Maladaptive Food Attitudes and Behaviors in Individuals with Celiac Disease and Their Association with Quality of Life.

BACKGROUND: The only treatment for celiac disease (CeD) is strict lifelong adherence to a gluten-free diet (GFD). In some individuals the demands of a GFD may contribute to maladaptive eating attitudes and behaviors that impair quality of life (QOL). The Celiac Disease Food Attitudes and Behaviors (CD-FAB) is an easily administered and scored 11-item tool querying potentially maladaptive food attitudes and behaviors resulting from beliefs around gluten exposures and food safety. OBJECTIVES: To assess the usefulness of the CD-FAB in establishing the presence of maladaptive food attitudes and behaviors among adults with CeD and to explore the relationship between these attitudes and behaviors and other factors including QOL, anxiety, depression, CeD symptoms and personality traits. METHODS: The study is a cross-sectional pilot of 50 adults (mean age 29.6 years) with biopsy-proven CeD who followed a GFD for at least one year and had no self-reported eating disorder diagnosis. High scores on the CD-FAB tool suggest higher disordered eating attitudes and beliefs. RESULTS: Compared to lower scores (mean 20.2), higher (worse) CD-FAB scores (mean 54.5) were positively associated with recency of diagnosis, number of CeD-related gastrointestinal symptoms, and the personality trait of neuroticism. Higher CD-FAB scores were statistically and clinically significantly associated with diminished QOL (p < 0.001). The relationship with anxiety and depression was less clear but trended in the expected direction. CONCLUSION: The CD-FAB may be a useful tool for dietitians who wish to monitor maladaptive food attitudes and behaviors among their CeD patients, especially in the first-year post-diagnosis.

Navigating celiac disease and the gluten-free diet in China.

BACKGROUND: Little is known about celiac disease (CeD) diagnosis and management in China. AIM: This pilot aimed to be the first study to describe, quantitatively and qualitatively, how individuals living in China navigate CeD and the gluten-free diet (GFD). METHODS: Participants were 13 adults and four parents of children with reported CeD, recruited from 11 mainland China cities via an online GFD support group. CeD-specific quality of life (CD-QOL and CD-PQOL) and diet adherence (CDAT) were assessed. In-depth interviews addressed experiences with CeD and the GFD. RESULTS: Six of 17 participants reported biopsy- or serology-confirmed CeD. The mean (SD) adult CDAT score was 15.2 (3.6), > 13 indicating inadequate GFD adherence. The mean adult CD-QOL score was 62.1 (24.1) out of 100, in the "medium" to "good" range. Results were similar in children. Major interview themes included: (1) a challenging journey to obtain diagnosis; (2) social and structural barriers to maintaining the GFD; and (3) reliance on self in management of CeD. CONCLUSION: Obtaining a diagnosis, maintaining a GFD, and living with CeD can be extremely challenging in mainland China. Results suggest an urgent need for CeD-specific education and Asian-adapted GFD guidance for both healthcare practitioners and patients.

Impact of a Child's Celiac Disease Diagnosis and Management on the Family.

BACKGROUND: Little attention has been paid to family-wide repercussions of a child's celiac disease diagnosis and concomitant gluten-free diet management. AIMS: We quantitatively and qualitatively describe positive and negative family-wide effects of a child's celiac disease diagnosis and disease management. METHODS: We interviewed 16 families with at least one child currently following a gluten-free diet, with a biopsy-confirmed celiac disease diagnosis ≥ 1 year prior. Mothers and fathers independently rated child's dietary adherence, concern about child's health status, burden in caring for child's dietary needs, and level of change in various aspects of life post- diagnosis. Children rated their own celiac-specific quality of life through a validated scale. Seventy-one in-depth semi-structured interviews were conducted with 16 children with celiac disease, 31 parents, and 24 siblings. RESULTS: Mothers and fathers rated the effects of their child's celiac disease differently, with mothers reporting more lifestyle changes and heavier burden. Negative and positive themes emerged from the interviews. Mothers felt the burden of managing a gluten-free diet. Fathers felt guilty for carrying a celiac disease-associated gene and both fathers and siblings regretted limited food choices at restaurants and home. The need to be a more creative cook was seen as a positive effect by mothers. Fathers appreciated new family traditions. Siblings felt they had developed empathy for others. A framework is proposed to illustrate these family-wide interactions. CONCLUSIONS: A child's celiac disease diagnosis and disease management affects the entire family. Our results will inform family-centered interventions that maximize quality of life for families.

