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  Patient Perspectives on Medication Assisted Therapy in Vermont

  Ashley D. Adkins, Holly Bachilas, Florence DiBiase, Michael J. Marallo, John Paul Nsubuga, Lloyd Patashnick, Curran Uppaluri, Elizabeth Cote, and Charles MacLean

  Introduction. Medication-Assisted Therapy (MAT) for opioid addiction has dramatically increased in Vermont, supported by a novel statewide system that integrates specialty treatment centers ("Hubs") with primary care office-based opioid therapy ("Spokes"). In 2010, Vermont had the highest per capita buprenorphine use in the US. Previous studies of patient perspectives of MAT have identified social barriers, rigid program rules, and concerns about withdrawal and relapse as common causes of treatment failure. Our goal was to elicit patient perspectives on barriers and enablers of successful MAT to further inform system refinement.

  Methods. An interview guide was developed based on previous literature as well as discussions with program leadership, staff and clinicians, and community stakeholders. Responses were organized using thematic content analysis with consensus across seven interviewers and two analysts. The interviews were conducted with 44 patients enrolled in MAT at two Hub sites in Burlington, VT in October 2016.

  Results. The median age of subjects was 34 years, 34% were employed at least part-time, and 72% were female. Half reported a mental health condition and 20% reported chronic pain. Barriers included transportation (25%), lack of stable housing, and stigma (41%). Enablers included feeling supported (82% felt well-supported; 52% felt supported by healthcare professionals). Subjects expressed high confidence in the treatment system and high self-efficacy for sobriety.

  Conclusions. Patients in MAT have complex medical, mental health, social, personal, and work lives. A comprehensive system that addresses this wide range of domains is critical to achieving optimal outcomes.

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  Gaps in Adolescent Tobacco Prevention and Counseling in Vermont

  Dexter C. Allen, Morgan Hadley, Margaret Klepack, Amber J. Meservey, Lynn Sipsey, Greg Whitcher, Mushtaba Yuridullah, Jill Sudhoff-Guerin, Jill Jemison, and Jan Carney

  Introduction. Tobacco use remains the leading cause of preventable death in Vermont. While the Vermont Blueprint for Health includes compensation for adult tobacco counseling, it includes no specific mention of pediatric populations. Research questions: To what extent are tobacco assessment and cessation efforts occurring in the primary care setting with pediatric patients? What factors influence their practices?
  
  Methods. A 12-question electronic survey, modeled on an American Academy of Pediatrics survey, was distributed to primary care providers throughout Vermont; through the UVM departments of pediatrics, family medicine, the Vermont Medical Society and the Vermont Area Health Education Center. We received 70 completed surveys.
  
  Results. 70% of the surveyed primary care providers begin tobacco counseling at the age recommended (11 years) by the Vermont Department of Health. Only 45.71% of providers are confident in their understanding of the recommendations for adolescent health screening written in the Blueprint for Health. Additionally, only 67.1% of the providers expressed confidence in their ability to provide guidance regarding the harmful effects of E-cigarettes, compared to 92.8% feeling confident regarding conventional cigarettes. 70% of providers listed time restraints as a significant factor in their decision not to counsel adolescents on tobacco use.
  
  Discussion. The Blueprint for Health is a guiding document for provider practices that is not well understood and does not specifically include pediatric tobacco prevention. In an environment where youth E-cigarette use is rising, especially among adolescents, it is especially critical that physicians are confident in their counseling practices.

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  Understanding Refugees' Perspectives on Health Care

  Khaled H. Al Tawil, Nathan L. Centybear, Julia Lane Cowenhoven, Emily Kinn, Joseph J. Lahey, Jayne Manigrasso, Chantal Mendes, Martha Friedman, and Shaden Eldakar-Hein

  Introduction. Burlington, Vermont accepts refugees from around the world. These individuals face unique barriers to accessing healthcare due to language, culture and finances. Research suggests that cultural beliefs about healthcare can affect ability or willingness to seek medical care. Gaining a better understanding of refugee perspectives of the healthcare system may offer insight into how to rectify this issue.

  Objectives. The goal of this study was to learn about refugee perspectives of the healthcare system and assess their use of services.

  Methods. We surveyed a convenience sample of 24 refugees to learn more about thoughts and practices surrounding healthcare and the use of the medical system.

