the top of the list of deterrents for nurse practitioners.
"We tend to have the perspective that we can handle our mental health on our own," says McCamey. "Sometimes that skews our realization of how bad our mental health is because we can still manage to be functional and productive in our roles."
"In our profession, we’re told we have to push through it, so we put our heads down and barrel through it," says Vern Langford, DNP, a nurse practitioner for 11 years and president of the Florida Association of Nurse Practitioners.
"We’d rather not work burned out, but we all know other providers who are, and we don’t do much about it. We have the mentality of being in this sinking ship together. It’s just the unfortunate nature of nursing."
Even though many Americans are more open to mental health discussions, stigma is also an issue. A survey by The Harris Poll for the American Psychological Association found that 87% of American adults believe mental health disorders are nothing to be ashamed of. However, this optimistic view has not wedged its way into nurse practitioners’ workplace culture.
"Some nurse practitioners don’t pursue mental health support because they worry about how they’re going to be treated by other colleagues," says Langford. "If they think the people around them may find out about it, they fear they may hold it against them.
"We can’t get better unless we have an open conversation and destigmatize mental health issues," Langford adds.
But Langford also says the stigma is more self-perpetuated than a reality. "We don’t acknowledge our mental health issues because we’re afraid the people we work with are going to shame us, but the truth is once you open up, you’ll find other nurse practitioners are some of the most supportive, compassionate people you can talk to."
Nurse practitioners also fear repercussions to their licenses. For example, many state boards require NPs to disclose their psychiatric history. If, for instance, an NP has spent time in a mental health facility or a psychiatric hospital, they must include this information in their renewal application. If they don’t disclose it, they risk getting denied.
Langford tells Medscape that it leaves us wondering why the board needs that information. But she thinks the board would help anyone who disclosed such mental health information the way they help someone with a drug or alcohol problem. "It’s a self-imposed doubt. Unfortunately, we live with this constant fear of losing our licenses. We don’t want to do anything to put our license in jeopardy."
Nurse practitioners who want to climb the corporate ladder also fear discussing their mental health. They’re afraid of getting passed over for promotions if they’re open about a mental illness.
"If an employer has to choose between someone who has disclosed a mental illness and someone who doesn’t have a mental illness, we’re afraid they may choose the one without," says Langford.
The bottom line is that nurse practitioners need mental health support, and they need to get it in a way that feels safe for them. The following strategies may help:
Wellness apps. Mindfulness or meditation apps can help NPs decompress during work shifts, on the drive home, or days off. These apps teach relaxation techniques such as guided breathing exercises.
Work "besties." "A work bestie is someone who understands you as a person and understands what you’re going through professionally," says McCamey. "It’s that person or a group of colleagues you can check in with and talk about your stressors. Those check-ins are instrumental in maintaining mental health."
Mentors. "A mentor is not only a professional but also someone to check in with, to have decompressive conversations, and to talk about work-life balance," says McCamey.
Smartwatches. Set reminders on a smartwatch for mindfulness and deep breathing exercises during shifts. A smartwatch can also help with fitness tracking at work. "Taking a break to go for a walk and get steps in is very beneficial for stress reduction," says Langford. Additionally, use a smartwatch to track sleep. "Quality and quantity of sleep can reduce the stress response," Langford tells Medscape.
NPower. NPower is a benefit of the American Association of Nurse Practitioners (AANP). The initiative provides a way for NPs to connect with mental health providers online at no additional cost.
Telehealth therapy. Nurse practitioners can meet with a mental health professional online from the convenience of home. Telehealth can also help NPs who want privacy and don’t want to go to a counselor that their colleagues may go to for therapy.
Unfortunately, these strategies don’t address the larger issue — the need for nurse practitioners to be open about mental health without feeling guilty or fearing repercussions.
Langford believes change must start in nursing schools with faculty and within the curriculum. For example, professors must be willing to talk about what to do when you have anxiety, burnout, or depression, where to get help, and ways to manage mental health when you’re an NP.
"They need to teach that mental health care is normal," says Langford. If schools raise a generation of nurses who talk about their mental health as openly as their diabetes or high blood pressure, then NPs may be more willing to seek help.
In the meantime, McCamey says mental health is a complex, multilayered problem. "Until we take steps to make people feel empowered to advocate for their wellness, we’re not going to change the culture.
"Until then, we’re going to have nurse practitioners who fly under the radar, who are highly functional at their jobs but burned out or depressed."
Ana Gascon Ivey is a health and medical writer based in Savannah. She also teaches creative writing at a men's correctional facility.
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A soon-to-be-released study from the University of Maine at Machias finds that Downeast clammers and lobstermen face steep barriers to healthcare access, despite greater risks of job-related injuries and other health issues that can sometimes lead to substance use disorders.
