A dietitian-delivered group nutrition program leads to reductions in dietary fat, serum cholesterol, and body weight: the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH)

Perspective: The Dietary Inflammatory Index (DII)-Lessons Learned, Improvements Made, and Future Directions

The literature on the role of inflammation in health has grown exponentially over the past several decades. Paralleling this growth has been an equally intense focus on the role of diet in modulating inflammation, with a doubling in the size of the literature approximately every 4 y. The Dietary Inflammatory Index (DII) was developed to provide a quantitative means for assessing the role of diet in relation to health outcomes ranging from blood concentrations of inflammatory cytokines to chronic diseases. Based on literature from a variety of different study designs ranging from cell culture to observational and experimental studies in humans, the DII was designed to be universally applicable across all human studies with adequate dietary assessment. Over the past 4 y, the DII has been used in >200 studies and forms the basis for 12 meta-analyses. In the process of conducting this work, lessons were learned with regard to methodologic issues related to total energy and nutrient intake and energy and nutrient densities. Accordingly, refinements to the original algorithm have been made. In this article we discuss these improvements and observations that we made with regard to misuse and misinterpretation of the DII and provide suggestions for future developments.

Impact of training primary care physicians in behavioral counseling to reduce cardiovascular disease risk factors in Ecuador

OBJECTIVE

To assess the feasibility of implementing a physician-based, patient-centered counseling intervention model in Ecuador to improve the ability of primary care physicians (PCPs) to reduce cardiovascular disease (CVD) risk factors among patients.

METHODS

This was a randomized clinical trial conducted in primary care clinics in Quito in 2014 - 2016. Participants included 15 PCPs and their adult patients at high risk of developing type-2 diabetes. A physician-based and patient-centered counseling program was delivered to eight PCPs. Seven PCPs who did not receive the training comprised the control group. The patient experience was assessed by a patient exit interview (PEI). Assessment of the patient's anthropometrics, blood pressure, and blood biochemistry parameters were conducted. Changes within and between groups were estimated utilizing chi-square, ANOVA, paired t-tests, and coefficient with intervention.

RESULTS

A total of 197 patients participated, 113 in the intervention care group (ICG) and 84 in the usual care group (UCG); 99 patients (87.6%) in the ICG and 63 (75%) in the UCG completed the study. Counseling steps, measured by the PEI, were significantly higher in the ICG (8.9±1.6 versus 6.6±2.3; P = 0.001). Comparison of the estimated difference between the ICG and the UCG showed greater decreases in HbA1c and total cholesterol in the ICG. Within the ICG, there were significant improvements in weight, BMI, HbA1C, total cholesterol, and LDL-cholesterol.

CONCLUSIONS

Training PCPs in a patient-centered behavioral intervention for CVD risk factor reduction is feasible and efficacious for reducing CVD risk factors in Ecuador. Developed and developing countries alike could benefit from such an intervention.

Trends and disparities in the prevalence of physicians' counseling on diet and nutrition among the U.S. adult population, 2000-2011

BACKGROUND

Although healthy eating plays a crucial role in addressing the obesity and chronic disease epidemics, a few Americans have diets that meet dietary guidelines. Because physicians-delivered counseling is a strong predictor for behavioral modification among patients, the Healthy People Objectives have emphasized diet counseling since 2000. However, research on impact of physicians' counseling over time on a national level has been limited.

METHODS

We used data from the 2000 and 2011 National Health Interview Surveys to apply a logistic regression model to identify predictors of physicians' counseling and examine any changes in disparities over a decade.

RESULTS

In 2000, only 23.7% of our national sample had received dietary counseling, it increased to 32.6% in 2011. Hispanics were less likely than Whites to receive advice on diet in 2000 (adjusted odds ratio [AOR]=0.74, 95% confidence interval [CI]=0.62-0.88). By 2011, Hispanics 18% (AOR=1.18, CI=1.09-1.28) and Blacks were 42% (AOR=1.42, CI=1.32-1.54) more likely to receive advice from their physicians on diet than Whites. In both years, men were significantly less likely than women to receive counseling. The uninsured patients were increasingly less likely than insured patients in receiving diet counseling, being 60% less likely in 2011 (AOR=0.40, CI=0.37-0.40). Obese patients were substantially (88% in 2000 to 290% in 2011) more likely to receive counseling than normal-weight patients.

CONCLUSIONS

The overall prevalence of physicians' counseling on diet increased moderately between 2000 and 2011. However, substantial disparities in dietary counseling related to access to care and gender continue to exist.

Evaluation of Veterans MOVE! Program for Weight Loss

OBJECTIVE

To evaluate the degree of weight loss in subjects enrolled in the Veterans Affairs weight management program (MOVE!).

DESIGN

Retrospective cohort design.

SETTING

Tertiary care US veterans hospital, July, 2007 to September, 2008, using a retrospective database.

PARTICIPANTS

Adult veterans (n = 1,659), mostly men (85%).

INTERVENTION

Encounters with existing nutrition education classes were collected and outcomes were assessed.

MAIN OUTCOME MEASURES

Primary outcome was weight change; the predictor was visits or encounters.

ANALYSIS

One-way ANOVA.

RESULTS

In this sample, ≥ 3 nutrition education encounters were associated with significantly more body weight loss compared with 1-2 encounters or no education (-1.62%, 0.2%, and -0.23%, respectively; P = .01).

CONCLUSIONS AND IMPLICATIONS

Three or more nutrition education encounters within the MOVE! weight management program at the Michael E. DeBakey Veterans Affairs Medical Center are associated with modest weight loss. Future prospective studies are needed to determine causality and confirm these findings.

Obesity Education Strategies for Cancer Prevention in Women's Health

Obesity is the cause of up to one-third of all cancers affecting women today, most notably endometrial, colon and breast cancer. Women's health providers are poised to advise women on obesity's link to cancer development, but often lack resources or training to provide appropriate counseling. Here, we review obesity's role in increasing the risk of several common reproductive system conditions faced by women, including polycystic ovarian syndrome, infertility, gynecologic surgical complications, and pregnancy complications. These events can be used as teachable moments to help frame the discussion of weight management and promote cancer prevention. We also review national guidelines and existing tangible weight-loss strategies that can be employed within the outpatient women's health setting to help women achieve weight loss goals and affect cancer prevention.