  Results. Survey findings suggested that refugees who had been living in the US for longer than one year access healthcare resources differently from more recent arrivals. Most respondents agreed that reasons for going to a healthcare provider revolved around the diagnosis and treatment of current ailments. Regardless of time spent in the U.S., most respondents were unlikely to seek out preventive care. Refugees who had been in the U.S. longer than one year were less likely to seek out emergency services for acute symptoms that would be better served by a visit with their PCP.

  Conclusions. Recent arrivals used the emergency room for primary care needs more than those living in the U.S. longer than one year, suggesting the efficacy of provided health education. Study data suggests an important area for improvement may be increased education for refugees about the importance of preventive care.

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  Assessing the Awareness of Lead Hazards in the Greater Burlington Area

  Tessa R. Barclay, Laura Taylor Director, Steven Everse, Bailey Fay, Aaron M. Gelinne, Eliot S. Jia, Julia McGinty, Sunit K. Misra, and Lauren Pyatt

  Introduction. Lead is a heavy metal found in and around homes built before 1978, comprising more than 80% of the housing stock in Chittenden County, Vermont. Lead exposure during infancy and childhood can have deleterious effects on development. Our study assessed baseline community understanding of potential household lead hazards in Chittenden County, Vermont.

  Methods.. 123 paper, 10-question surveys were randomly administered to Chittenden County, VT residents to assess recognition of lead toxicology symptoms and awareness of lead safety programs. Scores were treated as continuous variables, demographically grouped, and analyzed using non-parametric statistical analysis (Mann-Whitney & Kruskal-Wallis). Individual questions were treated as dichotomous variables, demographically grouped and analyzed using chi-squared testing.

  Results.. 48% of survey participants understood the interaction between ADHD and lead or knew the importance of window maintenance. 54.5% were aware of the Burlington Lead Program's assistance program. Participants earning less than $60,000 and those with less than a graduate degree scored statistically lower (p

  Conclusion.. Lesser-known lead poisoning symptoms and home interventions that decrease lead exposure should be emphasized to the community. High-risk groups requiring targeted education include those who rent, have lower income and education levels. Primary care providers could serve a larger role in educating patients. Additional efforts should be made to publicize services offered by the Burlington Lead Program.

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  Stress Identification and Management in COTS Family Shelter Residents

  Kristen J. Bartlett, James Duguay, Sebastian A. Franco, Marie Kenney, Callie Linehan, Alexander W. Marchese, Rebecca Robbins, Brian J. Rosen, Rebecca Mills, Anne Brena, and Jan Carney

  Introduction. Previous studies have demonstrated that the homeless population experience higher stress levels than the general population. The goal of our study was to identify potential sources of stress for families staying with COTS, the largest service provider for the homeless and those at risk of becoming homeless in Vermont, and also to gauge potential interest in evidence-based stress-reduction strategies.

  Methods. Interviews were conducted with seven adult representatives of seven different families (of fourteen eligible) currently residing at the family shelters managed by COTS, in fall 2016. Questions included a mix of short answer items and open ended prompts. Responses that yielded quantifiable data were compiled while responses that were open-ended were qualitatively analyzed to extract core themes.

  Results. 6 out of 7 residents indicated they were at least as stressed while living at COTS as when they were homeless, and 5 out of 7 were receptive to some form of stress reduction. Common stressors included health, finances, lack of privacy, children and employment status.

  Discussion. Residents at the family shelters come from a variety of cultural and experiential backgrounds. The composition of COTS' inhabitants and their needs are in dynamic flux. Accordingly, our conclusions may not translate into the future. Our observations underscore a need and a desire for stress-reduction intervention. Thus, we recommend COTS pilot both a weekly mediation class and weekly yoga class. We also suggest the organization provide nutritional information sheets to residents and explore implementing a car share program.

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  Prenatal Lead Exposure Risk Assessment by Vermont Maternity Care Providers

  Amy M. Berkman, Brendon Kinsley, Margaret S. Johnston, Rose Kristine Leu, Niketu P. Patel, Maia Sakradse, George Zhang, Wendy Davis, and Matthew Bradstreet

  Introduction. One percent of women of childbearing age in the U.S. have blood lead levels ≥ 5 ug/dL, which are associated with maternal hypertension during pregnancy, neural tube and cardiac defects in infants, low birth weight, prematurity, and spontaneous abortion. It is unknown whether obstetrics providers in Vermont are screening their pregnant patients for lead levels and educating them on lead exposure risks.