Tora Johnson, the lead author and an associate professor, said the study is one of the first of its kind to focus on Downeast Maine, where fisheries are big economic drivers.
“It’s pretty clear from the results here that harvesters are struggling to treat pain, and they experience a lot of it, and they get minimal help from the healthcare sector in treating that pain appropriately,” she said. “And so it’s pretty obvious that we need some new solutions.”
The study, now being drafted for publication, analyzed surveys and interviews with 83 shellfish harvesters and lobstermen, as well as healthcare providers, in Washington and Hancock counties in 2022.
It represents a small fraction of the fishermen working in these counties, which have the most active commercial harvesters across all species in the state. In 2021, there were around 2,000 fishermen in Washington County and 1,700 in Hancock County, which has fallen from the top spot in the past five years, according to state data. The vast majority fish for lobster, with soft-shell clams a distant second.
Johnson, who co-chairs the Environmental and Biological Sciences division at UMaine-Machias, said her study was done on a pilot scale that offers a model for future, larger research projects.
Most harvesters the team surveyed reported sustaining an injury while fishing in the preceding year. Especially common were back, neck, shoulder, arm and hand injuries, which could include frostbite, cuts and abrasions, or problems from falls or repetitive motions.
But as one respondent said, “unless it’s sticking out or very, very bloody, we work through it.” Some harvesters said they would stitch up their own injuries in the field, or use duct tape as a makeshift bandage. Self-prescribed rest or exercise were common treatments.
Fewer than one-third of harvesters surveyed said they visited a medical practitioner or received a prescription to treat on-the-job injuries. And 70% of the harvesters reported actively avoiding the doctor, primarily due to high costs or a lack of free time.
Instead, many respondents said they relied on Tylenol or other over-the-counter pain medications, which 19% reported taking “most days.” Self-medication with alcohol was also anecdotally common. Roughly a quarter of harvesters reported self-medicating with marijuana, opiates or other drugs, and researchers say this is likely an underestimate.
Certain kinds of injuries depended on the fishery, Johnson said. Lobstermen appeared more at risk of falls and injuries from heavy gear on their vessels, or could get hurt by rope or spiny bait.
Clammers tended to suffer from frostbite or neuropathy, which causes pain and tingling in the extremities. They could hurt their backs or legs trudging through deep mud, carrying heavy loads and frequently bending over, or cut themselves on shells or other debris in the mud when hand-digging for clams without gloves, risking dangerous infections without proper treatment.
Johnson said fishers’ high risk of injury can create a slippery slope to addiction, comorbidities or accidental overdoses, all common themes in anecdotes relayed by participants. “Not every harvester ends up in those kinds of straits,” she said, but their jobs put them at greater risk.
“We also found a lot of frustration, sadness, anguish, broken marriages, bankruptcy, homelessness,” Johnson said. “The overdose(s) and the deaths that have been widely reported are the tip of an iceberg.”
Johnson noted that the study doesn’t make detailed conclusions about how prevalent different health issues are among fishermen. Instead it gives a demo of experiences, showing broad areas where changes in public health practices could help.
Those changes could include providing wound kits to fishermen, increasing first-aid supplies or mobile health units on working waterfronts, or deploying community health workers or navigators to help injured fishermen access appropriate treatments.
Programs to help harvesters access insurance at lower costs, especially earlier in their careers, could also help. Participants in the study reported that it’s common for harvesters to go without insurance due to high costs.
Johnson plans to get industry feedback on her research at the Maine Fishermen’s Forum in early March at Rockport. She hopes to work with state officials and advocacy groups on potential injury prevention programs, insurance reforms and other new resources.
The study focuses on ways healthcare providers can do more to help fishermen rather than putting the onus on fishermen themselves. She saw a need for cultural competency training to help doctors better communicate with fishermen and meet them on their own terms.
“Some providers were really on it, and they knew to arrange hours around the tides and they knew never to say to harvesters, ‘just rest,’ ” she said. “But some of them were, like, genuinely hostile and angry and belligerent about harvesters who didn’t follow their advice — and their advice often was, ‘just don’t fish.’ And they don’t understand that what they’re saying is, ‘just don’t feed your family.’ “
Injury and addiction are not the only risks putting pressure on Maine shellfish harvesters and their health. In the softshell clam fishery, harvesters face increasing difficulty accessing clamming grounds by land as new property owners buy up more of the shoreline. This can lead to longer walks to harvesting areas, or force clammers to come into the mudflats by boat, which means they may have to stay out in the elements longer to follow the tide cycle.
All of these changes, Johnson said, create more opportunities for injury and less time for treatment. Moreover, as The Maine Monitor reported in late January, the clam fishery is under heavy strain from climate change, as warming waters cause a boom in populations of clam-eating green crabs.
