Transdisciplinary healthcare researcher and dietitian with expertise in implementation science, childhood nutrition, eating/ingestive behavior, innovations in clinical and community health care, and obesity prevention and treatment.

Current Role at Stanford

Quantitative Research Scientist in the Evaluation Sciences Unit (ESU)

Honors & Awards

  • Fellow, Stanford Medicine Center for Improvement (2021)

Education & Certifications

  • RDN, Commission on Dietetic Registration, Registered Dietitian (2017)
  • BS, Iowa State University, Dietetics (2011)
  • PhD, The Pennsylvania State University, Nutritional Sciences (2016)

All Publications

  • Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits. Neurology. Clinical practice Kling, S. M., Falco-Walter, J. J., Saliba-Gustafsson, E. A., Garvert, D. W., Brown-Johnson, C. G., Miller-Kuhlmann, R., Shaw, J. G., Asch, S. M., Yang, L., Gold, C. A., Winget, M. 1800; 11 (6): 472-483


    Background and Objectives: To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.Methods: Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).Results: Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.Discussion: Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

    View details for DOI 10.1212/CPJ.0000000000001065

    View details for PubMedID 34992955

  • Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. Annals of family medicine Vilendrer, S., Brown-Johnson, C., Kling, S. M., Veruttipong, D., Amano, A., Bohman, B., Daines, W. P., Overton, D., Srivastava, R., Asch, S. M. 2021; 19 (5): 427-436


    PURPOSE: Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures.METHODS: We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment.RESULTS: MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures.CONCLUSIONS: MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

    View details for DOI 10.1370/afm.2719

    View details for PubMedID 34546949

  • How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being. Mayo Clinic proceedings Vilendrer, S. M., Kling, S. M., Wang, H., Brown-Johnson, C., Jayaraman, T., Trockel, M., Asch, S. M., Shanafelt, T. D. 2021


    OBJECTIVE: To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.PARTICIPANTS AND METHODS: A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.RESULTS: Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).CONCLUSION: Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.

    View details for DOI 10.1016/j.mayocp.2021.03.039

    View details for PubMedID 34479736

  • Predicting and Responding to Clinical Deterioration in Hospitalized Patients by Using Artificial Intelligence: Protocol for a Mixed Methods, Stepped Wedge Study. JMIR research protocols Holdsworth, L. M., Kling, S. M., Smith, M., Safaeinili, N., Shieh, L., Vilendrer, S., Garvert, D. W., Winget, M., Asch, S. M., Li, R. C. 2021; 10 (7): e27532


    BACKGROUND: The early identification of clinical deterioration in patients in hospital units can decrease mortality rates and improve other patient outcomes; yet, this remains a challenge in busy hospital settings. Artificial intelligence (AI), in the form of predictive models, is increasingly being explored for its potential to assist clinicians in predicting clinical deterioration.OBJECTIVE: Using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, this study aims to assess whether an AI-enabled work system improves clinical outcomes, describe how the clinical deterioration index (CDI) predictive model and associated work processes are implemented, and define the emergent properties of the AI-enabled work system that mediate the observed clinical outcomes.METHODS: This study will use a mixed methods approach that is informed by the SEIPS 2.0 model to assess both processes and outcomes and focus on how physician-nurse clinical teams are affected by the presence of AI. The intervention will be implemented in hospital medicine units based on a modified stepped wedge design featuring three stages over 11 months-stage 0 represents a baseline period 10 months before the implementation of the intervention; stage 1 introduces the CDI predictions to physicians only and triggers a physician-driven workflow; and stage 2 introduces the CDI predictions to the multidisciplinary team, which includes physicians and nurses, and triggers a nurse-driven workflow. Quantitative data will be collected from the electronic health record for the clinical processes and outcomes. Interviews will be conducted with members of the multidisciplinary team to understand how the intervention changes the existing work system and processes. The SEIPS 2.0 model will provide an analytic framework for a mixed methods analysis.RESULTS: A pilot period for the study began in December 2020, and the results are expected in mid-2022.CONCLUSIONS: This protocol paper proposes an approach to evaluation that recognizes the importance of assessing both processes and outcomes to understand how a multifaceted AI-enabled intervention affects the complex team-based work of identifying and managing clinical deterioration.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27532.