  Objective. To gain an understanding of current lead screening practices in Vermont and issue recommendations for disseminating lead screening information.

  Methods. We developed and e-mailed a survey to practicing OB/GYN physicians, maternity care focused family medicine physicians, nurse midwives, and professional midwives. The survey assessed current screening practices for lead exposure in their pregnant patients, interest in receiving statewide guidelines, and guideline dissemination preferences.

  Results. Of the 41 respondents, 12% currently conduct risk assessments for lead exposure with all of their pregnant patients. Fifty four percent of maternity providers give all of their patients educational materials about lead exposure and risk of toxicity. Seventy one percent of maternity providers think that having guidelines provided by the Vermont Department of Health would encourage them to begin or continue lead exposure screening. The two preferred methods of communicating guidelines to physicians were grand rounds and email whereas non-physician providers preferred email and webinar.

  Discussion. The majority of pregnant patients in Vermont are not properly assessed or educated about lead risks. However, there is interest in having statewide standardized lead risk assessment guidelines, with dissemination preferences differing by provider type.

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  Willingness To Donate Blood During the Summer

  Christopher Bernard, Taylor Brown, Ramya Ghantasala, Obhijit Hazarika, Nicole Leonard, Cori Polonski, Zachary Wunrow, Michelle Heleba, Jan Carney, and Mark K. Fung

  Introduction. Each year donation rates fall in the summer months straining blood banks’ capacities to meet local demands. In hopes of identifying factors to increase summer donations, our study investigated donor reported barriers which influence summer donations habits.
  
  Methods. An anonymous 16 question survey investigating various donation factors was administered across multiple American Red Cross (ARC) donation centers in Vermont. Questions addressed donor demographics, frequency of blood donation, preference in appointment making modalities including smartphone app use, summer travel habits, willingness to donate during vacation, and factors that deter donors from donating on vacation.
  
  Results. A total of 292 surveys were received. Survey respondents across multiple demographic groups cited similar barriers to summer donation, namely “Too busy” (27.5 %) and “Traveling is a time for me to relax.” (30.6 %). Of the respondents who travel in the summer, very few reported donating while traveling (3.4 %). Summer donation rates between summertime travelers (36.5 %) and non-travelers (36.4 %) were essentially equivalent. The most preferred methods of scheduling appointments were via ARC website (45.6 %) and phone (28.4%). Willingness to use the ARC app was highest among respondents ages of 18 to 34 (45-55%) and lowest among ages 55 and older (13-15%). Of respondents with no prior knowledge of summer seasonal shortages (22 %), 2/3rds indicated newfound motivation to donate.
  
  Conclusion. Regardless of travel, increasing awareness of summer shortages may increase summer donations. Use of donor websites and smartphone apps may be instrumented as part of recruitment efforts.

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  The Effects of Poetry in Elderly Populations with Memory Impairment

  Michael Burton, Katherine Clifford, John P. Corbett, Midori Eckenstein, Jenna Conway Jorgensen, Stephanie S. Kulaga, Hyunsoo Joshua No, Nathaniel White, and Judith Christensen

  Introduction. A small body of research on therapeutic use of poetry in individuals with memory impairment demonstrates benefits similar to that of more widely studied music interventions. This project aims to assess the effects of participation in a poetry group on the residents of a memory care floor within the Converse Home, an assisted living facility in Burlington, Vermont.

  Methods.. We evaluated the effects of twelve group poetry sessions on residents' well-being in several domains. Each session included a reading and writing portion, which were evaluated separately to assess differences in measures of communication, interest, and enjoyment. These measures, along with negative responses, were recorded on Likert scales. T-tests, ANOVA, and post-hoc comparisons were used to compare behavioral and affective observations in the reading versus writing sessions.

  Results.. Positive responses were significantly higher in reading sessions (p

  Conclusion.. Although the limitations of this project preclude us from drawing individual conclusions regarding the therapeutic efficacy of poetry in individuals with memory impairment, we demonstrate that poetry sessions have a positive impact on global quality of life outcomes and introduction of poetry sessions in this population has a beneficial effect.