Johnson sees health struggles as a barrier to taking care of these fisheries in other key ways. Clammers who can’t afford medical care or begin to struggle with addiction may be less able to invest in or experiment with new harvesting techniques that, research says, may be necessary to make the sector sustainable.
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We all know that acts of kindness can brighten someone else's day. But new research suggests that good deeds can also help ease the doer's own symptoms of anxiety and depression, along with promoting social connection and improving overall life satisfaction.
According to a study from researchers at Ohio State University published in The Journal of Positive Psychology, performing acts of kindness may even result in greater social well-being than techniques used in cognitive behavioral therapy (CBT) to treat depression and anxiety.
“Social connection seems to be one of the most powerful ingredients for flourishing in life,” David Cregg, Ph.D., a clinical psychologist and co-author of the study, told TODAY in a segment aired Jan. 20.
“We demonstrated that performing acts of kindness promotes social connection, a construct that is a key predictor of both well-being and recovery from anxiety and depressive disorders,” the study authors wrote.
However, social connection is often impaired among individuals with anxiety or depressive disorders, the study authors noted, and "CBT techniques may be ineffective at improving social connection." The researchers set out to determine whether acts of kindness may Strengthen social connection more effectively.
The study involved 122 participants with elevated anxiety or depression symptoms who were randomly split into three groups. Two of the groups were assigned to practice CBT techniques, such as planning social activities, and the third was assigned to engage in acts of kindness.
The participants in the kindness group were asked to perform three small acts of kindness two days a week for five weeks. Participants did things like bake cookies for friends, smile at strangers and volunteer, TODAY reported.
"Folks who participated in the acts of kindness group reported that they felt less depressed, less anxious," Jennifer Cheavens, Ph.D., a professor of psychology at Ohio State University and a study co-author, told TODAY in a segment aired Jan. 20.
All three groups reported greater life satisfaction and a reduction in depression and anxiety symptoms, but participants in the acts of kindness group showed the most improvement, according to the study authors.
Those in the kindness group experienced such a benefit that 75% percent of them continued performing acts of kindness even after the study ended, TODAY reported.
“We further demonstrated that performing acts of kindness results in greater well-being benefits than established CBT techniques,” the study authors wrote.
Cregg added: "There just seems to be something about having social connection that brings meaning and purpose into our lives. ... Without it, everything else just kind of feels empty."
These findings highlight the clinical potential of acts of kindness to treat anxiety and depression, but future research is needed, the study authors wrote.
Whether it’s complimenting a stranger, buying a coffee for your co-worker or holding the door for others, performing acts of kindness is "one of the most powerful things that you can do, and it's so practical," Kojo Sarfo, who holds a doctorate of nursing practice and is psychotherapist and mental health nurse practitioner, told TODAY in a segment aired Jan. 20.
"For those who are struggling with depression and or anxiety who may feel hopeless and helpless, just having a connection with people, it goes a long way," Sarfo said, adding that acts of kindness may even help you make a new friend.
"Even if you're depressed and unable to get out of bed, you can call somebody, send them a message or leave them a nice voice recording just to make their spirits feel a bit better," Sarfo continued.
Doing nice things for others can also help people feel a greater sense of purpose or impact on others, which is important for people who are suffering with symptoms of anxiety or depression, Sarfo added.
"You realize that people do appreciate (you), people enjoy having (you) here on the planet. When you're depressed and you're hopeless, you sometimes forget that," Sarfo said.
Sarfo encouraged parents to teach their kids about the importance of being kind to others. It can start with something as simple as holding the door open for somebody. "It doesn't have to be the biggest thing ... but it could make their day," he said.
This story first appeared on TODAY.com. More from TODAY:
The human brain controls body functions — its health greatly influences a person’s well-being. There is still much about the brain that researchers are still working to understand, including what factors influence brain health.
In a new study, researchers from the Yale School of Medicine in New Haven, CT, have found that people who are genetically predisposed to poor oral health also tend to have poorer brain health.
The findings indicate the need for further research into the full impact of oral health and if good oral habits can positively impact brain health.
The study authors are planning to share the results of their research at the International Stroke Conference 2023.
The brain is a complex organ controlling major functions in the body essential for keeping us alive. It allows people to think, move, breathe, and express emotion.
“Brain health” is a broad term that often refers to the brain’s ability to carry out its normal functions, and a lack of neurological diseases that impact brain function.
Lexi Watson, an Institute for Functional Medicine Certified Practitioner (IFMCP) and Reversing Cognitive Decline (ReCODE) 2.0 Certified Practitioner, who was not involved in the current study, explained to Medical News Today that, in the simplest terms, “[b]rain health is the optimization of the many factors that contribute to brain and cognitive function in order to allow your body to achieve its highest expression of health.”