    View details for DOI 10.2196/27532

    View details for PubMedID 34255728

  • Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021


    BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

    View details for DOI 10.1016/j.surg.2021.03.029

    View details for PubMedID 33941389

  • Evaluation of Patient and Clinician Perspectives for New and Return Ambulatory Teleneurology Visits, with special attention to subspecialty differences Falco-Walter, J., Kling, S., Saliba-Gustafsson, E., Yang, L., Miller-Kuhlmann, R., Garvert, D., Brown-Johnson, C., Shaw, J., Asch, S., Winget, M., Gold, C. LIPPINCOTT WILLIAMS & WILKINS. 2021
  • Agreement in Infant Growth Indicators and Overweight/Obesity between Community and Clinical Care Settings JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS Harris, H. A., Kling, S. R., Marini, M., Hassink, S. G., Bailey-Davis, L., Savage, J. S. 2021; 121 (3): 493–500


    Infants from low-income backgrounds receive nutrition care from both community and clinical care settings. However, mothers accessing these services have reported receiving conflicting messages related to infant growth between settings, although this has not been examined quantitatively.Describe the agreement in infant growth assessments between community (Special Supplemental Nutrition Program for Women, Infants, and Children) and clinical (primary care providers) care settings.A cross-sectional, secondary data analysis of infant growth measures abstracted from electronic data management systems.Participants included a convenience sample of infants (N = 129) from northeastern Pennsylvania randomized to the WEE Baby Care study from July 2016 to May 2018. Infants had complete anthropometric data from both community and clinical settings at age 6.2 ± 0.4 months. Average time between assessments was 2.7 ± 1.9 weeks.Limits of agreement and bias in weight-for-age, length-for-age, weight-for-length, and body-mass-index-for-age z scores as well as cross-context equivalence in weight status between care settings.Bland-Altman analyses were used to describe the limits of agreement and bias in z scores between care settings. Cross-context equivalence was examined by dichotomizing infants' growth indicators at the 85th and 95th percentile cut-points and cross-tabulating equivalent and discordant categorization between settings.Strongest agreement was observed for weight-for-age z scores (95% limits of agreement -0.41 to 0.54). However, the limits of agreement intervals for growth indicators that included length were wider, suggesting weaker agreement. There was a high level of inconsistency for classification of overweight/obesity using weight-for-length z scores, with 15.5% (85th percentile cut-point) and 11.6% (95th percentile cut-point) discordant categorization between settings, respectively.Infant growth indicators that factor in length could contribute to disagreement in the interpretation of infant growth between settings. Further investigation into the techniques, standards, and training protocols for obtaining infant growth measurements across care settings is required.

    View details for DOI 10.1016/j.jand.2020.11.009

    View details for Web of Science ID 000620458700008

    View details for PubMedID 33339762

  • The prevalence of COVID-19 in healthcare personnel in an adult and pediatric academic medical center. American journal of infection control Shepard, J., Kling, S. M., Lee, G., Wong, F., Frederick, J., Skhiri, M., Holubar, M., Shaw, J. G., Stafford, D., Schilling, L., Kim, J., Ick Chang, S., Frush, K., Hadhazy, E. 2021; 49 (5): 542–46


    BACKGROUND: It is vital to know which healthcare personnel (HCP) have a higher chance of testing positive for severe acute respiratory syndrome coronavirus 2 (COVID-19).METHODS: A retrospective analysis was conducted at Stanford Children's Health (SCH) and Stanford Health Care (SHC) in Stanford, California. Analysis included all HCP, employed by SCH or SHC, who had a COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) test resulted by the SHC Laboratory, between March 1, 2020 and June 15, 2020. The primary outcome was the RT-PCR percent positivity and prevalence of COVID-19 for HCP and these were compared across roles.RESULTS: SCH and SHC had 24,081 active employees, of which 142 had at least 1 positive COVID-19 test. The overall HCP prevalence of COVID-19 was 0.59% and percent positivity was 1.84%. Patient facing HCPs had a significantly higher prevalence (0.66% vs 0.43%; P = .0331) and percent positivity (1.95% vs 1.43%; P = .0396) than nonpatient facing employees, respectively. Percent positivity was higher in food service workers (9.15%), and environmental services (5.96%) compared to clinicians (1.93%; P < .0001) and nurses (1.46%; P < .0001), respectively.DISCUSSION AND CONCLUSION: HCP in patient-facing roles and in support roles had a greater chance of being positive of COVID-19.