A Cooking-Based Intervention Promotes Gluten-Free Diet Adherence and Quality of Life for Adults with Celiac Disease.

Current treatment for celiac disease (CD) requires a life-long gluten-free diet (GFD).1 Among the top challenges are eating outside the home2 and over-reliance on processed foods, which are often high-fat, low-fiber, and high-sugar.3 Home cooking is a GFD management strategy that addresses both. Research not specific to CD suggests a variety of positive outcomes related to home cooking: healthier dietary pattern, positive self-management behaviors (eg, improved glycosylated hemoglobin and cholesterol levels), increased willingness to integrate complex dietary changes, and improved quality of life (QOL).4-6 In this study we assessed the feasibility and acceptability of a cooking-based nutrition education intervention to promote GFD adherence and QOL among adults with CD.

Feasibility, Acceptability, and Short-term Behavioral Impact of the MySmileBuddy Intervention for Early Childhood Caries.

OBJECTIVES: To evaluate acceptability, feasibility, and short-term behavioral impact of an early childhood caries (ECC) intervention. METHODS: Predominantly low-income Hispanic parent/child (2-6 years) dyads attending a busy pediatric dental clinic in New York City completed a single administration of the iPad-based technology-assisted education, goal-setting, and behavior change MySmileBuddy program. Self-reported behavior change was assessed via telephone survey one month post-intervention. RESULTS: Of 113 parent/child dyads approached, 108 (95.6%) participated and all completed MySmileBuddy in its entirety. Over 96% (n = 76) of 79 parents reached for follow-up recalled MySmileBuddy; 63.3% (n = 50) recalled their diet-and/or oral hygiene-related behavioral goal; and 79.7% (n = 79) reported taking action to initiate behavior change. CONCLUSIONS: Findings suggest that MySmileBuddy was feasibly implemented in a busy clinic, acceptable to this high-risk population, and effectively promoted preliminary ECC-related behavior changes. Larger, long-term studies are warranted to further investigate the impact of the MySmileBuddy program.

Benefits From and Barriers to Portable Detection of Gluten, Based on a Randomized Pilot Trial of Patients With Celiac Disease.

Research links diminished quality of life (QOL) to the challenges of a strict gluten-free diet (GFD), the only treatment for celiac disease (CD).1-4 This pilot study assessed the acceptability and feasibility of a portable gluten sensor device (Nima) to promote GFD adherence and QOL.

Correction to: Hypervigilance to a Gluten-Free Diet and Decreased Quality of Life in Teenagers and Adults with Celiac Disease.

The original version of the article unfortunately contained formatting errors in Table 3. The correct version of Table 3 is given in the Correction article.

Hypervigilance to a Gluten-Free Diet and Decreased Quality of Life in Teenagers and Adults with Celiac Disease.

BACKGROUND AND AIMS: Avoidance of gluten is critical for individuals with celiac disease (CD), but there is also concern that "extreme vigilance" to a strict gluten-free diet may increase symptoms such as anxiety and fatigue, and therefore, lower quality of life (QOL). We examined the associations of QOL with energy levels and adherence to, and knowledge about, a gluten-free diet. METHODS: This is a cross-sectional prospective study of 80 teenagers and adults, all with biopsy-confirmed CD, living in a major metropolitan area. QOL was assessed with CD-specific measures. Dietary vigilance was based on 24-h recalls and an interview. Knowledge was based on a food label quiz. Open-ended questions described facilitators and barriers to maintaining a gluten-free diet. RESULTS: The extremely vigilant adults in our sample had significantly lower QOL scores than their less vigilant counterparts [(mean (SD): 64.2 (16.0) vs 77.2 (12.2), p = 0.004]. Extreme vigilance was also associated with greater knowledge [5.7 (0.7) vs 5.1 (0.8), p = 0.035]. Adults with lower energy levels had significantly lower overall QOL scores than adults with higher energy levels [68.0 (13.6) vs 78.9 (13.0), p = 0.006]. Patterns were similar for teenagers. Cooking at home and using internet sites and apps were prevalent strategies used by the hypervigilant to maintain a strict gluten-free diet. Eating out was particularly problematic. CONCLUSION: There are potential negative consequences of hypervigilance to a strict gluten-free diet. Clinicians must consider the importance of concurrently promoting both dietary adherence and social and emotional well-being for individuals with CD.