Many factors can influence brain health, and people can make lifestyle modifications that may affect it. For example, limiting alcohol, quitting smoking, controlling high blood pressure, following a healthy diet, and getting enough physical activity may all contribute to good brain health.
“Factors that contribute to brain health include nutrient levels and nutrition as well as stress levels and your body’s response to that stress,” said Watson. “By the way,” she added, “stress is much more than just mental [or] emotional stress. Blood sugar imbalance, lack of quality sleep, an overload of toxins, and ongoing inflammation all contribute to stress on the body.”
Researchers are still working to understand all the factors that contribute to brain health and how people can best take steps to Strengthen it.
The authors of the new study wanted to examine how oral health impacts brain health. Study author Dr. Cyprien Rivier explained to MNT:
“The main goal was to investigate the link between poor oral health and brain health. We already know that poor oral health increases the risk of stroke, but we did not know whether poor oral health affected brain health. Brain health is a continuous measure that describes the functional status of a person’s brain using neuroimaging tools such as MRI (magnetic resonance imaging). Studying oral health is especially important because it is an easily modifiable risk factor: Everyone can effectively Strengthen their oral health with minimal time and financial investment.”
Researchers used a specific method called mendelian randomization, which involves looking at genetics and health outcomes.
They analyzed data from the UK Biobank, selecting individuals who had never experienced a stroke. They looked at over 100 genetic variants associated with poor oral health outcomes, such as missing teeth and cavities.
They then looked at brain scans to measure indicators of brain health. The researchers found that the genetically-increased risk of poor oral health was associated with poorer brain health.
This included a higher incidence of silent cerebrovascular disease, which affects the brain’s blood supply, and microstructural damage.
“People who were genetically prone to cavities, missing teeth, or needing dentures had a higher burden of silent cerebrovascular disease, as represented by a 24% increase in the amount of white matter hyperintensities visible on the MRI images,” Dr. Rivier explained.
“Those with overall genetically poor oral health had increased damage to the fine architecture of the brain, as represented by a 43% change in microstructural damage scores visible on the MRI scans. Microstructural damage scores are whole-brain summaries of the damage sustained by the fine architecture of each brain region,” he added.
Based on these findings, the study’s authors suggest that treating poor oral health early may help significantly Strengthen brain health.
The study did have several limitations that indicate the need for more extensive research. Mendelian randomization results indicate a causal relationship between the examined factors, but this is not entirely certain.
Because they used data from the UK Biobank, which includes predominantly white British participants as 94% of the participants self-report as white, further research could also include more diverse cohorts.
Commenting on the findings, Watson noted that they “confirm for me the importance of oral health in overall brain health.”
“What I would like to see next is a study demonstrating what I see in practice, that taking care of your oral health can mitigate your genetic risk. Genes are not your destiny, just information to help steer your efforts in the right direction,” she emphasized.
Dr. Rivier also noted that this study is a first step and that confirming the research will take time:
“One important next step is to replicate these findings in different populations, especially groups from other races/ ethnic backgrounds. If this research is confirmed, taking measures to Strengthen oral health could lead to significant benefits at a population level. It must be noted that our study is preliminary, and more evidence needs to be gathered, ideally through clinical trials, to show that improving oral health in the population leads to brain health benefits.”
The typical person living with arthritis in the UK is 20% less likely to be in work than their equivalent without the condition, new research shows.
And the most striking finding was that non-university educated women aged 60-plus are at least 37% less likely to be in work if they have arthritis, compared to matched individuals without the condition.
The study, published today by the University of Leeds, matched a group of 18,000 people with arthritis to another group of 18,000 people who were the most similar to the first group in terms of various characteristics, but had not been diagnosed with arthritis. These characteristics included age, gender, level of education, ethnicity and where they lived.
The research shows large differences in how arthritis affects people's working lives, depending on their age, level of education and gender.
The team is now suggesting that workplaces provide more support for people living with the condition, so they can keep working as long as they wish.
Principal Investigator Dr Adam Martin, Associate Professor in Health Economics at the University of Leeds' School of Medicine, said:
"We already know that arthritis is more common amongst women and people from lower socio-economic backgrounds. Our new findings show that substantial inequalities also exist in terms of how the work outcomes of these groups are affected by arthritis.
"Government and employers should consider how interventions in workplaces could better support people living with arthritis and Strengthen their health and employment prospects, whilst also potentially tackling inequalities and address the need to support people in their 50s and 60s to stay in work for longer if they want to.
"Given the increasing prevalence of arthritis and the trend towards older retirement ages, this need for better support represents a substantial and growing challenge for society."
This is a vital and important study and reinforces what we have heard from people with arthritis how the condition robs them of their health, their independence, and careers.
We know work matters to people with arthritis, benefitting health and wellbeing as well as their finances, yet this evidence demonstrates how arthritis is truly an unfair and unequal condition.
