Faculty Bibliography

BACKGROUND: Gestational diabetes mellitus (GDM) is a major pregnancy complication with detrimental effects for both mothers and their children. Accumulating evidence has suggested a potential role for arsenic (As) exposure in the development of GDM, but current studies have not assessed As exposure from water, urine or toenail samples. METHODS: We investigated the association between As exposure and risk of glucose intolerance and GDM among 1151 women enrolled in the New Hampshire Birth Cohort Study. Arsenic was measured in home well water and via biomarkers (i.e., maternal urine collected ~24-28 weeks gestation and toenail clippings collected 2 weeks postpartum). RESULTS: A total of 105 (9.1 %) of women were diagnosed with glucose intolerance and 14 (1.2 %) of women were diagnosed with GDM. A total of 10.3 % of women had water As levels above 10 mug/L, with a mean As level of 4.2. Each 5 mug/L increase in As concentration in home well water was associated with a ~10 % increased odds of GDM (OR: 1.1, 95 % CI 1.0, 1.2). A positive and statistically significant association also was observed between toenail As and GDM (OR: 4.5, 95 % CI 1.2, 16.6), but not urinary arsenic (OR: 0.8, 95 % CI 0.3, 2.4). In a stratified analysis, the association between water As and GDM and glucose intolerance was largely limited to obese women (OR: 1.7, 95 % CI 1.0, 2.8). CONCLUSIONS: Our findings support the role of As exposure via water from private wells in the incidence of GDM and that this association may be modified by body composition.

Under the Physician Payments Sunshine Act, "payments or transfers of value" by biomedical companies to physicians must be disclosed through the Open Payments Program. Designed to provide transparency of financial transactions between medication and device manufacturers and health care providers, the Open Payments Program shows financial relationships between industry and health care providers. Awareness of this program is crucial because its interpretation or misinterpretation by patients, physicians, and the general public can affect patient care, clinical practice, and research. This study evaluated nonresearch payments by industry to orthopedic surgeons. A retrospective cross-sectional review of the first wave of Physician Payments Sunshine Act data (August through December 2013) was performed to characterize industry payments to orthopedic surgeons by subspecialty, amount, type, origin, and geographic distribution. During this 5-month period, orthopedic surgeons (n=14,828) received $107,666,826, which included 3% of those listed in the Open Payments Program and 23% of the total amount paid. Of orthopedic surgeons who received payment, 45% received less than $100 and 1% received $100,000 or more. Median payment (interquartile range) was $119 ($34-$636), and mean payment was $7261±95,887. The largest payment to an individual orthopedic surgeon was $7,849,711. The 2 largest payment categories were royalty or license fees (68%) and consulting fees (13%). During the study period, orthopedic surgeons had substantial financial ties to industry. Of orthopedic surgeons who received payments, the largest proportion (45%) received less than $100 and only 1% received large payments (≥$100,000). The Open Payments Program offers insight into industry payments to orthopedic surgeons. [Orthopedics. 2016; 39(6):e1058-e1062.].

Importance: Strategies to improve the nutritional status of those participating in the Supplemental Nutrition Assistance Program (SNAP) are of interest to policymakers. Objective: To evaluate whether the proposed policy of incentivizing the purchase of fruits and vegetables and prohibiting the purchase of less nutritious foods in a food benefit program improves the nutritional quality of participants' diets. Design, Setting, and Participants: Lower income participants (n = 279) not currently enrolled in SNAP were randomized to 1 of 4 experimental financial food benefit conditions: (1) incentive (30% financial incentive for fruits and vegetables purchased using food benefits); (2) restriction (not allowed to buy sugar sweetened beverages, sweet baked goods, or candies with food benefits); (3) incentive plus restriction (30% financial incentive on fruits and vegetables and restriction of purchase of sugar sweetened beverages, sweet baked goods, or candy with food benefits); or (4) control (no incentive or restrictions on foods purchased with food benefits). Participants in all conditions were given a study-specific debit card where funds were added every 4 weeks for a 12-week period. Outcome measures were collected at baseline and in the final 4 weeks of the experimental period. Main Outcomes and Measures: Primary outcomes (from 24-hour dietary recalls) included intake of energy, discretionary calories, and overall diet quality. Results: A number of favorable changes were observed in the incentive plus restriction condition that were significantly different from changes in the control condition. These included (1) reduced intake of energy (-96 kcal/d, standard error [SE], 59.9); (2) reduced intake of discretionary calories (-64 kcal/d, SE 26.3); (3) reduced intake of sugar sweetened beverages, sweet baked goods, and candies (-0.6 servings/d, SE 0.2); (4) increased intake of solid fruit (0.2 servings/d, SE 0.1); and (5) improved Healthy Eating Index score (4.1 points, SE 1.4). Fewer improvements were observed in the incentive only and restriction only arms. Conclusions and Relevance: A food benefit program that pairs incentives for purchasing more fruits and vegetables with restrictions on the purchase of less nutritious foods may reduce energy intake and improve the nutritional quality of the diet of participants compared with a program that does not include incentives or restrictions. Clinical Trial Registration: clinicaltrials.gov Identifier: NCT02643576.

Geographic disparities in life expectancy are substantial and not fully explained by differences in race and socioeconomic status. To develop policies that address these inequalities, it is essential to identify other factors that account for this variation. In this study we investigated whether population well-being-a comprehensive measure of physical, mental, and social health-helps explain geographic variation in life expectancy. At the county level, we found that for every 1-standard-deviation (4.2-point) increase in the well-being score, life expectancy was 1.9 years higher for females and 2.6 years higher for males. Life expectancy and well-being remained positively associated, even after race, poverty, and education were controlled for. In addition, well-being partially mediated the established associations of race, poverty, and education with life expectancy. These findings highlight well-being as an important metric of a population's health and longevity and as a promising focus for intervention.

OBJECTIVE: Some experts recommend eliminating "teaspoon" and "tablespoon" terms from pediatric medication dosing instructions, as they may inadvertently encourage use of nonstandard tools (i.e. kitchen spoons), which are associated with dosing errors. We examined whether use of "teaspoon" or "tsp" on prescription labels affects parents' choice of dosing tools, and the role of health literacy and language. METHODS: Analysis of data collected as part of a controlled experiment (SAFE Rx for Kids study), which randomized English/Spanish-speaking parents (n=2110) of children <8 years old to 1 of 5 groups which varied in unit of measurement pairings on medication labels/dosing tools. Outcome assessed was parent self-reported choice of dosing tool. Parent health literacy measured using the Newest Vital Sign. RESULTS: 77.0% had limited health literacy (36.0% low, 41.0% marginal); 35.0% completed assessments in Spanish. Overall, 27.7% who viewed labels containing either "tsp" or "teaspoon" units (alone or with "mL") chose nonstandard dosing tools (i.e. kitchen teaspoon, kitchen tablespoon), compared to 8.3% who viewed "mL"-only labels (AOR=4.4[95%CI: 3.3-5.8]). Odds varied based on whether "teaspoon" was spelled out or abbreviated ("teaspoon"-alone: AOR=5.3[3.8-7.3]); "teaspoon" with mL: AOR=4.7[3.3-6.5]; "tsp" with mL (AOR=3.3[2.4-4.7]); p<0.001)). Similar findings were noted across health literacy and language groups. CONCLUSIONS: Use of teaspoon units ("teaspoon" or "tsp) on prescription labels is associated with increased likelihood of parent choice of nonstandard dosing tools. Future studies may be helpful to examine the real-world impact of eliminating teaspoon units from medication labels, and identify additional strategies to promote the safe use of pediatric liquid medications.