Failure of Colonoscopy Knowledge to Predict Colonoscopy Uptake.

UNLABELLED: Despite an increase in colorectal cancer screening uptake, a substantial minority of individuals over 50 years of age remains unscreened. In the context of an RCT evaluating three educational interventions to increase CRC screening uptake, we examined the relationship of baseline colonoscopy knowledge and both intention to receive a colonoscopy and documented receipt of colonoscopy. Colonoscopy knowledge score, generally high, was positively associated with intention to receive colonoscopy but not with receipt of colonoscopy within 1 year post-randomization. Knowledge score was, however, positively associated with certain perceived barriers to colonoscopy: embarrassment and having to take a powerful laxative. CONCLUSION: Knowledge is not sufficient to trigger colonoscopy uptake. If CRC screening promotion campaigns fail to acknowledge and address patients' emotional barriers to colonoscopy, CRC screening rates will not improve. CLINICAL TRIALS: gov: Identifier: NCT02392143.

Fear as a Barrier to Asymptomatic Colonoscopy Screening in an Urban Minority Population with Health Insurance.

This study identified barriers to colonoscopy in a high-risk population and examined associations between barriers and both intention to comply with physician recommendation to receive colonoscopy and documented receipt of colonoscopy. Participants, enrollees in a randomized controlled trial assessing the effectiveness of educational interventions to promote colorectal cancer screening, were all 50+ years old and out of compliance with recommended screening guidelines. Direct financial cost of the procedure was not a barrier. The most commonly cited barriers were being afraid of the colonoscopy procedure (43.1 %), embarrassment (42.3 %), having to take a powerful laxative (36.2 %), fear of cancer (31.2 %), and fear of sedation (30.3 %). There were dose-response relationships between barriers and both intention to comply with physician recommendation of colonoscopy: 0, 1, 2, 3 barriers, 88.9, 79.0, 69.2 and 60.0 % intending to comply, respectively (linear trend χ(2) = 27.9, p = .000) and documented receipt of a colonoscopy: 0, 1, 2, 3 barriers, 21.7, 21.6, 8.5, 12.0 %, respectively (linear trend χ(2) = 8.4, p = .004). Only 6.9 % of the 102 expressing both fear of procedure and concern about taking a powerful laxative had a colonoscopy. These findings highlight the need to address patients' fear and suggest the importance of offering alternative colorectal cancer screening tests. ClinicalTrials.gov Identifier: NCT02392143.

Validation of an early childhood caries risk assessment tool in a low-income Hispanic population.

OBJECTIVES: There is a recognized need for valid risk assessment tools for use by both dental and nondental personnel to identify young children at risk for, or with, precavitated stages of early childhood caries (i.e., early stage decalcifications or white spot lesions).The aim of this study is to establish concurrent criterion validity of "MySmileBuddy" (MSB), a novel technology-assisted ECC risk assessment and behavioral intervention tool against four measures of ECC activity: semi-quantitative assays of salivary mutans streptococci levels, visible quantity of dental plaque, visual evidence of enamel decalcifications, and cavitation status (none, ECC, severe ECC). METHODS: One hundred eight children 2-6 years of age presenting to a pediatric dental clinic were recruited from a predominantly Spanish-speaking, low-income, urban population. All children received a comprehensive oral examination and saliva culture for assessment of ECC indicators. Their caregivers completed the iPad-based MSB assessment in its entirety (15-20 minutes). MSB calculated both diet and comprehensive ECC risk scores. Associations between all variables were determined using ordinal logistic regression. RESULTS: MSB diet risk scores were significantly positively associated with salivary mutans (P < 0.05), and approached significance with visible plaque levels (P < 0.1). MSB comprehensive risk scores were significantly associated with both oral mutans and visible plaque (P < 0.05). Neither was associated with visually evident decalcifications or cavitations. CONCLUSIONS: Findings suggest that MSB may have clinical utility as a valid risk assessment tool for identifying children with early precursors of cavitations but does not add value in identifying children with extant lesions.