    View details for DOI 10.1016/j.ajic.2021.01.004

    View details for PubMedID 33896582

  • Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study. Journal of medical Internet research Patel, B., Vilendrer, S., Kling, S. M., Brown, I., Ribeira, R., Eisenberg, M., Sharp, C. 2021


    Telemedicine has been deployed by healthcare systems in response to the COVID-19 pandemic to enable healthcare workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown.To use real-time locating systems (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between healthcare workers and patients.A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2nd, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20th, 2020. A new telemedicine platform was deployed on March 29th, 2020. Number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and post-implementation phases and compared with t-tests to determine statistical significance.There were 15,741 RTLS events linked to 2,662 encounters for patients screened for COVID-19. There was no significant change in number of in-person interactions between the pre- and post-implementation phases for both nurses (5.7 vs 7.0 entrances per patient, p=0.07) and physicians (1.3 vs 1.5 entrances per patient, p=0.12). Total duration of in-person interaction did not change (56.4 vs 55.2 minutes per patient, p=0.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, p<0.01 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, p<0.01 for change in daily average).Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to healthcare workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline healthcare clinicians.

    View details for DOI 10.2196/29240

    View details for PubMedID 34236993

  • Accessing behavioral health care during COVID: rapid transition from in-person to teleconferencing medical group visits. Therapeutic advances in chronic disease Juarez-Reyes, M., Mui, H. Z., Kling, S. M., Brown-Johnson, C. 2021; 12: 2040622321990269


    Background and aim: Effective and safe behavioral health interventions in primary care are critical during pandemic and other disaster situations. California shelter-in-place orders necessitated rapid transition of an effective mindfulness-based medical group visit (MGV) program from in-person to videoconferenced sessions (VCSs). Aim: to Describe procedures, acceptability, and feasibility of converting from in-person to VCS.Patients and methods: Methods: qualitative. Dataset: primary care. Intervention: a six-session 2-h MGV program with educational and mindfulness components was converted. Four in-person sessions and two VCSs were held. General Anxiety Disorder and Patient Health Questionnaire-9 were administered at first and last sessions. A semi-structured focus group was conducted after session six. Population studied: six primary care patients (42±11years) with stress, anxiety, or depression participated.Results: Procedural changes included remote material distribution, scheduling, hosting, and facilitation functions using the Zoom platform. The focus group revealed that patients preferred in-person sessions during initial visits, but appreciated transitioning to VCS, which provided continued support during a challenging time. Instruction on technical (e.g. logging on) and social (e.g. signaling next speaker) aspects of VCS was suggested. Building relationships through conversations was an important part before and after in-person sessions missing from VCS. Patients suggested combining in-person and VCS to allow relationship building while also improving access.Conclusion: While many procedural changes were needed to facilitate conversion to VCS, primary care patients seeking stress, anxiety, and depression interventions found VCS acceptable during COVID-19. Future iterations of this program are proposed which incorporate procedural changes and facilitate relationship building between patients in VCS.

    View details for DOI 10.1177/2040622321990269

    View details for PubMedID 33633823

  • Advanced Health Information Technologies to Engage Parents, Clinicians, and Community Nutritionists in Coordinating Responsive Parenting Care: Descriptive Case Series of the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care Randomized Controlled Trial. JMIR pediatrics and parenting Kling, S. M., Harris, H. A., Marini, M., Cook, A., Hess, L. B., Lutcher, S., Mowery, J., Bell, S., Hassink, S., Hayward, S. B., Johnson, G., Franceschelli Hosterman, J., Paul, I. M., Seiler, C., Sword, S., Savage, J. S., Bailey-Davis, L. 2020; 3 (2): e22121


    BACKGROUND: Socioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs.OBJECTIVE: This analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists.METHODS: Parents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit.RESULTS: Dyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad).CONCLUSIONS: Results support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies.TRIAL REGISTRATION: NCT03482908; REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12887-018-1263-z.