We as a country need to tackle these health inequalities. Arthritis should no longer disproportionately and unfairly impact women and those less well served in our society, potentially driving millions into disability and unemployment."
Deborah Alsina MBE, Chief Executive of Versus Arthritis
Sandra Purdy, 61, from Churwell in Leeds, had to retrain due to chronic pain caused by ankylosing spondylitis, a type of arthritis in which the spine and other areas of the body become inflamed.
She said: "I had problems with pain since my late teens, and was misdiagnosed several times.
"When I was younger I had manual jobs but the pain meant I often couldn't work. There's a stigma in saying you have back pain at work, so I tried to hide it but that got more difficult as the pain became worse.
"Eventually I started looking for an office job which I thought would be more manageable. I got a job in a bank but sitting down all day was worse. Due to morning stiffness, I needed to get up at 4.30am to be ready for 7.30am. I needed crutches and sticks to walk at the start of the day. I wouldn't need them by the end of the day so I'd worry that people thought I was making it up. But during a bad flare up, the pain would last all day and I couldn't move.
"When I was 45, I developed iritis, a painful eye condition which causes swelling and irritation in the iris. I was referred to a rheumatologist and had an MRI scan, and they diagnosed me with ankylosing spondylitis.
"I took part in a trial for a drug called infliximab, which was liquid gold. It changed my life – but at the end of the trial I had a severe flare up. Because of this I was moved onto a different drug called adalimumab, which I still take now. However, it lowers my immune system, so I pick up a lot of bugs.
"I found a new job with a more understanding employer, where I could move about during the day. I now have a management role so I'm less customer-facing, and I can work from home.
"I hear a lot of people at my hospital patient participation group talking about how they have been treated and their employers aren't great.
"I have always thinking about losing my job, especially at first. I left school with no qualifications so I had to sit exams in English and maths to get work in an office. I've had to adapt but not everyone can do this.
"Patients need better access to diagnostics and more joined up thinking between employers and the health service."
The research, which was funded by the Nuffield Foundation, used two decades of data about people aged 18-80 years old. The team compared 18,000 people with arthritis to 18,000 people without the condition, to gain a more in-depth understanding of how it affects people's lives.
The study showed that as people with arthritis reach middle age, their likelihood of being in work diminishes at a faster rate than those who do not have the condition. Many of these will have taken early retirement. This effect is more pronounced in general for people without a university-level education, possibly as symptoms may be easier to manage in professional jobs than manual roles.
And once both men and women reach 60, their chances of being in work when living with arthritis are markedly more reduced when compared to people without the condition.
The chart below shows the percentage reduction in the likelihood of being in work for each group when compared with their counterparts without arthritis.
People who had a history of working in routine (such as lorry drivers or bar staff) and intermediate (such as paramedics or bank staff) occupational groups were also much less likely to be in work if they had arthritis. However, this was not the case for people in professional work (such as lawyers or architects). For them, arthritis did not seem to affect the likelihood of being in work, although some people with arthritis in this group did work fewer hours and had lower earnings if they had arthritis. This was especially true for working women aged over 40.
Among people living with arthritis, those with a history of working at small private companies were also generally less likely to be in work than people with arthritis who had worked in larger companies or in the public sector. The team's discussions with people living with arthritis indicated that this might be due to smaller firms having fewer resources available, or less scope for them to adjust work patterns or take on alternative roles.
Dr Martin said: "In light of this research, people living with arthritis told us that potential interventions could involve making appropriate adjustments to the working environment, tackling workplace discrimination and supporting changes in people's roles.
"Existing evidence suggests that providing personalized case management by an occupational health practitioner could help to encourage constructive dialogue between employees, healthcare practitioners and employers.
"Our study indicates that such support could be especially cost-effective if it is designed for and targeted for the people we identified who are most at risk of poor work outcomes."
Rajah, N., et al. (2023) How does arthritis affect employment? Longitudinal evidence on 18,000 British adults with arthritis compared to matched controls. Social Science & Medicine Part C Medical Economics. doi.org/10.1016/j.socscimed.2022.115606.
In states that grant full practice authority (FPA) to nurse practitioners (NPs), there are higher concentrations of NPs from communities of color, which benefits patients of color and underserved areas, according to a new study published in Policy, Politics, and Nursing Practice in February, Black History Month.
With FPA, NPs can practice to the full extent of their education, training, and certification without physician oversight. That includes evaluating, diagnosing, ordering, and interpreting diagnostic tests, initiating and managing treatments, and prescribing medications.
According to the report, Black NPs in FPA states served 2.8% more Black Medicare beneficiaries than did Black NPs in non-FPA states. In contrast, researchers found that FPA does not appear to influence the racial and ethnic diversity of the Medicare beneficiaries that White NPs serve.