A healthy lifestyle index is associated with reduced risk of colorectal adenomatous polyps among non-users of non-steroidal anti-inflammatory drugs

In a Columbia, South Carolina-based case-control study, we developed a healthy lifestyle index from five modifiable lifestyle factors (smoking, alcohol intake, physical activity, diet, and body mass index), and examined the association between this lifestyle index and the risk of colorectal adenomatous polyps (adenoma). Participants were recruited from a local endoscopy center and completed questionnaires related to lifestyle behaviors prior to colonoscopy. We scored responses on each of five lifestyle factors as unhealthy (0 point) or healthy (1 point) based on current evidence and recommendations. We added the five scores to produce a combined lifestyle index for each participant ranging from 0 (least healthy) to 5 (healthiest), which was dichotomized into unhealthy (0-2) and healthy (3-5) lifestyle scores. We used logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI) for adenoma with adjustment for multiple covariates. We identified 47 adenoma cases and 91 controls. In the main analyses, there was a statistically nonsignificant inverse association between the dichotomous (OR 0.54; 95% CI 0.22, 1.29) and continuous (OR 0.75; 95% CI 0.51, 1.10) lifestyle index and adenoma. Odds of adenoma were significantly modified by the use of non-steroidal anti-inflammatory drugs (NSAIDs) (p(interaction) = 0.04). For participants who reported no use of NSAIDs, those in the healthy lifestyle category had a 72% lower odds of adenoma as compared to those in the unhealthy category (OR 0.28; 95% CI 0.08, 0.98), whereas a one-unit increase in the index significantly reduced odds of adenoma by 53% (OR 0.47; 95% CI 0.26, 0.88). Although these findings should be interpreted cautiously given our small sample size, our results suggest that higher scores from this index are associated with reduced odds of adenomas, especially in non-users of NSAIDs. Lifestyle interventions are required to test this approach as a strategy to prevent colorectal adenomatous polyps.

Preventing Obesity in the USA: Impact on Health Service Utilization and Costs

BACKGROUND

With more than two-thirds of the US population overweight or obese, the obesity epidemic is a major threat for population health and the financial sustainability of the healthcare service. Whether, and to what extent, effective prevention interventions may offer the opportunity to 'bend the curve' of rising healthcare costs is still an object of debate.

OBJECTIVE

This study evaluates the potential economic impact of a set of prevention programmes, including education, counselling, long-term drug treatment, regulation (e.g. of advertising or labelling) and fiscal measures, on national healthcare expenditure and use of healthcare services in the USA.

STUDY DESIGN AND METHOD

The study was carried out as a retrospective evaluation of alternative scenarios compared with a 'business as usual' scenario. An advanced econometric approach involving the use of logistic regression and generalized linear models was used to calculate the number of contacts with key healthcare services (inpatient, outpatient, drug prescriptions) and the associated cost. Analyses were carried out on the Medical Expenditure Panel Survey (1997-2010).

RESULTS

In 2010, prevention interventions had the potential to decrease total healthcare expenditure by up to $US2 billion. This estimate does not include the implementation costs. The largest share of savings is produced by reduced use and costs of inpatient care, followed by reduced use of drugs. Reduction in expenditure for outpatient care would be more limited. Private insurance schemes benefit from the largest savings in absolute terms; however, public insurance schemes benefit from the largest cost reduction per patient. People in the lowest income groups show the largest economic benefits.

CONCLUSION

Prevention interventions aimed at tackling obesity and associated risk factors may produce a significant decrease in the use of healthcare services and expenditure. Savings become substantial when a long-term perspective is taken.

Short-term patient-centered nutrition counseling impacts weight and nutrient intake in patients with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematosus (SLE) are at a high risk for cardiovascular disease (CVD) due to increased prevalence of traditional and nontraditional CVD risks factors.

OBJECTIVE

To evaluate the effect of patient-centered nutrition counseling methods on changes in select nutrient, anthropometric, and clinical outcomes in SLE patients enrolled in a CVD prevention counseling program (CVD PCP).

METHODS

From March 2009 to June 2011 a subgroup of SLE patients enrolled in our CVD PCP were referred to a registered dietitian for individualized nutrition counseling. Outcomes of interest were assessed at baseline and six months. A primary analysis evaluated the six-month changes in nutrient intake, weight, body mass index (BMI), waist circumference, and lipid levels. A secondary analysis compared the same measurements between the nutrition counseling patients and the group that was referred but did not attend.

RESULTS

Of 71 referrals, 41 (58%) attended nutrition counseling (female: 89%, African American/Hispanic: 72%, mean age of 39.7 ± 12.82 years, and a mean disease duration of 11.49 ± 8.02 years). Over a six-month period, patients attending nutritional counseling: (a) reduced their intake of sodium (p = 0.006), total calories (p = 0.07), and percent calories from fat (p = 0.011) and saturated fat (p = 0.068); (b) had decreased weight (-1.64 kg, p = 0.025); and (c) were more likely to report increases in eating a diet rich in fruits and vegetables (p < 0.001), a high fiber diet (p = 0.011), ≥two servings of fish/week (p = 0.002), and a low cholesterol diet (p = 0.034). There were no significant changes observed over the six months in BMI and clinical outcomes among nutrition counseling patients. When comparing nutrition counseling patients to those who were referred but did not attend, we found at six months a higher percentage of nutrition counseling patients reportedly followed a high-fiber diet (p = 0.03), consumed two or more servings of fish per week (p = 0.01), followed a low-cholesterol diet (p = 0.03), and achieved a greater weight loss (p = 0.04) compared to the group that did not attend.

CONCLUSION

At six months we found that nutrition counseling using patient-centered methods appears to be an effective method for promoting changes in nutrient intake, diet habits, and, possibly, anthropometric measures in SLE patients. However, the counseling did not show a significant improvement in lipid levels, possibly due to short follow-up and/or SLE related factors.

Designing and Testing the Feasibility of a Multi-level Intervention to Treat Adolescent Obesity in the Pediatric Primary Care Setting

OBJECTIVE

To describe the development steps and feasibility test of a multi-level adolescent obesity intervention for delivery in pediatric primary care settings.

METHOD

To understand the target setting and population (i.e., perceptions of and receptivity to various intervention components), focus groups were conducted with clinicians, adolescents, and parents (N=58). Findings informed the development of a multi-level intervention (i.e., office support systems, brief clinician-delivered counseling, and nutritionist-led adolescent group sessions) targeting overweight and obese adolescents (N=22). The intervention was pilot-tested for feasibility using a single group pre- and post-test comparison.