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  Public Health Outcomes as a Measure of Efficacy of Syringe Exchange Programs

  Andrew Corse, Katelyn Donaldson, Andrew Gallagher, Anita Li, Morgan R. Pratt, Benjamin F. Smith, Amelia V. Tajik, Peter Jacobsen, T. Vezina, and Jerry Larrabee

  Introduction. A syringe exchange is a public health intervention that offers nonjudgmental services to intravenous drug users (IVDU), providing clean syringes in exchange for used syringes. While prior studies demonstrated that syringe exchanges can reduce transmission of HIV, hepatitis C, and other blood-borne pathogens, other measures of health improvements have been less studied.

  Methods. 91 members of Vermont CARES syringe exchange program were surveyed on their healthcare practices. New members were defined asprogram.

  Results. Long-term members tended to have a primary care provider (PCP). Lack of insurance and fear of judgment were commonly cited reasons for not having a PCP. Long-term members were significantly less likely (p=0.04) to use costly emergency department (ED) services and less likely to reuse their own or another person's needles. Long-term members were more likely to be in addiction treatment and reported a greater desire to abstain from drug use. New members were more likely to obtain hepatitis C and HIV testing in the past year.

  Discussion. Subjects responded positively to the possibility of accessing PCP services through VT CARES, offering a continuation of the nonjudgmental healthcare environment. Decreased ED visits significantly correlated with longer membership, reflecting the positive impact of the syringe exchange education services on reducing healthcare costs. Decreased testing among long-term members may reflect prior knowledge of their status. Long-term members were less likely to reuse their own needles or ones used by another person, suggesting the distribution of clean syringes encourages safer injection practices.

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  Diagnostic Medical Errors: Patient's Perspectives on a Pervasive Problem

  Cody J. Couperus, Sree Sahithi Kolli, Sergio Andres Munoz, Quinn Self, Russell R. Reeves, Erica Worswick, Sterling A. York, and Allen B. Repp

  Introduction. The Institute of Medicine defines diagnostic error as the failure to establish an accurate or timely explanation for the patient's health problem(s), or effectively communicate the explanation to the patient. To our knowledge, no studies exist characterizing diagnostic error from patient perspectives using this definition.

  Objective. We sought to characterize diagnostic errors experienced by patients and describe patient perspectives on causes, impacts, and prevention strategies.

  Methods. We screened 77 adult inpatients at University of Vermont Medical Center and conducted 27 structured interviews with patients who experienced diagnostic error in the past five years. We performed qualitative analysis using Grounded Theory.

  Results. In the past five years, 39% of interviewed patients experienced diagnostic error. The errors mapped to the following categories: accuracy (30%), communication (34%) and timeliness (36%). Poor communication (13 responses) and inadequate time with doctors (7) were the most identified causes of errors. Impacts of errors included emotional distress (17 responses), adverse health outcomes (7) and impaired activities of daily living (6). Patients suggested improved communication (11 responses), clinical management (7) and access to doctors (5) as prevention strategies. For communication, patients rated "talk to your doctor" highest (mean 8.4, on 1-10 Likert scale) and "text message" lowest (4.8).

  Conclusions/Recommendations. Diagnostic errors are common and have dramatic impact on patients' well-being. We suggest routine surveillance to identify errors, support for patients who have experienced errors, and implementation of patient and provider "checklists" to enhance communication. Future studies should investigate strategies to allow care providers adequate time with patients.

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  Analysis of Care Coordination for Children with Special Health Care Needs: A Parent's Perspective

  Kristen M. Dalton, Desiree N. DiBella, Alan Lee, Althea L. Morrison, Adam Michael Schlauch, Marc J. Vecchio, Paige M. Wood, Lisa Maynes, and Heather Link

  Introduction. Care coordination involves organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve improved outcomes, a recent national focus. Compared to the national average, a higher percentage of Vermont children are cared for in an office that meets medical home criteria. However, there is limited research on medical home and care coordination for children with special health care needs (CSHCN) in the state of Vermont.

  Objectives. The goal of this study was to assess family perceptions, knowledge, and attitudes about how well care coordination is working for Vermont families with CSHCN.

  Methods. A paper and an electronic anonymous survey was developed for Vermont families with CSHCN. The surveys were then distributed by Vermont Family Network and the UVMMC Department of Pediatrics. Focus group interviews were also conducted at Vermont Family Network to provide family insight to explain the quantitative data.