    View details for DOI 10.2196/22121

    View details for PubMedID 33231559

  • Development and Pilot Testing of Standardized Food Images for Studying Eating Behaviors in Children FRONTIERS IN PSYCHOLOGY Kling, S. R., Pearce, A. L., Reynolds, M. L., Garavan, H., Geier, C. F., Rolls, B. J., Rose, E. J., Wilson, S. J., Keller, K. L. 2020; 11: 1729


    Food images are routinely used to investigate the cognitive and neurobiological mechanisms of eating behaviors, but there is a lack of standardized image sets for use in children, which limits cross-study comparisons. To address this gap, we developed a set of age-appropriate images that included 30 high-energy-dense (ED) foods (>2.00 kcal/g), 30 low-ED foods (<1.75 kcal/g), and 30 office supplies photographed in two amounts (i.e., "larger" and "smaller"). Preliminary testing was conducted with children (6-10 years) to assess recognition, emotional valence (1 = very sad, 5 = very happy), and excitability (1 = very bored, 5 = very excited). After the initial testing, 10 images with low recognition were replaced; thus, differences between Image Set 1 and Image Set 2 were analyzed. Thirty (n = 30, mean age 8.3 ± 1.2 years) children rated Set 1, and a different cohort of 29 children (mean age 8.1 ± 1.1 years) rated Set 2. Changes made between image sets improved recognition of low-ED foods (Set 1 = 88.3 ± 10.5% vs. Set 2 = 95.6 ± 10.6%; p < 0.0001) and office supplies (83.7 ± 10.5 vs. 93.0 ± 10.6%; p < 0.0001). For the revised image set, children recognized more high-ED foods (98.4 ± 10.6%) than low-ED foods (95.6 ± 10.6%; p < 0.05) and office supplies (93.0 ± 10.6%; p < 0.0001). Recognition also improved with age (p < 0.001). Excitability and emotional valence scores were greater for high-ED foods compared with both low-ED foods and office supplies (p < 0.0001 for both). However, child fullness ratings influenced the relationship between excitability/emotional valence and category of item (p < 0.002). At the lowest fullness level, high-ED foods were rated the highest in both excitability and emotional valence, followed by low-ED foods and then office supplies. At the highest fullness level, high-ED foods remained the highest in excitability and emotional valence, but ratings for low-ED foods and office supplies were not different. This suggests that low-ED foods were more exciting and emotionally salient (relative to office supplies) when children were hungry. Ratings of recognition, excitability, and emotional valence did not differ by image amount. This new, freely available, image set showed high recognition and expected differences between image category for emotional valence and excitability. When investigating children's responsiveness to food cues, specifically energy density, it is essential for investigators to account for potential influences of child age and satiety level.

    View details for DOI 10.3389/fpsyg.2020.01729

    View details for Web of Science ID 000558444700001

    View details for PubMedID 32793062

    View details for PubMedCentralID PMC7385190

  • Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology Yang, L., Brown-Johnson, C. G., Miller-Kuhlmann, R., Kling, S. M., Saliba-Gustafsson, E. A., Shaw, J. G., Gold, C. A., Winget, M. 2020


    The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.

    View details for DOI 10.1212/WNL.0000000000010015

    View details for PubMedID 32611634

  • Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R. n., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L. n., Falco-Walter, J. n., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. n. 2020


    Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

    View details for DOI 10.2196/24328

    View details for PubMedID 33245699

  • A Biopsychosocial Model of Sex Differences in Children's Eating Behaviors. Nutrients Keller, K. L., Kling, S. M., Fuchs, B. n., Pearce, A. L., Reigh, N. A., Masterson, T. n., Hickok, K. n. 2019; 11 (3)


    The prevalence of obesity and eating disorders varies by sex, but the extent to which sex influences eating behaviors, especially in childhood, has received less attention. The purpose of this paper is to critically discuss the literature on sex differences in eating behavior in children and present new findings supporting the role of sex in child appetitive traits and neural responses to food cues. In children, the literature shows sex differences in food acceptance, food intake, appetitive traits, eating-related compensation, and eating speed. New analyses demonstrate that sex interacts with child weight status to differentially influence appetitive traits. Further, results from neuroimaging suggest that obesity in female children is positively related to neural reactivity to higher-energy-dense food cues in regions involved with contextual processing and object recognition, while the opposite was found in males. In addition to differences in how the brain processes information about food, other factors that may contribute to sex differences include parental feeding practices, societal emphasis on dieting, and peer influences. Future studies are needed to confirm these findings, as they may have implications for the development of effective intervention programs to improve dietary behaviors and prevent obesity.

