Letter to the Editor on "Leveraging Biomedical Engineering Engineers to Improve Obstructive Sleep Apnea (OSA) Care for Our Stroke Patients".

Obstructive sleep apnea (OSA), a condition of recurring, episodic complete or upper airway collapse, is a common disorder, affecting an estimated 17.4% of women and 33.9% of men in the United States [1]. The first line treatment for OSA is Continuous Positive Airway Pressure (CPAP) therapy, a medical device that delivers adequate airflow and oxygenation during sleep by way of a tube that connects an air compressor to a face mask that can fit over the nose, under the nose, or over the nose and mouth.

An Integrated Interdisciplinary Sleep Care Model-The Ultimate Dream Team.

This Viewpoint discusses the need for diverse physicians to manage sleep health.

Sleep Disturbances in Neurological Disease: A Target for Intervention.

Sleep is a biological function required for neurological and general health, but a significant and under-recognized proportion of the population has disturbed sleep. Here, we briefly overview the biology of sleep, sleep requirements over the lifespan, and common sleep disorders. We then turn our attention to five neurological diseases that significantly contribute to global disease burden and neurology practice makeup: epilepsy, headache, ischemic stroke, Parkinson's disease, and Alzheimer's disease. For each disease, we review evidence that sleep disturbances contribute to disease risk and severity and discuss existing data that addressing sleep disturbances may have disease-modifying effects. We provide recommendations derived from the literature and existing clinical guidelines to facilitate the evaluation and management of sleep disturbances within the context of each neurological disease. Finally, we synthesize identified needs and commonalities into future directions for the field and practical sleep-related recommendations for physicians caring for patients at risk for or currently suffering from neurological disease.

Sleep in Patients With Neurologic Disease.

PURPOSE OF REVIEW: This article provides a discussion of the current evidence and contemporary views on the relationship between sleep disorders and neurologic disease. RECENT FINDINGS: Disrupted or disordered sleep can be associated with increased morbidity and mortality, the risk of cardiovascular events, increased seizure frequency, and altered immune responses. Studies have implicated disrupted sleep and circadian rhythm dysfunction with both amyloid-ß (Aß) deposition and tau deposition. A bidirectional relationship exists between disrupted sleep and the progression of Alzheimer disease pathology. Insomnia has been reported as a prodromal symptom in autoimmune encephalitis. Primary sleep disorders have now been increasingly recognized as a common comorbid condition in multiple sclerosis, making it imperative that neurologists feel comfortable differentiating multiple sclerosis fatigue from excessive daytime sleepiness caused by primary sleep disorders to optimally treat their patients. SUMMARY: Sleep disorders are common across the population. By recognizing sleep disorders in patients with neurologic conditions, neurologists can provide comprehensive care and, in some cases, reduce neurologic disease burden.

A review of state regulations to promote physical activity and safety on playgrounds in child care centers and family child care homes.

BACKGROUND: As interventions increasingly emphasize early child care settings, it is necessary to understand the state regulatory context that provides guidelines for outdoor physical activity and safety and sets standards for child care environments. METHODS: Researchers reviewed regulations for child care facilities for 50 states, the District of Columbia and the Virgin Islands. We compared state regulations with national standards for 17 physical activity- and safety-related items for outdoor playground settings outlined in Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs (CFOC). State regulations were coded as fully, partially or not addressing the CFOC standard and state-level summary scores were calculated. RESULTS: On average, state regulations fully addressed one-third of 17 CFOC standards in regulations for centers (34%) and family child care homes (27%). Data suggest insufficient attention to outdoor play area proximity and size, equipment height, surfacing, and inspections. CONCLUSIONS: Considerable variation exists among state regulations related to physical activity promotion and injury prevention within outdoor play areas. Many states' regulations do not comply with published national health and safety standards. Enhancing regulations is one component of a policy approach to promoting safe, physically active child care settings.

Best-practice guidelines for physical activity at child care.