Patient Test Preference for Colorectal Cancer Screening and Screening Uptake in an Insured Urban Minority Population.

The study examines the role of patient colorectal cancer (CRC) screening test preference and CRC screening uptake in an insured, urban minority population. Study subjects were enrolled in a randomized controlled trial to promote CRC screening. The interventions were educational, with an emphasis on colonoscopy screening. Subjects were 50+ years of age, fully insured for CRC screening, and out of compliance with current CRC screening recommendations. This paper includes those who answered a question about CRC screening test preference and indicated that they intended to receive such a test in the coming year (n = 453). CRC screening uptake was ascertained from medical claims data. Regardless of test preference, few received CRC screening (22.3 %). Those preferring the home stool test (HST) were less likely to get tested than those preferring a colonoscopy (16.6 vs 29.9 %, χ(2) = 9.9, p = .002). Preference for HST was more strongly associated with beliefs about colonoscopy than with knowledge about colonoscopy. In the context of an RCT emphasizing colonoscopy screening for CRC, patients expressing a preference for HST are at heightened risk of remaining unscreened. Colonoscopy should be recommended as the preferred CRC test, but HSTs should be accessible and encouraged for patients who are averse to colonoscopy.Clinical trials.gov: Identifier: NCT02392143.

Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach.

BACKGROUND: In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake. METHODS: Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don't overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery. RESULTS: The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor. CONCLUSION: The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance.

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Pedestrian Behavior at Five Dangerous and Busy Manhattan Intersections.

Technology-related distracted behavior is an emergent national concern. Listening to, looking at or talking into an electronic device while walking divides attention, increasing the risk of injury. The purpose of this study was to quantify technology-related distracted pedestrian behavior at five dangerous and busy Manhattan intersections. Data were collected over ten cycles of signal changes at each of the four corners of five intersections at four times of day. Data for 'Walk' and 'Don't Walk' signals were tallied separately. A total of 21,760 pedestrians were observed. Nearly one-third crossing on a 'Walk' signal (n = 5414, 27.8%), and nearly half crossing on a 'Don't Walk' signal (n = 974; 42.0%) were wearing headphones, talking on a mobile phone, and/or looking down at an electronic device. Headphone use was the most common distraction.

Public bike sharing in New York City: helmet use behavior patterns at 25 Citi Bike™ stations.

Urban public bicycle sharing programs are on the rise in the United States. Launched in 2013, NYC's public bicycle share program, Citi Bike™ is the fastest growing program of its kind in the nation, with nearly 100,000 members and more than 330 docking stations across Manhattan and Brooklyn. The purpose of this study was to assess helmet use behavior among Citi Bike™ riders at 25 of the busiest docking stations. The 25 Citi Bike™ Stations varied greatly in terms of usage: total number of cyclists (N = 96-342), commute versus recreation (22.9-79.5% commute time riders), weekday versus weekend (6.0-49.0% weekend riders). Helmet use ranged between 2.9 and 29.2% across sites (median = 7.5 %). A total of 4,919 cyclists were observed, of whom 545 (11.1%) were wearing helmets. Incoming cyclists were more likely to wear helmets than outgoing cyclists (11.0 vs 5.9%, p = .000). NYC's bike share program endorses helmet use, but relies on education to encourage it. Our data confirm that, to date, this strategy has not been successful.