RESULTS

Families and clinicians agreed on the importance of developing approaches to address adolescent obesity in the pediatric primary care setting, and favored family involvement. The pilot-study showed that it was feasible to implement office system changes to support obesity treatment. All but one component of the clinician- delivered counseling algorithm were feasible. Adolescents participating in the intervention reported dietary improvements and movement toward the action stage for decreasing sedentary behavior.

CONCLUSION

Multi-level interventions for adolescent obesity in the pediatric primary care setting are feasible. Research to test the effectiveness of such interventions is warranted.

Considering the value of dietary assessment data in informing nutrition-related health policy

Dietary assessment has long been known to be challenged by measurement error. A substantial amount of literature on methods for determining the effects of error on causal inference has accumulated over the past decades. These methods have unrealized potential for improving the validity of data collected for research studies and national nutritional surveillance, primarily through the NHANES. Recently, the validity of dietary data has been called into question. Arguments against using dietary data to assess diet-health relations or to inform the nutrition policy debate are subject to flaws that fall into 2 broad areas: 1) ignorance or misunderstanding of methodologic issues; and 2) faulty logic in drawing inferences. Nine specific issues are identified in these arguments, indicating insufficient grasp of the methods used for assessing diet and designing nutritional epidemiologic studies. These include a narrow operationalization of validity, failure to properly account for sources of error, and large, unsubstantiated jumps to policy implications. Recent attacks on the inadequacy of 24-h recall-derived data from the NHANES are uninformative regarding effects on estimating risk of health outcomes and on inferences to inform the diet-related health policy debate. Despite errors, for many purposes and in many contexts, these dietary data have proven to be useful in addressing important research and policy questions. Similarly, structured instruments, such as the food frequency questionnaire, which is the mainstay of epidemiologic literature, can provide useful data when errors are measured and considered in analyses.

Dash of faith: a faith-based participatory research pilot study

The Dash of Faith pilot used a community-based participatory research approach to design an experiential dietary intervention based on two African-American churches, one intervention and one comparison. Congregation members identified components that were incorporated into 12 weekly and 4 monthly sessions, with a goal of increasing fruit and vegetable and lowering fat intake. At 2 months, a marginally significant (p = 0.07) increase in fruit and vegetable consumption was observed in the intervention group but was not maintained at study conclusion. We propose that these mixed findings may be attributable, in part, to bias introduced by the participatory nature of the design.

Residency and specialties training in nutrition: a call for action

Despite evidence that nutrition interventions reduce morbidity and mortality, malnutrition, including obesity, remains highly prevalent in hospitals and plays a major role in nearly every major chronic disease that afflicts patients. Physicians recognize that they lack the education and training in medical nutrition needed to counsel their patients and to ensure continuity of nutrition care in collaboration with other health care professionals. Nutrition education and training in specialty and subspecialty areas are inadequate, physician nutrition specialists are not recognized by the American Board of Medical Specialties, and nutrition care coverage by third payers remains woefully limited. This article focuses on residency and fellowship education and training in the United States and provides recommendations for improving medical nutrition education and practice.

A comprehensive analysis of dyslipidaemia management in a large health care system

RATIONALE, AIMS AND OBJECTIVES

Dyslipidaemia is a cardiovascular risk factor, and national screening and treatment guidelines have been established, but achievement of these remains inadequate. Multidisciplinary approaches, such as the chronic care model, have been applied to other chronic diseases and likely would be applicable to the management of dyslipidaemia. We therefore aimed to comprehensively study the different components of a multidisciplinary management approach to dyslipidaemia in a large health care system for patients at a high risk for cardiovascular events.

METHODS

All patients at a Veterans Affairs Medical Center in the United States over 3 years with diabetes and/or coronary artery disease were included. Various clinical and demographic variables were collected and achievement of national cholesterol goals was determined. Univariate and multivariate analyses were conducted to determine the association of different health care variables with improved patient cholesterol guideline achievement.

RESULTS

There were 3559 patients in the study population and 51.0% had achieved national cholesterol goals. Multivariate analyses showed that patients who had achieved goals were more likely to have attended cardiology clinic [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.01] and nutrition clinic (OR = 1.3, 95% CI = 1.04-1.7) and were more likely to have primary care providers who were nurse practitioners (OR = 1.6, 95% CI = 1.2-2.0), practicing full-time (OR = 1.8, 95% CI = 1.5-2.1) and at the main hospital-based clinics (OR = 1.5, 95% CI = 1.3-1.9).

CONCLUSIONS

Our study identifies different components of a multidisciplinary approach to management of dyslipidaemia that are efficacious and these results may help guide future investment in this area.

A population-based dietary inflammatory index predicts levels of C-reactive protein in the Seasonal Variation of Blood Cholesterol Study (SEASONS)

OBJECTIVE

To perform construct validation of the population-based Dietary Inflammatory Index (DII) using dietary data from two different dietary assessments and serum high-sensitivity C-reactive protein (hs-CRP) as the construct validator.

DESIGN

Using data derived from (i) three 24 h dietary recalls (24HR) at baseline and at the end of each subsequent quarter (i.e. up to fifteen over a year) and (ii) a 7 d dietary recall (7DDR) measured at baseline and then quarterly, regression analyses were conducted to test the effect of the DII score on serum hs-CRP as dichotomous (≤3 mg/l, >3 mg/l), while controlling for important potential confounders.

SETTING

Existing data from the Seasonal Variation of Blood Cholesterol Study (SEASONS), a longitudinal observational study of healthy participants recruited in Worcester, MA, USA and participants were followed for 1 year.

SUBJECTS

Participants who had at least one hs-CRP measurement over her/his 1-year participation (n 495 for 24HR, n 559 for 7DDR).

RESULTS

Higher DII scores were associated with values of hs-CRP >3 mg/l (OR = 1·08; 95 % CI 1·01, 1·16, P = 0·035 for the 24HR; and OR = 1·10; 95 % CI 1·02, 1·19, P = 0·015 for the 7DDR).

CONCLUSIONS

The population-based DII was associated with interval changes in hs-CRP using both the 24HR and 7DDR. The success of this first-of-a-kind attempt at relating individuals' intakes of inflammation-modulating foods using this refined DII, and the finding that there is virtually no drop-off in predictive capability using a structured questionnaire in comparison to the 24HR standard, sets the stage for use of the DII in a wide variety of other epidemiological and clinical studies.