The researchers focused on Black, Asian, and Hispanic communities and compared backgrounds of NPs, patients, and overall state populations nationwide.
Currently, NPs in 26 states and Washington, DC, have FPA in primary care.
Many rural counties in the US don't have physicians, and the need is greater there for NPs with FPA, according to lead author Alicia Plemmons, PhD, assistant professor in the Department of General Business and coordinator of scope of practice research in the knee center at West Virginia University.
She told Medscape Medical News that her team wanted to see whether granting NPs FPA could draw more NPs to underserved areas and what effect FPA might have on diversity in the NP workforce.
The study includes all the NPs who served Medicare beneficiaries from 2014–2020. Researchers merged Centers for Medicare & Medicaid Services data with National Provider Identifier data to locate NPs with active licenses.
They found that ethnic diversity among NPs was more representative of the general population in states that had FPA compared to those that did not.
The research team also wanted to see what kind of patients the NPs served.
"We saw that these nurse practitioners from marginalized groups were also serving marginalized patients," including Black, Asian and Hispanic communities, Plemmons said.
People from marginalized racial and ethnic groups tend to be more comfortable or receive better access to care when seen by someone else from a marginalized background, researchers found.
Danielle McCamey, DNP, CRNP, ACNP, founder of the national organization DNPs of Color, who was not involved in the study, said she was not surprised by the findings; the study documents the benefit of NPs practicing to the full extent of their authority.
She said the study points out that "those that belong to communities of color tend to go back to their communities to serve them. That's essentially the expectation culturally: You give back to your community and you don't forget where you come from."
When barriers to practice are lifted, practitioners will be more likely to return to their home states, said McCamey, assistant dean for clinical practice and relationships at Johns Hopkins School of Nursing in Baltimore, Maryland.
Having a provider with whom patients can identify creates an automatic level of trust, she added. "There's spoken and unspoken language of that community. The ability to structure care so that it makes it understandable to certain populations ― it carries a large amount of weight with people of color."
The research also highlights that NPs are often more enthusiastic about providing primary care if they are allowed full authority, and they can help fill physician shortage gaps, McCamey said.
One limitation of the study is that the researchers had to predict the races of the NPs using data clues, rather than direct reporting, so more comprehensive data collection for US NPs is needed, Plemmons said.
"I hope this brings one more nuance to the [FPA] conversation in that quality, access, and cost piece for legislators when they're deciding what might be the benefits or the costs of being able to expand scope of practice within their state," she said.
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.
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For generations, Black children have faced a unique set of challenges regarding their mental health, from enduring more adversity to a lack of access to effective treatment. Finally, a new study pinpoints structural racism as a potential cause.
"Black youth in the United States experience significant illness, poverty, and discrimination," according to the American Psychological Association. "These issues put them at higher risk for suicide, depression, and other mental health problems."
For example, a exact study in Pediatrics found Black youth ages 5 to 24 saw a much greater increase in suicide deaths than white youth during the first 10 months of the pandemic when looking at the expected suicide rate versus the actual rate. A 2021 report from the U.S. surgeon general noted that suicide rates in Black kids under 13 have risen so much in exact years that they’re now almost twice as likely to die by suicide as white kids.
A 2022 study published in the journal Current Psychiatry Reports found that rates of depression, anxiety, post-traumatic stress, substance use disorders and suicide are rising in minority youth.
But at the same time, Black kids are less likely to receive mental health treatment for a range of reasons, from stigma to a lack of a diverse providers, the American Psychological Association stated. And when they do receive treatment, it's less likely to be evidence-based, per a 2020 study in Children and Youth Services Review.
These disparities have been understudied for decades, experts tell TODAY.com. The new, first-of-its-kind study, published in the American Journal of Psychiatry on Feb. 1, will help close some of these gaps, they hope.
The new study found that Black kids were more likely than white kids to experience "toxic stress," which it defined as “prolonged exposure to adverse experiences that leads to excessive activation of stress response systems and an accumulation of stress hormones.” Toxic stress can contribute to changes in the volume, size and shape of certain regions of the brain that are linked to PTSD, depression and anxiety, according to the study.
The study found the link by analyzing MRI brain scans of Black kids and white kids across the country, as well as surveys completed by the kids and their parents about their race, parental education and employment, income, measurements of neighborhood disadvantage and conflicts within the home.
Nathaniel Harnett, Ph.D, led the study and tells TODAY.com that the conclusions do not indicate a genetic, race-related difference in the child participants' brains.
"We have the folklore belief that Black and white people just have categorically different brains, but ... what we really want to point out here, when we interpret these data, is that these are not children with just different brains," Harnett explains. "They’re children with different experiences that shaped and molded how they develop, and how they might develop through to adulthood."
