Impact of group nutrition education and surplus value of Prochaska-based stage-matched information on health-related cognitions and on Mediterranean nutrition behavior

Description of Baseline Nutrition and Physical Activity Knowledge and Behavior in Acute Stroke/TIA Patients Enrolled in the Health Education on Information Retention and Behavior Change in Stroke (HERBS) Pilot Trial

Lifestyle modifications after stroke are associated with better risk factor control and lower mortality. The primary objective of this study was to describe the knowledge of American Heart Association (AHA) recommendations for diet and exercise in survivors of stroke and transient ischemic attack (TIA). The secondary objectives were to describe their diet and exercise behaviors, self-efficacy (SE), behavioral intent (BI), stage of change, and barriers to change. Data are described from participants enrolled in a prospective educational intervention in mild stroke/TIA survivors. A multiple-choice questionnaire ascertained knowledge of AHA recommendations for diet and exercise, nutrition and physical activity behavior, SE, BI, stage of change, and barriers to change. Twenty-eight stroke/TIA survivors, with a mean age of 61.7 ± 11.8 years, completed questionnaires during their acute hospitalization. Participants underestimated the recommended intake of fruits, vegetables, whole grains, and participation in aerobic exercise and overestimated the recommended intake of sugar and salt. SE demonstrated a significant positive association with combined behavior scores (rs = 0.36, p = 0.043). Greater knowledge of the AHA recommendations was not associated with healthier behavior, greater SE, higher BI, or more advanced stage of change. The gaps between AHA recommendations and stroke/TIA patient knowledge identifies an area for potential intervention in stroke prevention and recovery.

A peer support dietary change intervention for encouraging adoption and maintenance of the Mediterranean diet in a non-Mediterranean population (TEAM-MED): lessons learned and suggested improvements

Peer support interventions for dietary change may offer cost-effective alternatives to interventions led by health professionals. This process evaluation of a trial to encourage the adoption and maintenance of a Mediterranean diet in a Northern European population at high CVD risk (TEAM-MED) aimed to investigate the feasibility of implementing a group-based peer support intervention for dietary change, positive elements of the intervention and aspects that could be improved. Data on training and support for the peer supporters; intervention fidelity and acceptability; acceptability of data collection processes for the trial and reasons for withdrawal from the trial were considered. Data were collected from observations, questionnaires and interviews, with both peer supporters and trial participants. Peer supporters were recruited and trained to result in successful implementation of the intervention; all intended sessions were run, with the majority of elements included. Peer supporters were complimentary of the training, and positive comments from participants centred around the peer supporters, the intervention materials and the supportive nature of the group sessions. Attendance at the group sessions, however, waned over the intervention, with suggested effects on intervention engagement, enthusiasm and group cohesion. Reduced attendance was reportedly a result of meeting (in)frequency and organisational concerns, but increased social activities and group-based activities may also increase engagement, group cohesion and attendance. The peer support intervention was successfully implemented and tested, but improvements can be suggested and may enhance the successful nature of these types of interventions. Some consideration of personal preferences may also improve outcomes.

The feasibility of a peer support intervention to encourage adoption and maintenance of a Mediterranean diet in established community groups at increased CVD risk: the TEAM-MED EXTEND study: a pilot cluster randomised controlled trial

This study aimed to evaluate the feasibility of a peer support intervention to encourage adoption and maintenance of a Mediterranean diet (MD) in established community groups where existing social support may assist the behaviour change process. Four established community groups with members at increased Cardiovascular Disease (CVD) risk and homogenous in gender were recruited and randomised to receive either a 12-month Peer Support (PS) intervention (PSG) (n 2) or a Minimal Support intervention (educational materials only) (MSG) (n 2). The feasibility of the intervention was assessed using recruitment and retention rates, assessing the variability of outcome measures (primary outcome: adoption of an MD at 6 months (using a Mediterranean Diet Score (MDS)) and process evaluation measures including qualitative interviews. Recruitment rates for community groups (n 4/8), participants (n 31/51) and peer supporters (n 6/14) were 50 %, 61 % and 43 %, respectively. The recruitment strategy faced several challenges with recruitment and retention of participants, leading to a smaller sample than intended. At 12 months, a 65 % and 76·5 % retention rate for PSG and MSG participants was observed, respectively. A > 2-point increase in MDS was observed in both the PSG and the MSG at 6 months, maintained at 12 months. An increase in MD adherence was evident in both groups during follow-up; however, the challenges faced in recruitment and retention suggest a definitive study of the peer support intervention using current methods is not feasible and refinement based on the current feasibility study should be incorporated. Lessons learned during the implementation of this intervention will help inform future interventions in this area.