Scientific decision making, policy decisions, and the obesity pandemic

Rising and epidemic rates of obesity in many parts of the world are leading to increased suffering and economic stress from diverting health care resources to treating a variety of serious, but preventable, chronic diseases etiologically linked to obesity, particularly type 2 diabetes mellitus and cardiovascular diseases. Despite decades of research into the causes of the obesity pandemic, we seem to be no nearer to a solution now than when the rise in body weights was first chronicled decades ago. The case is made that impediments to a clear understanding of the nature of the problem occur at many levels. These obstacles begin with defining obesity and include lax application of scientific standards of review, tenuous assumption making, flawed measurement and other methods, constrained discourse limiting examination of alternative explanations of cause, and policies that determine funding priorities. These issues constrain creativity and stifle expansive thinking that could otherwise advance the field in preventing and treating obesity and its complications. Suggestions are made to create a climate of open exchange of ideas and redirection of policies that can remove the barriers that prevent us from making material progress in solving a pressing major public health problem of the early 21st century.

Antenatal dietary interventions in obese pregnant women to restrict gestational weight gain to Institute of Medicine recommendations: a meta-analysis

OBJECTIVE

To estimate whether antenatal dietary interventions restrict maternal weight gain in obese pregnant women without compromising newborn birth weight.

DATA SOURCES

PubMed and Cochrane Controlled Trials Register were searched using free-text search terms: pregnancy, obesity, overweight, dietary intervention, lifestyle, and randomis(z)ed controlled trial through March 2011 in a similar search strategy to that used in a previous systematic review.

METHODS OF STUDY SELECTION

We included randomized controlled trials in which antenatal dietary intervention was provided to pregnant women who were overweight or obese at booking. We extracted 263 abstracts or reports, from which 39 full-text articles were reviewed.

TABULATION, INTEGRATION, AND RESULTS

Four randomized controlled trials were identified involving 537 women. The results suggested that there was a significant pool treatment effect (z=11.58, P<.001), because antenatal dietary intervention programs were effective in reducing the total gestational weight gain by 6.5 kg. Despite this, antenatal dietary interventions did not alter newborn birth weight (z=0.18, P=.859).

CONCLUSION

Antenatal dietary interventions in obese pregnant women can reduce maternal weight gain in pregnancy without an effect on newborn birth weight.

Assessing patients' involvement in decision making during the nutritional consultation with a dietitian

BACKGROUND

Shared decision making (SDM) represents an interesting approach to optimize the impact of dietary treatment, but there is no evidence that SDM is commonly integrated into diet-related health care.

OBJECTIVE

To assess the extent to which dietitians involve patients in decisions about dietary treatment.

METHODS

We audiotaped dietitians conducting nutritional consultations with their patients, and we transcribed the tapes verbatim. Three trained raters independently evaluated the content of the nutritional consultations using a coding frame based on the 12 items of the French-language version of the OPTION scale, a validated and reliable third-observer instrument designed to assess patients' involvement by examining specific health professionals' behaviours. Coding was facilitated by the qualitative research software NVivo 8. We assessed internal consistency with Cronbach's alpha and inter-rater reliability with the intraclass correlation coefficient (ICC).

RESULTS

Of the 40 dietitians eligible to participate in the study, 19 took part. We recruited one patient per participating dietitian. The overall mean OPTION score was 29 ± 8% [range, 0% (no patient involvement in the decision] to 100% [high patient involvement)]. The mean duration of consultations was 50 ± 26 min. The OPTION score was positively correlated with the duration of the consultation (r = 0.65, P < 0.01). Internal consistency and inter-rater reliability were both good (Cronbach's alpha = 0.72; ICC = 0.65).

CONCLUSION

This study is the first to use a framework based on the OPTION scale to report on dietitians' involvement of patients in decisions about patients' dietary treatment. The results suggest that involvement is suboptimal. Interventions to increase patients' involvement in diet-related decision making are indicated.

A diet, physical activity, and stress reduction intervention in men with rising prostate-specific antigen after treatment for prostate cancer

BACKGROUND

Nearly 35% of men treated for prostate cancer (PrCA) will experience biochemically defined recurrence, noted by a rise in PSA, within 10 years of definitive therapy. Diet, physical activity, and stress reduction may affect tumor promotion and disease progression.

METHODS

A randomized trial of an intensive diet, physical activity, and meditation intervention was conducted in men with rising post-treatment PSA after definitive treatment for PrCA. Intention-to-treat methods were used to compare usual care to the intervention in 47 men with complete data. Signal detection methods were used to identify dietary factors associated with PSA change.

RESULTS

The intervention and control groups did not differ statistically on any demographic or disease-related factor. Although the intervention group experienced decreases of 39% in intakes of saturated fatty acid (SFA as percent of total calories) (p<0.0001) and 12% in total energy intake (218 kcal/day, p<0.05)], no difference in PSA change was observed by intervention status. Signal detection methods indicated that in men increasing their consumption of fruit, 56% experienced no rise in PSA (vs. 29% in men who did not increase their fruit intake). Among men who increased fruit and fiber intakes, PSA increased in 83% of participants who also increased saturated fatty acid intake (vs. 44% in participants who decreased or maintained saturated fatty acid intake).

CONCLUSION

Results are discussed in the context of conventional treatment strategies that were more aggressive when this study was being conducted in the mid-2000s. Positive health changes in a number of lifestyle parameters were observed with the intervention, and both increased fruit and reduced saturated fat intakes were associated with maintaining PSA levels in men with biochemically recurrent disease.

A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement

BACKGROUND

Total knee replacement (TKR) is a common and effective surgical procedure to relieve advanced knee arthritis that persists despite comprehensive medical treatment. Although TKR has excellent technical outcomes, significant variation in patient-reported functional improvement post-TKR exists. Evidence suggests that consistent post-TKR exercise and physical activity is associated with functional gain, and that this relationship is influenced by emotional health. The increasing use of TKR in the aging US population makes it critical to find strategies that maximize functional outcomes.