Research has indicated that the child care center is a very strong predictor of preschool-aged children's physical activity levels, making this an important setting to help young children obtain physical activity that is appropriate for their health and development. However, some evidence suggests that organized child care may not adequately support children's physical activity needs. Although many organizations provide recommendations, guidelines, or standards for motor skill development and physical activity opportunities, no set of guidelines exist that directly target the overall physical activity environment at child care. Because of the lack of comprehensive recommendations, the Nutrition and Physical Activity Self-assessment for Child Care best-practice guidelines for healthy weight development were created on the basis of an extensive review of existing guidelines, research evidence, and expert review. The purpose of this article is to present these physical activity best-practice guidelines and provide data on how these guidelines compare to current practice in a large sample (N = 96) of child care centers in North Carolina. These best-practice guidelines include recommendations for 8 unique components of the child care environment, including active opportunities, fixed play environment, portable play environment, sedentary opportunities, sedentary environment, staff behavior, staff training/education, and physical activity policies. Our results showed that only a few of the best-practice guidelines were achieved by a majority of the 96 North Carolina child care centers that participated in this study. Establishing comprehensive guidelines for physical activity at child care could result in higher activity levels and healthier children, but more research is needed.

Early child care and adiposity at ages 1 and 3 years.

BACKGROUND: The majority of infants in the United States are in nonparental child care, yet little is known about the effect of child care on development of obesity. OBJECTIVE: To examine the relationship between child care attendance from birth to 6 months and adiposity at 1 and 3 years of age. METHODS: We studied 1138 children from a prospective cohort of pregnant women and their offspring. The main exposure was time in child care from birth to 6 months of age, overall and by type of care: (1) child care center; (2) someone else's home; and (3) child's own home by nonparent. The main outcomes were weight-for-length (WFL) z score at 1 year and BMI z score at 3 years of age. RESULTS: A total of 649 (57%) infants attended child care; 17% were cared for in a center, 27% in someone else's home, and 21% in their own home by a nonparent. After adjustment for confounders, overall time in child care was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age but not skinfold thicknesses. Center and own home care were not associated with the outcomes, but care in someone else's home was associated with an increase in both the 1- and 3-year outcomes. CONCLUSION: Child care in the first 6 months of life, especially in someone else's home, was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age.

State and regional variation in regulations related to feeding infants in child care.

OBJECTIVE: The purpose of this study was to compare state and regional variation in infant feeding regulations for child care facilities and to compare these regulations to national standards. METHODS: We reviewed regulations for child care for all US states and Washington, DC, and examined patterns according to type of facility and geographic region. We compared state regulations with national standards for feeding infants in child care. The standards included were: (1) infants are fed according to a feeding plan from a parent or physician; (2) breastfeeding is supported by the child care facility; (3) no solid food is given before 6 months of age; (4) infants are fed on demand; (5) infants are fed by a consistent caregiver; (6) infants are held while feeding; (7) infants cannot carry or sleep with a bottle; (8) caregivers cannot feed >1 infant at a time; (9) no cow's milk is given to children <12 months of age; (10) whole cow's milk is required for children 12 to 24 months of age; and (11) no solid food is fed in a bottle. RESULTS: The mean number of regulations for states was 2.8 (SD: 1.6) for centers and 2.0 (SD: 1.3) for family child care homes. No state had regulations for all 11 standards for centers; only Delaware had regulations for 10 of the 11 standards. For family child care homes, Ohio had regulations for 5 of the 11 standards, the most of any state. States in the South had the greatest mean number of regulations for centers (3.3) and family child care homes (2.2), and the West had the fewest (2.3 and 1.9, respectively). CONCLUSIONS: Many states lacked infant feeding regulations. Encouraging states to meet best-practice national standards helps ensure that all child care facilities engage in appropriate and healthful infant feeding practices.

Menus in child care: a comparison of state regulations with national standards.

The purpose of this project was to compare individual state regulations regarding menus for child-care centers and family child-care homes with national menu standards. For all 50 states and the District of Columbia, state regulations were compared with menu standards found in Caring for Our Children--National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. Specifically, these guidelines suggest that (a) menus must be posted or made available to parents, (b) menus must be dated, (c) menus must reflect food served, (d) menus must be planned in advance, and (e) menus must be kept on file. One additional standard, that menus in child care are reviewed by a nutrition professional, was added to this review. Data were collected between June and August of 2007. Substantial variation existed among state regulations regarding menus. For child-care centers, seven states (14%) included regulations on all five standards, and 13 states (25%) had regulations on four of the five menu standards. Ten states (20%) did not have any regulations on the five menu standards. For family child-care homes, only three states (6%) had regulations on all five menu standards; four states (8%) had regulations on four of the five menu standards. Twenty-seven states (53%) did not have any regulations on the five standards for menus. Within the same state, regulations for child-care centers and family child-care homes often did not match. Overall, great discrepancies were found between model child-care menu policies and current state regulations in most states. States have the opportunity to improve regulations regarding menus to ensure that child-care providers develop accurate, specific, and healthful menus.