  Results. 30 participants responded to the survey; only 20 completed it. The overall composite satisfaction score is 54%. This score takes into account 4 questions regarding care coordination satisfaction. Each question was formatted into a numerical value ranging from zero to five, with an overall score of 20 equating to 100% satisfaction.

  Discussion. Findings indicate that families with CSHCN are not satisfied with the level of care coordination currently provided. Respondents reported many barriers regarding care coordination, including lack of communication among health care providers, insurance coverage, and lack of support during transitional periods in care. Recommended improvements were identified.

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  Asthma in Vermont Dairy Farmers

  Wyll T. Everett, Victoria Lauren Close, Rebecca Merriam-Stelfox, Sravana Paladugu, Jacob B. Reibel, Ruby L. Russell, Rebecca Ryan, and David Kaminsky

  Introduction. Although 5.4% of the Vermont population participates in agriculture as an occupation, little data exists on the prevalence of asthma in Vermont dairy farmers, due to inadequate sample sizes. Previous studies have shown dairy farmers are at risk of respiratory illness due to unique exposures intrinsic to their occupation. We conducted a study to assess the prevalence of asthma in dairy farmers in Vermont, to understand rates among this population and potential occupational risks.
  
  Methods. We distributed a paper survey modeled after previously-validated surveys, such as the BRFSS, to farmers at Vermont Farmer Bureau meetings, farmers markets, and individual farmers through Cabot Creamery. Out of 309 distributed surveys, we received 176 completed surveys for a response rate of 57%.
  
  Results. Self-reported asthma rate in dairy farmers was 21% (22% in dairy only farmers), with 90% of these cases reported as confirmed by a doctor. Of non-dairy farmers, 11% self-reported experiencing asthma. Farming activities associated with exacerbation of asthma symptoms were milking, prepping or cleaning bedding, and haying. 31% of dairy-only farmers reported symptom exacerbations due to these occupational triggers.
  
  Conclusions. The prevalence of asthma in Vermont dairy farmers is one of the highest reported rates in any Vermont occupation. Our data suggest that certain occupational exposures may increase risk of asthma and warrant further study; certain farming practices were associated with exacerbation of respiratory symptoms in farmers diagnosed with asthma. These findings and further research can assist in development of health care and preventive health measures for farmers.

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  Public Awareness of Medical Imaging as a Source of Ionizing Radiation Exposure

  Tim Fields, Michael J. Hall, Arjun Janardhan, Lawrence J. Leung, Samantha Magier, Allison B. Robbins, Katie C. Warther, Razelle Hoffman-Contois, William Irwin, and Jan Carney

  Background. Biological effects of exposure to ionizing radiation (IR) are well known. Literature suggests most patients and physicians lack proficient understanding of risks associated with ionizing radiation. Our study goals were to: assess the extent to which productive, informed conversations regarding ionizing radiation are occurring between patients and providers; characterize public awareness of medical imaging procedures as sources of IR exposure; and investigate best practices in patientprovider communications.

  Methods. We developed and administered a 17-question survey to 303 adults at five locations across Chittenden County, Vermont, over a 6-week period in fall 2016. Descriptive and statistical analyses were conducted using SPSS.

  Results. The three age groups of respondents had different knowledge levels about ionizing radiation (p

  Conclusions/Recommendations. 1. A standard oral presentation for pre-imaging patient-provider communication, along with a written handout, be developed; 2. A section of the electronic medical record (also accessible through the patient portal) containing IR exposure be created for patients and physicians to track individuals' information.

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  Effects of Art from the Heart on Nurse Satisfaction and Patient Well-Being

  Kassandra J. Gibbs, Eric C. King, Nicholas S. LoSchiavo, UnChan Pyon, Jasmine Y. Robinson, Luke Soelch, Brianna F. Waller, Rebecca Schwarz, Buffy F. Dekmar, and Sarah McCarthy

  Introduction. Art programs have been shown to positively affect unit culture, quality of care, and nursing practices. Art interventions improve well-being, reduce stress, and enhance nurse-patient communication. Art from the Heart (AFTH) is an art program that provides art supplies, visual art, and patient "About Me" pages to patients, families and employees at University of Vermont Medical Center (UVMMC).
  
  Objective. Assess the efficacy of AFTH through nursing staff perceptions, understanding, and attitudes toward the program.
  