    View details for DOI 10.3390/nu11030682

    View details for PubMedID 30909426

    View details for PubMedCentralID PMC6470823

  • Feasibility of enhancing well-child visits with family nutrition and physical activity risk assessment on body mass index. Obesity science & practice Bailey-Davis, L. n., Kling, S. M., Wood, G. C., Cochran, W. J., Mowery, J. W., Savage, J. S., Stametz, R. A., Welk, G. J. 2019; 5 (3): 220–30


    Integration of behavioural risk assessment into well-child visits is recommended by clinical guidelines, but its feasibility and impact is unknown.A quasi-experimental study evaluated the feasibility and effectiveness of risk assessment on body mass index (BMI) at 1-year follow-up. Children with assessments (intervention) were compared with those who did not complete assessments (non-respondent) and those who received standard care (non-exposed).Analyses included 10,647 children aged 2-9 years (2,724 intervention, 3,324 non-respondent and 4,599 non-exposed). Forty-five per cent of parents completed the assessments. Intervention and non-respondent groups differed in change in BMI z-score at 1 year by -0.05 (confidence interval [CI]: -0.08, -0.02; P = 0.0013); no difference was observed with non-exposed children. The intervention group had a smaller increase in BMI z-score (0.07 ± 0.63) than non-respondent group (0.13 ± 0.63). For children with normal weight at baseline, intervention versus non-respondent groups differed in BMI z-score change by -0.06 (CI: -0.10, -0.02; P = 0.0025). However, children with overweight at baseline in the intervention versus the non-exposed group differed in BMI z-score change (0.07 [CI: 0.02, 0.14]; P = 0.016). When analysed by age, results were similar for 2- to 5-year-olds, but no differences were found for 6- to 9-year-olds.Automating risk assessment in paediatric care is feasible and effective in promoting healthy weight among preschool but not older children.

    View details for DOI 10.1002/osp4.339

    View details for PubMedID 31275595

    View details for PubMedCentralID PMC6587309

  • Portion size has sustained effects over 5 days in preschool children: a randomized trial. The American journal of clinical nutrition Smethers, A. D., Roe, L. S., Sanchez, C. E., Zuraikat, F. M., Keller, K. L., Kling, S. M., Rolls, B. J. 2019; 109 (5): 1361–72


    Although short-term studies have found that serving larger portions of food increases intake in preschool children, it is unknown whether this portion size effect persists over a longer period or whether energy intake is moderated through self-regulation.We tested whether the portion size effect is sustained in preschool children across 5 consecutive days, a period thought to be sufficient for regulatory systems to respond to the overconsumption of energy.With the use of a crossover design, over 2 periods we served the same 5 daily menus to 46 children aged 3-5 y in their childcare centers. In 1 period, all foods and milk were served in baseline portions, and in the other period, all portions were increased by 50%. The served items were weighed to determine intake.Increasing the portion size of all foods and milk by 50% increased daily consumption: weighed intake increased by a mean ± SEM of 143 ± 21 g/d (16%) and energy intake increased by 167 ± 22 kcal/d (18%; both P < 0.0001). The trajectories of intake by weight and energy across the 5-day period were linear and the slopes did not differ between portion conditions (both P > 0.13), indicating that there were sustained increases in intake from larger portions without compensatory changes over time. Children differed in their response to increased portions: those with higher weight status, lower ratings for satiety responsiveness, or higher ratings for food responsiveness had greater increases in intake from larger portions (all P < 0.03).This demonstration that preschool children failed to adjust their intake during prolonged exposure to larger portions challenges the suggestion that their self-regulatory behavior is sufficient to counter perturbations in energy intake. Furthermore, overconsumption from large portions may play a role in the development of overweight and obesity, as the magnitude of the effect was greater in children of higher weight status. This trial was registered at as NCT02963987.

    View details for DOI 10.1093/ajcn/nqy383

    View details for PubMedID 30976782

    View details for PubMedCentralID PMC6499504

  • Integrating and coordinating care between the Women, Infants, and Children Program and pediatricians to improve patient-centered preventive care for healthy growth. Translational behavioral medicine Bailey-Davis, L. n., Kling, S. M., Cochran, W. J., Hassink, S. n., Hess, L. n., Franceschelli Hosterman, J. n., Lutcher, S. n., Marini, M. n., Mowery, J. n., Paul, I. M., Savage, J. S. 2018; 8 (6): 944–52


    New care delivery models call for integrating health services to coordinate care and improve patient-centeredness. Such models have been embraced to coordinate care with evidence-based strategies to prevent obesity. Both the Special Supplemental Program for Women, Infants and Children (WIC) Program and pediatricians are considered credible sources of preventive guidance, and coordinating these independent siloes would benefit a vulnerable population. Using semistructured focus groups and interviews, we evaluated practices, messaging, and the prospect of integrating and coordinating care. Across Pennsylvania, WIC nutritionists (n = 35), pediatricians (n = 15), and parents (N = 28) of an infant or toddler participated in 2016. Three themes were identified: health assessment data sharing (e.g., iron, growth measures), benefits and barriers to integrated health services, and coordinating care to reduce conflicting educational messages (e.g., breastfeeding, juice, introduction of solids). Stakeholders supported sharing health assessment data and integrating health services as strategies to enhance the quality of care, but were concerned about security and confidentiality. Overall, integrated, coordinated care was perceived to be an acceptable strategy to facilitate consistent, preventive education and improve patient-centeredness.