METHODS/DESIGN

This randomized clinical trial (RCT) will test the efficacy of a theory-based telephone-delivered Patient Self-Management Support intervention that seeks to enhance adherence to independent exercise and activity among post- TKR patients. The intervention consists of 12 sessions, which begin prior to surgery and continue for approximately 9 weeks post-TKR. The intervention condition will be compared to a usual care control condition using a randomized design and a probabilistic sample of men and women. Assessments are conducted at baseline, eight weeks, and six- and twelve- months. The project is being conducted at a large healthcare system in Massachusetts. The study was designed to provide greater than 80% power for detecting a difference of 4 points in physical function (SF36/Physical Component Score) between conditions (standard deviation of 10) at six months with secondary outcomes collected at one year, assuming a loss to follow up rate of no more than 15%.

DISCUSSION

As TKR use expands, it is important to develop methods to identify patients at risk for sub-optimal functional outcome and to effectively intervene with the goal of optimizing functional outcomes. If shown efficacious, this peri-TKR intervention has the potential to change the paradigm for successful post-TKR care. We hypothesize that Patient Self-Management Support to enhance adherence to independent activity and exercise will enhance uniform, optimal improvement in post-TKR function and patient autonomy, the ultimate goals of TKR.

Evaluating clinic and community-based lifestyle interventions for obesity reduction in a low-income Latino neighborhood: Vivamos Activos Fair Oaks Program

Background

Obesity exerts an enormous health impact through its effect on coronary heart disease and its risk factors. Primary care-based and community-based intensive lifestyle counseling may effectively promote weight loss. There has been limited implementation and evaluation of these strategies, particularly the added benefit of community-based intervention, in low-income Latino populations.

Design

The Vivamos Activos Fair Oaks project is a randomized clinical trial designed to evaluate the clinical and cost-effectiveness of two obesity reduction lifestyle interventions: clinic-based intensive lifestyle counseling, either alone (n = 80) or combined with community health worker support (n = 80), in comparison to usual primary care (n = 40). Clinic-based counseling consists of 15 group and four individual lifestyle counseling sessions provided by health educators targeting behavior change in physical activity and dietary practices. Community health worker support includes seven home visits aimed at practical implementation of weight loss strategies within the person's home and neighborhood. The interventions use a framework based on Social Cognitive Theory, the Transtheoretical Model of behavior change, and techniques from previously tested lifestyle interventions. Application of the framework was culturally tailored based on past interventions in the same community and elsewhere, as well as a community needs and assets assessment. The interventions include a 12-month intensive phase followed by a 12-month maintenance phase. Participants are obese Spanish-speaking adults with at least one cardiovascular risk factor recruited from a community health center in a low-income neighborhood of San Mateo County, California. Follow-up assessments occur at 6, 12, and 24 months for the primary outcome of percent change in body mass index at 24 months. Secondary outcomes include specific cardiovascular risk factors, particularly blood pressure and fasting glucose levels.

Discussion and Conclusions

If successful, this study will provide evidence for broad implementation of obesity interventions in minority populations and guidance about the selection of strategies involving clinic-based case management and community-based community health worker support.

Clinical Trial Registration

ClinicalTrials.gov: NCT01242683

They think they know but do they? Misalignment of perceptions of lifestyle modification knowledge among health professionals

OBJECTIVE

The present study aimed to evaluate the knowledge and practices of public-sector primary-care health professionals and final-year students regarding the role of nutrition, physical activity and smoking cessation (lifestyle modification) in the management of chronic diseases of lifestyle within the public health-care sector.

DESIGN

A comparative cross-sectional descriptive quantitative study was conducted in thirty primary health-care facilities and four tertiary institutions offering medical and/or nursing programmes in Cape Town in the Western Cape Metropole. Stratified random sampling, based on geographical location, was used to select the health facilities while convenience sampling was used to select students at the tertiary institutions. A validated self-administered knowledge test was used to obtain data from the health professionals.

RESULTS

Differential lifestyle modification knowledge exists among both health professionals and students, with less than 10 % achieving the desired scores of 80 % or higher. The majority of health professionals seem to be promoting the theoretical concepts of lifestyle modification but experience difficulty in providing practical advice to patients. Of the health professionals evaluated, doctors appeared to have the best knowledge of lifestyle modification. Lack of time, lack of patient adherence and language barriers were given as the main barriers to providing lifestyle counselling.

CONCLUSIONS

The undergraduate curricula of medical and nursing students should include sufficient training on lifestyle modification, particularly practical advice on diet, physical activity and smoking cessation. Health professionals working at primary health-care facilities should be updated by providing lifestyle modification education as part of continuing medical education.

The evidence for dietary prevention and treatment of cardiovascular disease

During the past few decades numerous studies have reported the atherogenic potential of saturated fatty acids, trans-fatty acids, and cholesterol, and beneficial effects of fiber, phytostanols/phytosterols, n-3 fatty acids, a Mediterranean diet, and other plant-based approaches. The purpose of this article is to provide a comprehensive and systematic review of the evidence associated with key dietary factors and risk of cardiovascular disease-an umbrella term encompassing diseases that affect the heart and blood vessels, including coronary heart disease, coronary artery disease, dyslipidemia, and hypertension-in conjunction with the work of the American Dietetic Association Evidence Analysis Library review on diet and lipids, updated with new evidence from the past 2 years. The criteria used and results cited provide scientific rationale for food and nutrition professionals and other health professionals for counseling patients. Details of these searches are available within the American Dietetic Association Evidence Analysis Library online (http://adaevidencelibrary.com). Potential mechanisms and needs for future research are summarized for each relevant nutrient, food, or food component.

Both food habit change in the past and obesity status may influence the association between dietary factors and postmenopausal breast cancer

OBJECTIVE

Valid dietary data are essential when trying to identify whether or not one or more dietary exposures are responsible for disease. We examined diet composition in women who reported dietary change in the past compared with non-changers, and how the associations between dietary factors and postmenopausal breast cancer are influenced by dietary change, obesity status and misreporting of energy.

DESIGN

A population-based prospective cohort study. Data were obtained by a diet history method, anthropometrical measurements and an extensive lifestyle questionnaire including items on past food habit change.

SETTING

The Malmö Diet and Cancer (MDC) study, conducted in Malmö, Sweden.

SUBJECTS

A subsample of 12,781 women from the MDC cohort recruited from 1991 to 1996. A total of 428 postmenopausal women were diagnosed with incident breast cancer, during 9.2 years of follow-up.