Improving nutrition and physical activity in child care: what parents recommend.

A large percentage of children in the United States spend part of their day in out-of-home child care. As rates of obesity continue to rise, especially among young children, child care has become a focus for nutrition and physical activity intervention. Parental involvement is an important component of these efforts. During summer 2006, parents of children in child care were surveyed to better understand their perceived quality of meals, snacks, and physical activity at the child-care center, and their recommendations for improvement. Parents of children who attended 94 licensed child-care centers in North Carolina were invited to complete a brief survey of perceived quality of meals, snacks, and physical activity at their centers using close-ended questions. Open-ended questions were used to identify suggestions for improvement. Five hundred eight parents from 91 child-care centers completed the questionnaire. The majority of parents reported quality of meals and snacks at the center as either excellent (30% meals, 27% snacks) or good (42% meals, 46% snacks). The main recommendations for improving meals and snacks were to increase fruits and vegetables and provide a variety of healthful foods. The majority of parents categorized the quality of physical activity at the center as excellent (36%) or good (46%), and suggested more structured, outdoor activities for children. Findings from this study provide insight into key areas of concern for parents regarding the nutrition and activity environment of child-care centers. This information may be used to create or modify interventions or policies and to help motivate parents to become advocates for change in child care.

Nutrition and physical activity in child care: results from an environmental intervention.

BACKGROUND: With evidence of increased levels of obesity in younger children, the child-care setting is an important intervention target. Few environmental interventions exist, and none target both diet and physical activity. The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention was developed to fill this research and practice gap. DESIGN: Randomized controlled. SETTING/PARTICIPANTS: Health professionals (child-care health consultants) serving child-care centers in North Carolina were recruited (n=30), randomly assigned into intervention or delayed-intervention control groups, and trained to implement the NAP SACC program. Up to three child-care centers were recruited (n=84) from each consultant's existing caseload. INTERVENTION: Implemented in 2005, the NAP SACC intervention includes an environmental self-assessment, selection of areas for change, continuing education workshops, targeted technical assistance, and re-evaluation. Implementation occurred over a 6-month period. MAIN OUTCOME MEASURES: An observational instrument, Environment and Policy Assessment and Observation (EPAO), provided objective evidence of intervention impact and was completed by trained research staff blinded to study assignment. Data were collected in 2005 and 2006. Statistical analyses were conducted in 2006. RESULTS: Intention-to-treat analysis results were nonsignificant. Exploratory analyses using only centers that completed most of the NAP SACC program suggest an intervention effect. CONCLUSIONS: Factors in the intervention design, the fidelity of implementation, the selection of outcome measure, or a combination of these may have contributed to the lack of intervention effect observed. Because of this study's use of existing public health infrastructure and its potential for implementation, future studies should address strategies for improving effectiveness.

Obesity prevention in child care: a review of U.S. state regulations.

OBJECTIVE: To describe and contrast individual state nutrition and physical activity regulations related to childhood obesity for child care centers and family child care homes in the United States. METHODS: We conducted a review of regulations for child care facilities for all 50 states and the District of Columbia. We examined state regulations and recorded key nutrition and physical activity items that may contribute to childhood obesity. Items included in this review were: 1) Water is freely available; 2) Sugar-sweetened beverages are limited; 3) Foods of low nutritional value are limited; 4) Children are not forced to eat; 5) Food is not used as a reward; 6) Support is provided for breastfeeding and provision of breast milk; 7) Screen time is limited; and 8) Physical activity is required daily. RESULTS: Considerable variation exists among state nutrition and physical activity regulations related to obesity. Tennessee had six of the eight regulations for child care centers, and Delaware, Georgia, Indiana, and Nevada had five of the eight regulations. Conversely, the District of Columbia, Idaho, Nebraska and Washington had none of the eight regulations. For family child care homes, Georgia and Nevada had five of the eight regulations; Arizona, Mississippi, North Carolina, Oregon, Tennessee, Texas, Vermont, and West Virginia had four of the eight regulations. California, the District of Columbia, Idaho, Iowa, Kansas, and Nebraska did not have any of the regulations related to obesity for family child care homes. CONCLUSION: Many states lack specific nutrition and physical activity regulations related to childhood obesity for child care facilities. If widely implemented, enhancing state regulations could help address the obesity epidemic in young children in the United States.