    View details for DOI 10.1093/tbm/ibx046

    View details for PubMedID 29370433

  • A patient-centered, coordinated care approach delivered by community and pediatric primary care providers to promote responsive parenting: pragmatic randomized clinical trial rationale and protocol. BMC pediatrics Savage, J. S., Kling, S. M., Cook, A. n., Hess, L. n., Lutcher, S. n., Marini, M. n., Mowery, J. n., Hayward, S. n., Hassink, S. n., Hosterman, J. F., Paul, I. M., Seiler, C. n., Bailey-Davis, L. n. 2018; 18 (1): 293


    Economically disadvantaged families receive care in both clinical and community settings, but this care is rarely coordinated and can result in conflicting educational messaging. WEE Baby Care is a pragmatic randomized clinical trial evaluating a patient-centered responsive parenting (RP) intervention that uses health information technology (HIT) strategies to coordinate care between pediatric primary care providers (PCPs) and the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) community nutritionists to prevent rapid weight gain from birth to 6 months. It is hypothesized that data integration and coordination will improve consistency in RP messaging and parent self-efficacy, promoting shared decision making and infant self-regulation, to reduce infant rapid weight gain from birth to 6 months.Two hundred and ninety mothers and their full-term newborns will be recruited and randomized to the "RP intervention" or "standard care control" groups. The RP intervention includes: 1) parenting and nutrition education developed using the American Academy of Pediatrics Healthy Active Living for Families curriculum in conjunction with portions of a previously tested RP curriculum delivered by trained pediatric PCPs and WIC nutritionists during regularly scheduled appointments; 2) parent-reported data using the Early Healthy Lifestyles (EHL) risk assessment tool; and 3) data integration into child's electronic health records with display and documentation features to inform counseling and coordinate care between pediatric PCPs and WIC nutritionists. The primary study outcome is rapid infant weight gain from birth to 6 months derived from sex-specific World Health Organization adjusted weight-for-age z-scores. Additional outcomes include care coordination, messaging consistency, parenting behaviors (e.g., food to soothe), self-efficacy, and infant sleep health. Infant temperament and parent depression will be explored as moderators of RP effects on infant outcomes.This pragmatic patient-centered RP intervention integrates and coordinates care across clinical and community sectors, potentially offering a fundamental change in the delivery of pediatric care for prevention and health promotion. Findings from this trial can inform large scale dissemination of obesity prevention programs.Restrospective Clinical Trial Registration: NCT03482908 . Registered March 29, 2018.

    View details for DOI 10.1186/s12887-018-1263-z

    View details for PubMedID 30180831

    View details for PubMedCentralID PMC6123992

  • What is eaten when all of the foods at a meal are served in large portions? Appetite Roe, L. S., Kling, S. M., Rolls, B. J. 2016; 99: 1–9


    Portion size affects intake, but when all foods are served in large portions, it is unclear whether every food will be consumed in greater amounts. We varied the portion size (PS) of all foods at a meal to investigate the influence of food energy density (ED) on the PS effect as well as that of palatability and subject characteristics. In a crossover design, 48 women ate lunch in the laboratory on four occasions. The meal had three medium-ED foods (pasta, bread, cake) and three low-ED foods (broccoli, tomatoes, grapes), which were simultaneously varied in PS across meals (100%, 133%, 167%, or 200% of baseline amounts). The results showed that the effect of PS on the weight of food consumed did not differ between medium-ED and low-ED foods (p < 0.0001). Energy intake, however, was substantially affected by food ED across all portions served, with medium-ED foods contributing 86% of energy. Doubling the portions of all foods increased meal energy intake by a mean (±SEM) of 900 ± 117 kJ (215 ± 28 kcal; 34%). As portions were increased, subjects consumed a smaller proportion of the amount served; this response was characterized by a quadratic curve. The strongest predictor of the weight of food consumed was the weight of food served, both for the entire meal (p < 0.0001) and for individual foods (p = 0.014); subject characteristics explained less variability. Intake in response to larger portions was greater for foods that subjects ranked higher in taste (p < 0.0001); rankings were not related to food ED. This study demonstrates the complexity of the PS effect. While the response to PS can vary between individuals, the effect depends primarily on the amounts of foods offered and their palatability compared to other available foods.