RESULTS

Past food habit changers reported healthier food habits and lower energy intake compared with non-changers, a finding that raises issues regarding possible reporting biases. When excluding diet changers, the trend of increased breast cancer risk across omega-6 fatty acid quintiles was stronger, and a tendency of decreased risk emerged for 'fruit, berries and vegetables'. When excluding individuals with non-adequate reports of energy intake, risk estimates were similar to that of the whole sample. In women with body mass index < 27 kg m- 2, significant trends of increased breast cancer risk were seen for total fat and omega-6 fatty acids, and of decreased risk for 'fruit, berries and vegetables'.

CONCLUSIONS

This study indicates that both obesity and self-reported past food habit change may be important confounders of diet-breast cancer relationships. The study demonstrates that sensitivity analysis, through stratification, may facilitate interpretation of risk relationships and study results.

Low-carbohydrate and high-fat intake among adult patients with poorly controlled type 2 diabetes mellitus

OBJECTIVE

This study examined baseline dietary intake, body weight, and physiologic status in patients enrolled in a dietary intervention for type 2 diabetes mellitus (T2DM).

METHODS

Dietary, physiologic, and demographic information were collected at baseline from 40 adult patients with poorly controlled T2DM (glycosylated hemoglobin >7%) who participated in a clinical trial at an academic medical center in Worcester, Massachusetts, USA.

RESULTS

The average age at enrollment was 53.5 y (SD 8.4), average body mass index was 35.48 kg/m(2) (SD 7.0), and glycosylated hemoglobin was 8.3% (SD 1.2). Participants were predominantly white, married, and employed full time. Forty-eight percent were men. Seventy-eight percent had hyperlipidemia, and 68% had hypertension. Reported baseline daily average energy intake was 1778 kcal (SD 814), daily carbohydrate was 159 g (SD 71.5), and dietary fiber was 11.4 g (SD 5.2). The dietary composition was 35% carbohydrate, 45% fat (15% saturated fat), and 20% protein. The American Diabetes Association (ADA) guidelines recommends 45-65% of energy from carbohydrate, 20-35% from fat (<7% saturated), and 20% from protein.

CONCLUSION

These patients reported a low-carbohydrate, low-fiber, high-fat (especially saturated) diet, although they stated they are not following any of the popular low-carbohydrate diets. Patients with T2DM may find the current trend toward reducing weight through low-carbohydrate diets attractive for control of blood glucose, despite ADA recommendations. This dietary pattern may represent a popular trend that extends beyond our particular study and, if so, has serious cardiovascular implications in this vulnerable population of T2DM patients.

Seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population

OBJECTIVE

To describe seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population.

DESIGN

A longitudinal observational study.

SETTING

Most of the study participants were recruited from a health maintenance organization (HMO) in central Massachusetts, USA. Additional individuals of Hispanic descent were recruited from outside of the HMO population to increase the ethnic diversity of this sample.

SUBJECTS

Data from 593 participants, aged 20-70, were used for this investigation. Each participant was followed quarterly (five sampling points: baseline and four consecutive quarters) for 1-year period. Body weight measurements and three 24-h dietary and physical activity recalls were obtained on randomly selected days (including 2 weekdays and 1 weekend day) per quarter. Sinusoidal regression models were used to estimate peak-to-trough amplitude and phase of the peaks.

RESULTS

Daily caloric intake was higher by 86 kcal/day during the fall compared to the spring. Percentage of calories from carbohydrate, fat and saturated fat showed slight seasonal variation, with a peak in the spring for carbohydrate and in the fall for total fat and saturated fat intake. The lowest physical activity level was observed in the winter and the highest in the spring. Body weight varied by about 1/2 kg throughout the year, with a peak in the winter (P<0.001 winter versus summer). Greater seasonal variation was observed in subjects who were male, middle aged, nonwhite, and less educated.

CONCLUSIONS

Although there is seasonal variation in diet, physical activity and body weight, the magnitude of the change is generally small in this population.

SPONSORSHIP

US National Heart, Lung and Blood Institute.

Association of socio-psychological factors with the effects of low protein diet for the prevention of the progression of chronic renal failure

OBJECTIVE

Our objectives were to investigate the therapeutic effects of low protein diet (LPD) for chronic renal failure (CRF) in compliant patients with the diet, and to clarify the relationships to the sociopsychological factors.

PATIENTS AND METHODS

Sixty-five patients (47 men and 18 women) with CRF who followed LPD (0.69 g/kg/day) for more than 3 months were recruited in this study. Compliance with the diet therapy was strictly assessed by the patients' dietary records, subsequent interviews regarding the status of daily dietary intake and estimated protein intakes calculated from urinary nitrogen excretion by 24-hour urine collections. The changes of glomerular filtration rate (GFR), serum creatinine (Cr), blood urea nitrogen (BUN), the reciprocal of serum creatinine (1/Cr), scores of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), scales of Profile of Mood States (POMS), scores of self-efficacy and social support were investigated.

RESULTS

Decline rate of GFR, elevation of Cr and BUN and reduction in 1/Cr were significantly lower in compliant patients than in noncompliant patients (p<0.05). There were no differences in SF36 scores between compliant and noncompliant patients. The POMS scales of depression/dejection were high in female noncompliant patients compared to other groups of patients (p<0.05). Self-efficacy score was higher in compliant patients than in noncompliant patients (p<0.05). Social support scores were significantly higher in male compliant patients than in others (p<0.05), and both emotional support and behavioral support showed interaction with both gender and compliance with diet therapy (p<0.05).

CONCLUSION

LPD therapy is effective in suppressing the progression of CRF when it is well-adhered to. There are no correlations of this diet therapy to health-related QOL. Social support and high self-efficacy for men and high self-efficacy for women are associated with improvement of the compliance with LPD therapy, leading to good therapeutic effects.