Diet-Related Colorectal Cancer Prevention Beliefs and Dietary Intakes in an Urban Minority Population.

In the United States, colorectal cancer (CRC) is the third leading cause of cancer-related death and third most commonly diagnosed cancer among adults. This study is the first to examine the relationship between diet-related beliefs for colorectal cancer prevention and dietary intake among an urban, predominantly Black population (n = 169). More than two-thirds reported diet-related CRC prevention beliefs. Those with diet-related CRC prevention beliefs had healthier intakes for dietary fiber (p = .005), fruit, vegetable, bean (p = .027), red meat (p = .032), vitamin C (p = .039), and cholesterol (p = .045). Most people may already have diet-related CRC prevention beliefs and having them is associated with a more healthful dietary intake.

Screening colonoscopy bowel preparation: experience in an urban minority population.

METHODS: Suboptimal bowel preparation, present in over 20% of colonoscopies, can severely compromise the effectiveness of the colonoscopy procedure. We surveyed 93 primarily urban minority men and women who underwent asymptomatic 'screening' colonoscopy regarding their precolonoscopy bowel-preparation experience. RESULTS: Print materials alone (39.8%) and in-person verbal instructions alone (35.5%) were reportedly the most common modes of instruction from the gastroenterologists. Liquid-containing laxative (70.6%) was the most common laxative agent; a clear liquid diet (69.6%) the most common dietary restriction. Almost half of the participants mentioned 'getting the laxative down' as one of the hardest parts of the preparation; 40.9% mentioned dietary restrictions. The 24.7% who mentioned 'understanding the instructions' as one of the hardest parts were more likely to be non-US born and to have lower education and income. There was no relationship between difficulty in understanding instructions and mode of instruction or preparation protocol. One quarter suggested that a smaller volume and/or more palatable liquid would have made the preparation easier. Three quarters agreed that it would have been helpful to have someone to guide them through the preparation process. CONCLUSIONS: These findings suggest a variety of opportunities for both physician- and patient-directed educational interventions to promote higher rates of optimal colonoscopy bowel preparation.

Distinguishing factors for asymptomatic colonoscopy screening.

Demographic, medical history, physician factors, knowledge, beliefs and perceived barriers related to colorectal cancer (CRC) and CRC screening were compared for age-eligible individuals who received asymptomatic colonoscopy screening (n=100) versus those who did not receive any kind of CRC screening (n=142). All participants had health insurance that covered the full cost of colonoscopy screening. Screeners were more likely to have lower levels of income and education, to know the purpose of a colonoscopy, believe it was more normative, and report fewer barriers. Addressing these and other factors associated with CRC screening warrant testing as empirically based interventions.

Implementing and evaluating a school-based program to improve childhood vision.

BACKGROUND: Approximately 20% of the American schoolchildren have a vision problem. Children from low-income urban areas have been shown to have more than twice the normal rate of vision problems. This study evaluated the effectiveness of A Vision for Success, a school-based program designed to provide eyeglasses to children in a timely manner in selected New York City public elementary schools and to encourage their regular use at school. METHODS: An intervention-control group design with 265 first- and second-grade students across 8 New York City public schools was implemented. Participating students had failed a prior mandated vision screening. Students in A Vision for Success received (1) a school-based professional optometric screening, (2) provision of 2 pairs of eyeglasses (1 kept by the teacher for classroom use), and (3) teachers' encouragement of eyeglass use as prescribed in school. Mean rates of classroom eyeglass use were assessed between groups by direct observation prior to and after the optometric screening. RESULTS: Mean rates of eyeglass use for students in intervention and control groups at baseline were 22% and 19%, respectively (p > .10). At follow-up, eyeglass use rose to 47% in the intervention group, whereas the control group's rate remained consistent at 19% (p < .001). Significant differences persisted for boys and girls. CONCLUSIONS: Children disproportionately affected by visual dysfunction can receive glasses in a timely manner and wear them regularly in the classroom. Even more intensive efforts will be needed for some children to help ensure that they wear glasses in school.