    View details for DOI 10.1016/j.appet.2016.01.001

    View details for PubMedID 26767612

    View details for PubMedCentralID PMC4762726

  • Double trouble: Portion size and energy density combine to increase preschool children's lunch intake. Physiology & behavior Kling, S. M., Roe, L. S., Keller, K. L., Rolls, B. J. 2016; 162: 18–26


    Both portion size and energy density (ED) have substantial effects on intake; however, their combined effects on preschool children's intake have not been examined when multiple foods are varied at a meal.We tested the effects on intake of varying the portion size and ED of lunches served to children in their usual eating environment.In a crossover design, lunch was served in 3 childcare centers once a week for 6weeks to 120 children aged 3-5y. Across the 6 meals, all items were served at 3 levels of portion size (100%, 150%, or 200%) and 2 levels of ED (100% or 142%). The lunch menu had either lower-ED or higher-ED versions of chicken, macaroni and cheese, vegetables, applesauce, ketchup, and milk. Children's ratings of the foods indicated that the lower-ED and higher-ED meals were similarly well liked.The total weight of food and milk consumed at meals was increased by serving larger portions (P<0.0001) but was unaffected by varying the ED (P=0.22). Meal energy intake, however, was independently affected by portion size and ED (both P<0.0001). Doubling the portions increased energy intake by 24% and increasing meal ED by 42% increased energy intake by 40%. These effects combined to increase intake by 175±12kcal or 79% at the higher-ED meal with the largest portions compared to the lower-ED meal with the smallest portions. The foods contributing the most to this increase were chicken, macaroni and cheese, and applesauce. The effects of meal portion size and ED on intake were not influenced by child age or body size, but were significantly affected by parental ratings of child eating behavior.Strategically moderating the portion size and ED of foods typically consumed by children could substantially reduce their energy intake without affecting acceptability.

    View details for DOI 10.1016/j.physbeh.2016.02.019

    View details for PubMedID 26879105

    View details for PubMedCentralID PMC4899121

  • Does milk matter: Is children's intake affected by the type or amount of milk served at a meal? Appetite Kling, S. M., Roe, L. S., Sanchez, C. E., Rolls, B. J. 2016; 105: 509–18


    Increasing the energy density (ED) and portion size of foods promotes additional energy intake, but the effect of similar changes in milk is unknown. Using a crossover design, we tested the effect of varying the ED and portion size of milk served with lunch on preschool children's intake. Lunch was served in childcare classrooms on 4 days to 125 children aged 3-5 y (67 boys; 58 girls). Across the meals, milk was varied in ED (lower-ED [1% fat]; higher-ED [3.25% fat]) and portion size (100% [183 g]; 150% [275 g]). Foods in the meal were not varied; children ate as much of the meal as they wanted. Serving higher-ED milk did not affect milk intake by weight, but increased energy intake from milk by 31 ± 2 kcal compared to serving lower-ED milk (P < 0.0001). Serving the 150% portion of milk increased milk intake by 20 ± 3 kcal compared to serving the 100% portion (P < 0.0001). Increases in both ED and portion size combined to increase milk intake by 49 ± 4 kcal (63%; P < 0.0001). Across all children, food intake decreased when higher-ED rather than lower-ED milk was served, but meal energy intake (food + milk) did not change significantly. This response varied by sex: for boys, serving higher-ED milk decreased food intake by 43 ± 8 kcal (P < 0.0001) but did not affect meal energy intake, while for girls, higher-ED milk did not reduce food intake so that meal energy intake increased by 24 ± 10 kcal (P = 0.03). Thus, boys adjusted food intake in response to changes in ED of milk consumed with lunch, but girls did not. Serving milk in larger portions promotes intake of this nutrient-dense beverage, but the effects of milk ED on meal intake vary between children.

    View details for DOI 10.1016/j.appet.2016.06.022

    View details for PubMedID 27338218

    View details for PubMedCentralID PMC4980227