Harnett, director of the Neurobiology of Affective Traumatic Experiences Laboratory at McLean Hospital in Massachusetts, worked with a team of researchers to analyze data from more than 7,300 white children and nearly 1,800 Black children in the U.S. who were 9 and 10 years old.
They found that three areas of the brain — the amygdala, hippocampus and prefrontal cortex — were slightly smaller in volume, size and shape in Black children compared to white children. These regions of the brain regulate fear, threat perceptions, emotions and memory.
“What we’ve seen in PTSD and, in some cases, depression and anxiety, is that the actual size of some of these brain regions, particularly the hippocampus and prefrontal cortex, are smaller in individuals with PTSD compared to those without PTSD,” Harnett explains.
Physical changes in these brain regions, the study suggests, may be due to how much race-related trauma Black children witness or experience firsthand.
The study found that white children on average experience less family conflict, material hardship, neighborhood disadvantage, and fewer traumatic events compared to Black children. For example, white children’s parents were three times more likely to be employed than Black children’s parents; 75% of white parents had a college degree compared to nearly 41% of Black parents; and about 88% of white parents made $35,000 a year or more compared to about 47% of Black parents who made as much.
“Individuals exposed to more childhood trauma have a greater risk for developing (PTSD) later in life, suggesting that changes in these brain regions may be particularly important mediators of actually developing that disorder,” Harnett says.
Harnett plans to continue to evaluate the same group of kids every couple of years to better understand the longterm effects of the traumas they experience. With further research, he’s hoping to find out if changing a child’s environment and exposure levels to adversity can reverse the changes in the brain.
“All children are susceptible to these effects of adversity, but ... we ultimately really need ... changes to the levels of adversity that we expose kids to,” he says. “We really need to pay attention to the groups that are disproportionately affected,” such as Black children.
Racial mental health disparities in kids have been historically understudied due to "structural racism in medicine," Dr. Cheryl Wills, a board member of the American Psychiatric Association, tells TODAY.com, adding that the few ideas that did manage to get the green light were not taken as seriously as other non-race related studies in the field.
"In the '80s, people began to talk about it, and in the '90s, people began to deal with it," and slowly smaller research projects came out, but many ideas failed to get funding, she explains.
Racial bias "has made it difficult to find studies of this caliber and scale and to conduct them," she says, referring to Harnett's study. "People have done small studies here and there. ... However, this is the first study where you had funding and a database that by design has incorporated diversity into it."
Dr. Melissa Vallas, a children's psychiatrist and medical director of Southern California Evolve-PC Residential Treatment Centers, published a paper in 2010 in the journal Child and Adolescent Psychiatric Clinics of North America that had similar findings on home life and poverty. But the fact that Harnett could connect adversity and stress to physical changes in the brain adds another layer of understanding of these racial disparities.
Vallas tells TODAY.com that another reason more research in this area has not happened is because psychiatry is a relatively new field that wasn't originally created to study this issue.
"When we go back and understand the history of psychiatry specifically, it's important to know that the founders of psychiatry were all white men," she says. "Between the '30s and the '50s is when psychiatry was really (coming into) its own."
At that time, "Black people in this country were really more focused on just trying to survive and have equal rights," she adds.
In fact, the American Psychiatric Association recognized the structural racism in its profession with a 2021 statement apologizing for "enabling discriminatory and prejudicial actions within the APA and racist practices in psychiatric treatment for Black (people)."
"Early psychiatric practices laid the groundwork for the inequities in clinical treatment that have historically limited quality access to psychiatric care for (Black people). These actions sadly connect with larger social issues, such as race-based discrimination and racial injustice, that have furthered poverty along with other adverse outcomes," the APA wrote.
The history of racism in the U.S. still impacts Black youth's mental health today. Chase Casine, a clinical therapist in New Orleans whose caseload is 40% Black youth, tells TODAY.com that structural racism's impact on the brain often goes misdiagnosed.
For example, the amygdala, home to the fight-or-flight response, can lead a child to act hyperactive if it's triggered constantly, which can make it seem like the child has ADHD when they actually have PTSD, Casine explains.
"Research (shows) our kids being overly medicated, misdiagnosed, often labeled with ADHD or conduct disorder," he says, adding that these misdiagnoses can lead to incorrect treatment plans and stereotypes about Black kids when "it’s not even what they have."
"I'm a trauma informed therapist, and I take culture into consideration, but a lot of other practitioners who don't look like (me) don't take culture into consideration," he continues. "Looking at the whole person takes into account what happened to you."
He says he thinks non-Black practitioners don't usually have this approach because they don't want to contribute to racial stereotypes.
"As much as we want to strive to live in a colorblind society ... that type of a toxic positivity is more of an avoidance of what's in front of us," he explains. "There is a clear divide between Blacks and whites. The research consistently and continually shows that there is an obvious disconnect."
Casine emphasizes that culturally competent mental health care is not just about being the same race. It's also about using the same reference points.