  Methods. Structured interviews were conducted on Baird 4, an adult inpatient ward, at UVMMC. A 19-question survey using Likert scales and short answer formats was administered to nursing staff. Questions assessed perceptions of effects of art on patient anxiety and pain, communication, and job satisfaction. Surveys were analyzed to extract major and minor themes.
  
  Results. Twenty-eight interviews were obtained and two major themes emerged: nurse satisfaction and patient well-being. Nursing staff satisfaction minor themes included improved productivity, promoting conversation, and creating a positive influence on the unit. Respondents reported that AFTH helped initiate conversations with patients (100% of respondents) and reduced workday stress (68%). The second major theme, patient well-being, included benefits to patients with dementia, providing comfort, and serving as an outlet or distraction. Utilizing AFTH improved perceived patient mood (100%), health (78.5%), and reduced patient anxiety (89.3%).
  
  Conclusions. AFTH provides positive benefits by reducing nursing staff stress and perceived patient anxiety; improving communication, perceived patient mood and health; and creating a sense of community. AFTH should be expanded to the entire 6 Community Agency: Burlington City Arts, Art from the Heart

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  Vermont Healthy Kids' Meals: Parents' Perspectives

  Ashley C. Hodges, Geordie C. Lonza, Lindsay S. Howe, Omkar Betageri, Ryan Erik Landvater, Sean Closs, Tina Zuk, and Paula Tracy

  Introduction. Childhood obesity has increased for decades. Options on kids’ menus in restaurants typically involve unhealthy choices such as fries, chicken fingers, and grilled cheese, with soda as the drink. When healthy options are the default choice, children are more likely to eat them. Though initially skeptical of modifications, restaurants will enact changes to maintain customer satisfaction and profits, and there is no significant difference in price of healthier kids’ meals.
  
  Methods. 187 paper and electronic surveys were administered throughout Vermont to explore attitudes towards availability, cost, and importance of healthy kids’ meals, as well as income, education, and children in the household. Open-ended questions sought parental opinions.
  
  Results. 69% of parents believe healthier food options at restaurants would cost more; however, 95% were willing to pay more. 89% of parents reported feeling concerned or highly concerned about sugary drinks, and 62% of parents were very likely to choose the healthier food option at a restaurant. The majority of parents who reported difficulty in finding healthy meals felt the amount of fruits/vegetables was the most important nutritional factor. Low income Vermonters were most concerned about cost.
  
  Conclusions. The majority of parents are concerned about kids’ meal nutrition and are likely to purchase healthier options, even at increased prices. If restaurants enact changes to kids’ menus, prices should remain the same to ensure families of all socioeconomic classes will be able to purchase healthier meals. Priority modifications to meals should include increased amounts of fruits/vegetables and elimination of added sugar.

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  Nutrition Education in Vermont Public Schools

  Garyn Worrall, Allison Greene, Suven Cooper, Francis G. Gause IV, Patrick Saunders, Daniel Lambert, Rebekah Misir, Alison Howe, and Katy Davis

  Introduction. Despite positive changes, childhood obesity and food insecurity remain prevalent across the country. Vermont is not immune to these issues. We set out to: research the level of nutrition education Vermont elementary schools provide their students, understand teacher perceptions of these programs, and recommend ways to fill identified gaps.

  Methods. Our study is a cross-sectional survey of Vermont educators around nutrition education. The survey consisted of 17 questions, used LimeSurvey, and included demographic and nutrition education questions. The survey was distributed statewide through newsletters and list-servers.

  Results. 64 responses met inclusion criteria. Vermont elementary school (K-6) teachers report a mean satisfaction score of 2.51 out of 5.0 for their schools' current nutrition education programs. School nurses reported a score of 2.5 out of 5.0. Highest satisfaction scores included school administrators and health and wellness coordinators (3.3 out of 5.0). When comparing teachers to non-classroom educators (administrators and nutrition educators) data showed a significant difference between high satisfaction (3-5) and low satisfaction (1-2); (Fischer p = 0.009). Overall, Vermont elementary school teachers report a high level of knowledge about nutrition, (4.1/5.0), but a lower level of understanding in their students (2.5/5.0).

  Conclusions. Given teacher perceptions regarding current school nutrition education programs, development and implementation of a state-wide nutrition education curriculum with dedicated teaching time may be warranted. Programs recommended by the CDC include "Eat Well & Get Moving" and "Planet Health," designed by the Harvard School of Public Health. These could be adapted as a framework for Vermont.