Dietary intakes in North Carolina child-care centers: are children meeting current recommendations?

The purpose of this study was to determine whether food consumed by children while in center-based child care meets the new MyPyramid food group recommendations for children 2 to 5 years of age. Dietary observation of 117 children from 20 child-care centers throughout North Carolina was conducted. The type and amount of food served to and consumed by children was observed and assessed using Nutrition Data System for Research (NDS-R) software (version 2005, Nutrition Coordinating Center, University of Minnesota, Minneapolis). Portion sizes were then compared to the new MyPyramid food group recommendations to see whether 1/2 to 2/3 (for time spent in full-day child care) of the recommended amounts were consumed. On average, of the five main food groups, children consumed only the 1/2 to 2/3 recommendation for milk. Children also consumed less than 13% of MyPyramid recommendations for whole grains and 7% of MyPyramid recommendations for dark vegetables. Also noteworthy, 50% of milk consumed was whole milk and 75% of the meat consumed was of the high-fat or fried variety. Overall, our data suggest that children are not consuming recommended amounts of whole grains, fruits (excluding 100% fruit juice), or vegetables while attending full-time child care, and are consuming excess amounts of saturated fat and added sugar.

The childcare environment and children's physical activity.

BACKGROUND: With increased numbers of children attending child care, this setting presents an ideal opportunity to promote physical activity and the early development of healthy behaviors. The purpose of this study was to examine the relationships between the childcare environment and physical activity behavior of preschool children. METHODS: Aspects of the environment hypothesized to influence children's physical activity were assessed in 20 childcare centers using the Environment and Policy Assessment and Observation (EPAO) instrument. Physical activity behavior was assessed over 2 days using direct observation. RESULTS: Children in centers with supportive environments achieved more moderate-to-vigorous physical activity (15% of observations vs 9%; effect size [ES]=1.17), spent less time in sedentary activities (50% vs 61%; ES=-1.52), and had higher mean physical activity levels (2.68 vs 2.43; ES=1.41) compared to centers with less supportive environments. Facets of the physical and social environment related to physical activity behavior included active opportunities, portable play equipment, fixed play equipment, sedentary environment, and physical activity training and education. CONCLUSIONS: Previous research indicates that the childcare center that children attend significantly affects physical activity behavior. The current findings extend this evidence by identifying aspects of the childcare environment that relate to the physical activity behavior of children. These factors should be considered when identifying determinants of physical activity and designing interventions.

Preparing Child Care Health Consultants to address childhood overweight: a randomized controlled trial comparing web to in-person training.

OBJECTIVES: Child care centers have recently become targets for overweight prevention efforts directed at young children. Child Care Health Consultants (CCHCs), who provide consultation to these centers, receive little training on the basic nutrition and physical activity principles important for the promotion of child healthy weight. Traditional approaches, such as in-person training, are limited in their ability to disseminate health information to a geographically diverse population of health professionals. The purpose of this study was to determine if web-based training is as effective as in-person training. METHODS: A randomized controlled trial was conducted between August 2005 and June 2006 with 50 CCHCs. Web-based and in-person trained CCHCs were compared to each other and to controls. The main outcome of this study was performance on a test of nutrition knowledge related to childhood overweight measured by a 28-item multiple choice test administered pre- and post-training. RESULTS: Results from the ANCOVA model suggest that web trained CCHCs performed similarly to in-person trained CCHCs on the knowledge test (P < .0001). Additionally, both training groups improved significantly compared to controls (P < .0001 for each group). CONCLUSIONS: This study found no significant differences in post-training knowledge between in-person and web trained Child Care Health Consultants. Scores on the post-training knowledge test were within 0.5 points for the in-person and web trained groups. These results demonstrate that web-based instruction is as effective as in-person training on improving basic nutrition and physical activity knowledge for promoting healthy weight in preschool children.

Reliability and validity of a nutrition and physical activity environmental self-assessment for child care.