Nutrition education is positively associated with substance abuse treatment program outcomes

The scope and types of nutrition services provided in substance abuse treatment programs has not been well defined nor has there been an attempt to determine if associations exist between the provision of nutrition services and substance abuse treatment outcomes. The objectives of this study were to assess the provision (use and extent) of nutrition education in substance abuse treatment programs in facilities that provide a single or two or more substance abuse treatment programs, and to determine the possible association between nutrition intervention and substance abuse treatment program outcome measures (defined as changes in Addiction Severity Index [ASI] composite scores). A descriptive, single, cross-sectional survey of registered dietitians with clinical nutrition program management responsibility (n=152) was used to define the use and extent of nutrition services in substance abuse treatment programs. Positive associations between nutrition services provided, particularly nutrition education services and substance abuse treatment program outcome measures, were detected. When group nutrition/substance abuse education was offered, ASI psychological and medical domain scores improved by 68% and 56%, respectively (P<.05). Individual nutrition/substance abuse education was a predictor of ASI family/social domain change scores improving by 99% (P<.05). In those programs where group nutrition/substance abuse education was offered, moderate to strong correlations with various nutrition education services were observed, specifically in individual nutrition/substance abuse education (r=0.51; P<.05), group normal/nutrition education (r=0.64; P<.01), and individual normal/nutrition education (r=0.46; P<.05). Substance abuse treatment programs offering group nutrition/substance abuse education offered significantly (P<.05) more nutrition services overall. Findings support the position that nutrition education is an essential component of substance abuse treatment programs and can enhance substance abuse treatment outcomes. Dietitians should promote and encourage the inclusion of nutrition education into substance abuse treatment programs.

Differences between estimated caloric requirements and self-reported caloric intake in the women's health initiative

PURPOSE

To compare energy intake derived from a food frequency questionnaire (FFQ) with estimated energy expenditure in postmenopausal women participating in a large clinical study.

METHODS

A total of 161,856 women aged 50 to 79 years enrolled in the Women's Health Initiative (WHI) Observational Study (OS) or Clinical Trial (CT) [including the Diet Modification (DM) component] completed the WHI FFQ, from which energy intake (FFQEI) was derived. Population-adjusted total energy expenditure (PATEE) was calculated according to the Harris-Benedict equation weighted by caloric intakes derived from the National Health and Nutrition Examination Survey. Stepwise regression was used to examine the influence of independent variables (e.g., demographic, anthropometric) on FFQEI-PATEE. Race, region, and education were forced into the model; other variables were retained if they increased model explanatory ability by more than 1%.

RESULTS

On average, FFQEI was approximately 25% lower than PATEE. Regression results (intercept=-799 kcal/d) indicated that body mass index (b=-23 kcal/day/kg.m(-2)); age (b=15 kcal/day/year of age); and study arm (relative to women in the OS, for DM women b=169 kcal/d, indicating better agreement with PATEE) increased model partial R(2)>.01. Results for CT women not eligible for DM were similar to those of women in the OS (b=14 kcal/d). There also were apparent differences by race (b=-152 kcal/d in Blacks) and education (b=-67 kcal/d in women with<high school).

CONCLUSION

This large, carefully studied population confirms previous observations regarding underestimates in self-reported caloric intake relative to estimates of metabolic need in younger women, and those with higher weight, with less education, and in Blacks. These differences, along with effects related to intervention assignment, underline the need for additional research to enhance understanding of errors in dietary measurement.

Toward the development of a motivational model of pain self-management

Adaptive management of chronic pain depends to a large degree on how patients choose to cope with pain and its impact. Consequently, patient motivation is an important factor in determining how well patients learn to manage pain. However, the role of patient motivation in altering coping behavior and maintaining those changes is seldom discussed, and theoretically based research on motivation for pain treatment is lacking. This article reviews theories that have a direct application to understanding motivational issues in pain coping and presents a preliminary motivational model of pain self-management. The implications of this model for enhancing engagement in and adherence to chronic pain treatment programs are then discussed. The article ends with a call for research to better understand motivation as it applies to chronic pain self-management. In particular, there is a need to determine whether (and which) motivation enhancement interventions increase active participation in self-management treatment programs for chronic pain.

Results of an adjunct dietary intervention program in the Women's Health Initiative

OBJECTIVE

The purpose of this study was to develop, implement, and evaluate the efficacy of an intensive intervention program (IIP) based on motivational interviewing to motivate participants within the dietary study of the Women's Health Initiative (WHI) to meet the study's nutritional goals.

SUBJECTS/DESIGN

WHI dietary intervention participants (n=175) from 3 clinical centers were randomly assigned to either intervention or control status. Participants assigned to IIP intervention received 3 individual motivational interviewing contacts from a dietitian, plus the usual WHI Dietary Intervention. Participants randomly assigned to IIP control received the usual WHI dietary modification (DM) Intervention. Percent of energy from fat was estimated at study baseline and at follow-up (1 year later) using the WHI Food Frequency Questionnaire.

RESULTS

The change in percent energy from fat between IIP baseline and IIP 1-year follow-up was -1.2% for IIP intervention participants and +1.4% for IIP control participants, giving an overall difference of 2.6% (P<.001). Participants having the highest IIP baseline fat intake (>30% energy) showed the largest overall change in percent energy from fat between IIP baseline and IIP follow-up.

CONCLUSIONS

The results of this study indicate that a protocol based on motivational interviewing and delivered through contacts with trained dietitians is an efficacious way to further lower dietary fat intake among participants exposed to ongoing intervention. These data will be useful in future intervention situations when there is a need to increase motivation to change.

Cardiovascular risk reduction and dietary compliance with a home-delivered diet and lifestyle modification program

Lack of adherence to diet contributes to ineffective dietary responsiveness and elevated cardiovascular risk factors in coronary heart disease (CHD) patients. Our purpose was to determine if home-delivered, heart-healthy meals and snacks, combined with telephone diet education, would be efficacious in improving dietary compliance, quality of life, and cardiovascular risk factors (primarily low-density lipoprotein [LDL] cholesterol and body weight) in CHD patients. Participants were 35 free-living subjects (21 men, 14 postmenopausal women) with a mean age of 62 (ranging from 40 to 79 years) in an 8-week diet intervention. A registered dietitian provided diet education over the telephone and weekly menus averaging 67% carbohydrate, 16% protein, 17% fat, 4% saturated fat, 5% monounsaturated fat, 128 mg cholesterol, and 25 g fiber. Lipid profiles, anthropometric measures, food records, and quality of diet, and life questionnaires were obtained at baseline, week 4, and week 8. Mean compliance-defined as percentage of prepared food energy consumed divided by percentage of prepared food energy provided-was 91% at 4 weeks and 88% at 8 weeks. After 8 weeks, significant reductions in weight (-3.7 kg), waist circumference (-2.0 in), hip circumference (-1.3 in), body mass index (-1.21 kg/m2), total cholesterol (-0.17 mmol/dL, -7.0 mg/dL), and LDL cholesterol (-0.19 mmol/dL, -7.5 mg/dL) (P<.05) were achieved without significant changes in high-density lipoprotein cholesterol (0.00 mmol/dL, 0.0 mg/dL) or triglycerides (+0.06 mmol/dL, +2.5 mg/dL). Significant improvements in quality of life and quality of diet (P < .05) were also demonstrated. This program could be a useful additive component to traditional medical nutrition therapy to improve dietary adherence.