"I'm a person-centered therapist. ... I allow the clients to lead," he says. For example, if a client tells him they're spiritual or into music, he'll use scriptures or songs to help them process their thoughts.
Vallas and Casine say white children can start learning about privilege and structural racism at an age-appropriate level, and there are resources available to help teach them.
For Black parents, Harnett, Vallas and Casine realize that many factors that may contribute to toxic stress — such as their income and educational levels — are difficult, if not impossible, to change, so they say it’s important for Black parents to give themselves grace.
Vallas, who is a mother to a 14-year-old and twins who are 12, stresses the importance of listening to your children, especially as a Black parent.
"I think the first step is just being aware (of) what's happening, so if you see your child acting out, they don't necessarily just need a (punishment). Maybe the first step is to just try to have a conversation with them," Vallas advises.
She says her line of work "(puts) into perspective how easily kids can have these lives that parents don’t know."
"It teaches me a lot about the importance of the connection that you need to have with your kids in order for them to feel comfortable to communicate with you," she adds.
Changes to school nutrition standards that pushed more fruits, vegetables, whole grains and low-fat dairy products significantly decreased kids’ and teens’ body mass index after the standards were implemented in 2010, a new study finds.
The new study comes as the United States again considers updates that would put more limits on added sugars and sodium in school meals.
The study, published in JAMA Pediatrics, followed 14,121 US youths ages 5 to 18 from January 2005 to March 2020. The study didn’t include data following widespread school shutdowns due to the Covid-19 pandemic.
The researchers found an overall decrease in annual body mass index, or BMI, in the period following implementation of the Healthy, Hunger-Free Kids Act. BMI is a measure of body fat based on height and weight.
Previous research had shown that school-provided meals were linked with childhood obesity in the years before stricter nutritional guidelines.
“This [study] is providing the evidence base to continue to have strong school nutrition standards for kids. We still have an overweight and obesity problem in the US and policies that strengthen the nutrition standards in school meals are needed to help Strengthen the health of our children,” said Dr. Lauren Au, an assistant professor at UC Davis’ Department of Nutrition who studies the effectiveness of school nutrition programs and was not involved with the new study.
The overall BMI decrease was seen across ages and income levels, which researchers say is significant. Children from higher income families – who may be able to purchase foods outside of what is provided to them through the free or reduced-price meal program – experienced equal benefits from the nutritional qualities in schools.
Additionally, according to the study, prior to the implementation of the Healthy, Hunger-Free Kids Act, BMI increased in teenage years. However, that trend reversed after the nutritional changes were made.
“The Healthy Hunger Free Kids Act does still have impact in adolescents when they have such differences in dietary preferences, and the ability to purchase their own foods compared to younger children,” Au said.
According to the US Centers for Disease Control and Prevention, about 20% of children and adolescents ages 2 to 19 are obese, which can lead to lifelong health complications including high blood pressure, type 2 diabetes and breathing problems such as asthma and sleep apnea.
The National School Breakfast and School Lunch Program, both of which were reformed by the Healthy, Hunger-Free Kids Act of 2010, provide meals at low or no cost to more than 30 million children. These meals make up an estimated 50% of the calories in a child’s day.
“I think when you’re looking at these population level, large scale evaluations, what might look like a small effect in any one child at any one moment, actually means a lot at the broader level over time,” said Dr. Aruna Chandran, an author of the study and epidemiologist at Johns Hopkins Bloomberg School of Public Health.
Efforts to Strengthen school nutrition standards are ongoing. The US Department of Agriculture recently proposed new school food guidelines, which included reduction of added sugars and sodium.
“I think the steps are at least in the right direction,” said Dr. Lauren Fiechtner, director of Nutrition at Mass General for Children Hospital who was not involved with the study.
Fiechtner, who wrote a related editorial also published in JAMA Pediatrics, called for further action including limiting juices and promoting consumption of fruit in its whole form to increase dietary fiber intake.
Experts say implementing high nutrition standards in schools can have long-term positive effects including creating healthy habits and influencing the kinds of foods youth prefer.
Additionally, Fiechtner says that “continuing to invest in the National School Lunch Program is important because we know obesity costs the healthcare system a lot of money in the long term” and that a “reduction in obesity among children would also Strengthen their health and their quality of life.”
The US Department of Agriculture has not finalized proposed updates to school nutrition standards. Experts hope this research can support movements to Strengthen school meals.
“With continual efforts to make improvements, we hope that this means that public health practitioners and policymakers, no matter where they’re from, what their political views might be, or what their personal ideas are, this is something we can come together on because this is an actionable place where we can make a difference in our obesity epidemic, which has felt so just intractable and so difficult to overcome,” Chandran said. “Now, we can think of this not as a foregone conclusion, we can make a difference.”