BACKGROUND: Few assessment instruments have examined the nutrition and physical activity environments in child care, and none are self-administered. Given the emerging focus on child care settings as a target for intervention, a valid and reliable measure of the nutrition and physical activity environment is needed. METHODS: To measure inter-rater reliability, 59 child care center directors and 109 staff completed the self-assessment concurrently, but independently. Three weeks later, a repeat self-assessment was completed by a sub-sample of 38 directors to assess test-retest reliability. To assess criterion validity, a researcher-administered environmental assessment was conducted at 69 centers and was compared to a self-assessment completed by the director. A weighted kappa test statistic and percent agreement were calculated to assess agreement for each question on the self-assessment. RESULTS: For inter-rater reliability, kappa statistics ranged from 0.20 to 1.00 across all questions. Test-retest reliability of the self-assessment yielded kappa statistics that ranged from 0.07 to 1.00. The inter-quartile kappa statistic ranges for inter-rater and test-retest reliability were 0.45 to 0.63 and 0.27 to 0.45, respectively. When percent agreement was calculated, questions ranged from 52.6% to 100% for inter-rater reliability and 34.3% to 100% for test-retest reliability. Kappa statistics for validity ranged from -0.01 to 0.79, with an inter-quartile range of 0.08 to 0.34. Percent agreement for validity ranged from 12.9% to 93.7%. CONCLUSION: This study provides estimates of criterion validity, inter-rater reliability and test-retest reliability for an environmental nutrition and physical activity self-assessment instrument for child care. Results indicate that the self-assessment is a stable and reasonably accurate instrument for use with child care interventions. We therefore recommend the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) instrument to researchers and practitioners interested in conducting healthy weight intervention in child care. However, a more robust, less subjective measure would be more appropriate for researchers seeking an outcome measure to assess intervention impact.

An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design.

Health professionals are faced with the growing challenge of addressing childhood overweight. Few overweight prevention efforts have targeted young children, particularly children in child care settings. We describe the theory and development of a novel nutrition and physical activity environmental intervention. On the basis of findings from interviews and focus groups, a review of national recommendations and standards, and a review of the literature, we developed a nutrition and physical activity environmental self-assessment instrument to assess physical activity and nutrition policies and practices in child care settings. An intervention model was built around existing public health infrastructure to support use of the self-assessment instrument and encourage environmental changes at the child care level, and this intervention model became the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program. The NAP SACC program was designed for dissemination and has potential for implementation in many settings. Broad interest in NAP SACC has been expressed by a number of states and institutions, and many groups are using NAP SACC intervention and materials. The NAP SACC program shows promise as a useful approach to promoting healthy weight behaviors in child care settings.

Nutrition and physical activity self-assessment for child care (NAP SACC): results from a pilot intervention.

OBJECTIVE: To determine the feasibility, acceptability, and reported impact of a nutrition and physical activity environmental intervention in child care. DESIGN: Self-assessment instrument completed pre- and post-intervention by randomly assigned intervention and comparison child care centers. SETTING: Child care centers in 8 counties across North Carolina. PARTICIPANTS: A convenience sample of 19 child care centers (15 intervention and 4 comparison). INTERVENTION: Intervention centers completed the self-assessment instrument at baseline and then selected 3 environmental improvements to make over the 6-month intervention period with assistance from a trained NAP SACC Consultant. MAIN OUTCOME MEASURE: Changes in pre- and post-intervention self-assesment of the nutrition and physical activity child care environment with additional process measures to evaluate project implementation, feasibility and acceptability. ANALYSIS: Comparison of pre- and post-test scores for the intervention group using a Wilcoxon signed-rank test and descriptions of environmental changes. RESULTS: Intervention centers rated themselves higher at follow-up than at baseline, and relative to comparison centers, reported a variety of environmental nutrition and physical activity improvements confirmed by research staff. CONCLUSIONS AND IMPLICATIONS: The NAP SACC pilot intervention shows promise as an approach to promote healthy weight environments in preschool settings. Additional evaluation of the project is needed using a greater number of centers and a more objective outcome measure.

Development and reliability of an observation method to assess food intake of young children in child care.

To our knowledge, a direct observation protocol for assessing dietary intake among young children in child care has not been published. This article reviews the development and testing of a diet observation system for child care facilities that occurred during a larger intervention trial. Development of this system was divided into five phases, done in conjunction with a larger intervention study; (a) protocol development, (b) training of field staff, (c) certification of field staff in a laboratory setting, (d) implementation in a child-care setting, and (e) certification of field staff in a child-care setting. During the certification phases, methods were used to assess the accuracy and reliability of all observers at estimating types and amounts of food and beverages commonly served in child care. Tests of agreement show strong agreement among five observers, as well as strong accuracy between the observers and 20 measured portions of foods and beverages with a mean intraclass correlation coefficient value of 0.99. This structured observation system shows promise as a valid and reliable approach for assessing dietary intake of children in child care and makes a valuable contribution to the growing body of literature on the dietary assessment of young children.