Information sessions for outpatients referred to a hospital Nutrition and Dietetic Service for cholesterol lowering advice

AIM

To assess the feasibility of recruiting outpatients referred for cholesterol lowering advice to attend a 1-h evening information session provided by a hospital dietitian and to evaluate the service.

METHOD

A Cholesterol Information Session was held on one evening each month between April and September 2000. Patients referred to the Nutrition and Dietetic Service for cholesterol lowering advice were sent appointments for these sessions by post instead of a one-to-one daytime appointment with the dietitian. At the session, the dietitian explained what cholesterol is and gave advice about the healthy eating and lifestyle changes needed to control it. Video material and literature were used to support verbal information. Questions were encouraged throughout the session.

RESULTS

Thirty-four patients were sent appointments. Twenty-seven (79%) attended, 10 of whom were accompanied by a spouse/partner/carer/family member. All patients who attended completed evaluation forms. There was a high level of satisfaction with the sessions. Twenty-six patients (96%) said they liked the way the session was run and found the advice and videos helpful. Twenty-five patients (93%) preferred the evening appointment to a day time one. Patients who attended with a spouse/partner/carer/family member indicated it was helpful to them and the accompanying person. Feedback through patient comments was positive. The seven patients (21%) who did not attend the sessions made contact with the dietetic service.

CONCLUSION

As a result of the positive outcome of the evaluation, the Cholesterol Information Session is continuing as a service to patients. It provides a facility outside the usual hours of outpatient services and can readily accommodate accompanying people. The information session uses the group format, which may be applicable to other specialist areas of the Nutrition and Dietetic service in the future, such as diabetes management.

Technical skills for weight loss: preliminary data from a randomized trial

BACKGROUND

Optimal behavioral interventions for sustainable weight loss are uncertain. We therefore conducted a study among overweight/obese women comparing conventional dietary counseling of individuals (counseling-based intervention) to a novel, group-based skill-building intervention.

METHODS

Eighty subjects were randomly assigned to either the counseling-based or to the skill-building intervention. Outcomes included weight loss, dietitian hours per group and per unit weight loss, and dollars spent per group and per unit weight lost.

RESULTS

Weight loss at 6 months (follow-up rate 61.3%) in the counseling-based group was 8.8 lb (P = 0.0001), and in the skill-building group was 3.8 lb (P = 0.01). A total of 160 dietitian hours were required for the counseling-based group, and 131 for the skilled-building group. The counseling-based group cost an average of $21 per pound lost, while the skill-building cost an average of $48 per pound lost (P = 0.16).

CONCLUSIONS

At 6 months, individualized office-based counseling produced more weight loss than a skill-building approach and cost less than half as much per pound of weight loss. Longer-term follow-up is required to determine if, as hypothesized, the skill-building intervention produces more sustainable weight loss.

Change in women's diet and body mass following intensive intervention for early-stage breast cancer

OBJECTIVE

To determine the effectiveness of an intensive dietary intervention on diet and body mass in women with breast cancer.

DESIGN

Randomized clinical trial.

SUBJECTS

172 women aged 20 to 65 years with stage I or II breast cancer.

INTERVENTION

A 15-session, mainly group-based and dietitian-led nutrition education program (NEP) was compared to a mindfulness-based stress reduction clinic program (SRC); or usual supportive care (UC).

MAIN OUTCOME MEASURES

Dietary fat, complex carbohydrates, fiber, and body mass were measured.

STATISTICAL ANALYSIS

In addition to descriptive statistics, analysis of variance was conducted to test for differences according to intervention group.

RESULTS

Of the 157 women with complete dietary data at baseline, 149 had complete data immediately postintervention (at 4 months) and 146 had complete data at 1 year. Women randomized to NEP (n = 50) experienced a large reduction in fat consumption (5.8% of energy as fat) at 4 months and much of this reduction was preserved at 1 year (4.1% of energy) (both P < .0002) vs no change in either SRC (n = 51) or UC (n = 56). A 1.3-kg reduction in body mass was evident at 4 months in the NEP group (P = .003) vs no change in the SRC and UC groups. Women who had higher-than-average expectations of a beneficial effect of the intervention experienced larger changes.

APPLICATIONS

Dietitians' use of group nutrition interventions appear to be warranted. Increasing their effectiveness and maintaining high levels of adherence may require additional support, including the involvement of significant others, periodic individual meetings, or group booster sessions.

Facilitating dietary change: the patient-centered counseling model

Recent data indicate that the patient-centered counseling model enhances long-term dietary adherence. This model facilitates change by assessing patient needs and subsequently tailoring the intervention to the patient's stage in the process of change, personal goals, and unique challenges. This article describes this model, including its theoretical foundations, a 4-step counseling process, and applications. This behavioral counseling model can help nutrition professionals enhance patient adherence to nutrition care plans and dietary guidelines.

Comparing food intake using the Dietary Risk Assessment with multiple 24-hour dietary recalls and the 7-Day Dietary Recall

The Dietary Risk Assessment (DRA) is a brief dietary assessment tool used to identify dietary behaviors associated with cardiovascular disease. Intended for use by physicians and other nondietitians, the DRA identifies healthful and problematic dietary behaviors and alerts the physician to patients who require further nutrition counseling. To determine the relative validity of this tool, we compared it to the 7-Day Dietary Recall (an instrument developed to assess intake of dietary fat) and to the average of 7 telephone-administered 24-hour dietary recalls. Forty-two free-living subjects were recruited into the study. The 7-Day Dietary Recall and DRA were administered to each subject twice, at the beginning and the end of the study period, and the 24-hour recalls were conducted during the intervening time period. Correlation coefficients were computed to compare the food scores derived from the 3 assessment methods. Correlations between the DRA and 7-Day Dietary Recall data were moderate (r = .47, on average, for postmeasures); correlations between the DRA and 24-hour recalls were lower. The ability of the DRA to assess dietary fat consumption and ease of administration make it a clinically useful screening instrument for the physician when counseling patients about dietary fat reduction.