A mini-flipped, game-based Mediterranean diet learning program on dietary behavior and cognitive function among community-dwelling older adults in Taiwan: A cluster-randomized controlled trial

The Mediterranean diet has been recommended to delay cognitive decline, but adherence to the diet among older adults remain poor, and research on interventions that effectively promote the diet has been inconclusive. This study examined the effects of a mini-flipped, game-based Mediterranean diet learning program in improving dietary behavior and cognitive function in community-dwelling older adults in Taiwan. A cluster randomized controlled trial was conducted. The experimental group completed an 8-week, mini-flipped, game-based learning program. Data were collected at baseline and 8 weeks after intervention. Outcome measures included dietary behavior, global cognitive function, and subjective cognitive dysfunction. Compared with the control group, the experimental group exhibited significantly improved Mediterranean diet behavior and global cognitive function after the intervention, although there was no significant difference in subjective cognitive function. Future research should be conducted with larger populations and longer-term follow-up to evaluate the effect of this learning program.

Trends in the Number of Behavioural Theory-Based Healthy Eating Interventions Inclusive of Dietitians/Nutritionists in 2000-2020

Nutrition interventions developed using behaviour theory may be more effective than those without theoretical underpinnings. This study aimed to document the number of theory-based healthy eating interventions, the involvement of dietitians/nutritionists and the behaviour theories employed from 2000 to 2020. We conducted a review of publications related to healthy eating interventions that used behaviour change theories. Interventional studies published in English between 2000 and 2020 were retrieved from searching Medline, Cinahl, Embase, Psycinfo and Cochrane Central. Citation, country of origin, presence or absence of dietitian/nutritionist authors, participants, dietary behaviours, outcomes, theories and any behaviour change techniques (BCTs) stated were extracted. The publication trends on a yearly basis were recorded. A total of 266 articles were included. The number of theory-based interventions increased over the two decades. The number of studies conducted by dietitians/nutritionists increased, but since 2012, increases have been driven by other researchers. Social cognitive theory was the most used behaviour theory. Dietitians/nutritionists contributed to growth in publication of theory-based healthy eating interventions, but the proportion of researchers from other professions engaged in this field increased markedly. The reasons for this growth in publications from other professions is unknown but conjectured to result from greater prominence of dietary behaviours within the context of an obesity epidemic.

A mixed methods pilot randomised controlled trial to develop and evaluate the feasibility of a Mediterranean diet and lifestyle education intervention 'THINK-MED' among people with cognitive impairment

BACKGROUND

Accumulating evidence supports the role of a Mediterranean diet (MD) in cognition, with a greater adherence to a MD associated with reduced dementia risk. It is important to understand how best to achieve behaviour change towards a MD, particularly in non-Mediterranean and high-risk populations. The aim of this study was to evaluate the feasibility of a MD and lifestyle education intervention (THINK-MED) among older adults with cognitive impairment.

METHODS

Qualitative interviews (Phase I), conducted with mild cognitive impairment (MCI) participants, evaluated the intervention materials to allow refinement before pilot testing. THINK-MED was a 12-month, pilot RCT (Phase II) whereby MCI participants were randomised into one of three groups: education on one occasion vs education staged and supported by a dietitian vs control. The primary outcome was a change in MD score. Secondary outcome measurements were collected to gather data on variability of the outcomes to inform a full trial power calculation and to test their acceptability. Slower recruitment rates necessitated a change in primary outcome to a revised focus primarily on feasibility. A sub-study of the same THINK-MED intervention and data collection measures was also conducted among community-dwelling participants with subjective cognitive impairment (SCI) (NCT03569319).

RESULTS

A total of 20 participants (n = 15 MCI; n = 5 SCI) were enrolled in the THINK-MED study. However, there were 10 (50%) participants (n = 9 MCI; n = 1 SCI) who withdrew from the study. Although, those who remained in the intervention rated and evaluated their experience as generally positive, recruitment and retention, especially from a MCI population, was extremely challenging. This highlights the complex needs of this heterogeneous clinical cohort. Recruiting participants from a community-based sample with SCI was more feasible, reaching a wider audience in a shorter time period. There were challenges relating to data collection and incompleteness, with the occurrence of missing data particularly among the questionnaire-based assessments.

CONCLUSIONS

Owing to the challenges with recruitment and retention of older adults with cognitive impairment in this study, it is difficult to confirm if this intervention is feasible. This research has highlighted considerations for a future trial, including a review of the recruitment strategies used and prioritisation of the outcome measures assessed.

TRIAL REGISTRATION

Clinical trials registration NCT03265522 / NCT03569319.

Effectiveness of diet and physical activity interventions amongst adults attending colorectal and breast cancer screening: a systematic review and meta-analysis

Purpose

To estimate the effectiveness of tailored physical activity and dietary interventions amongst adults attending colorectal and breast cancer screening.

Methods

Five literature databases were systematically searched to identify randomised controlled trials (RCTs) of tailored physical activity and/or dietary interventions with follow-up support initiated through colorectal and breast cancer screening programmes. Outcomes included markers of body fatness, physical activity, and dietary intake. Mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs) were pooled using random effects models.

Results

Five RCTs met the inclusion criteria encompassing a total of 722 participants. Diet and physical activity interventions led to statistically significant reductions in body mass (MD − 1.6 kg, 95% CI − 2.7 to − 0.39 kg; I² = 81%; low quality evidence), body mass index (MD − 0.78 kg/m², 95% CI − 1.1 to − 0.50 kg/m²; I² = 21%; moderate quality evidence), and waist circumference (MD − 2.9 cm, 95% CI − 3.8 to − 1.91; I² = 0%; moderate quality evidence), accompanied by an increase in physical activity (SMD 0.31, 95% CI 0.13 to 0.50; I² = 0%; low quality evidence) and fruit and vegetable intake (SMD 0.33, 95% CI 0.01 to 0.64; I² = 51%; low quality evidence).

Conclusion

There is low quality evidence that lifestyle interventions involving follow-up support lead to modest weight loss and increased physical activity and fruit and vegetable intake. Due to the modest intervention effects, low quality of evidence and small number of studies, further rigorously designed RCTs with long-term follow-up of modifiable risk factors and embedded cost–benefit analyses are warranted (PROSPERO ref: CRD42020179960).

Electronic supplementary material

The online version of this article (10.1007/s10552-020-01362-5) contains supplementary material, which is available to authorized users.

Change in Weight, BMI, and Body Composition in a Population-Based Intervention Versus Genetic-Based Intervention: The NOW Trial

OBJECTIVE

The aim of this study was to compare changes in body fat percentage (BFP), weight, and BMI between a standard intervention and a nutrigenomics intervention.

METHODS

The Nutrigenomics, Overweight/Obesity and Weight Management (NOW) trial is a parallel-group, pragmatic, randomized controlled clinical trial incorporated into the Group Lifestyle Balance^TM (GLB) Program. Statistical analyses included two-way ANOVA and split-plot ANOVA. Inclusion criteria consisted of: BMI ≥ 25.0 kg/m² , ≥18 years of age, English speaking, willing to undergo genetic testing, having internet access, and not seeing another health care provider for weight-loss advice outside of the study. Pregnancy and lactation were exclusion criteria. GLB groups were randomly assigned 1 to 1 (N = 140) so that participants received either the standard 12-month GLB program or a modified 12-month program (GLB plus nutrigenomics), which included the provision of nutrigenomics information and advice for weight management. The primary outcome was percent change in BFP. Secondary outcomes were change in weight and BMI.

RESULTS

The GLB plus nutrigenomics group experienced significantly (P < 0.05) greater reductions in percent and absolute BFP at the 3-month follow-up and percent BFP at the 6-month follow-up compared with the standard GLB group.

CONCLUSIONS

The nutrigenomics intervention used in the NOW trial can optimize change in body composition up to 6 months.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this.

OBJECTIVES

To assess the effects of increased intake of fish- and plant-based omega-3 fats for all-cause mortality, cardiovascular events, adiposity and lipids.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression.

MAIN RESULTS

We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high-certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate-certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high-certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate-certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low-certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334, RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low-certainty evidence) and coronary heart disease events (NNTB 167, RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low-certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre-planned subgrouping or meta-regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate-certainty evidence),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate-certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate-certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low-certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events (NNTB 500, RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low-certainty evidence), and probably slightly reduces risk of arrhythmia (NNTB 91, RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate-certainty evidence). Effects on stroke are unclear. Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose-dependent way (high-certainty evidence).

AUTHORS' CONCLUSIONS

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and low-certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia.

The Mediterranean Diet in the Stroke Belt: A Cross-Sectional Study on Adherence and Perceived Knowledge, Barriers, and Benefits

The Mediterranean diet (MedDiet) is recommended by the current Dietary Guidelines for Americans, yet little is known about the perceived barriers and benefits to the diet in the U.S., particularly in the Stroke Belt (SB). Thus, the purpose of this study was to examine MedDiet adherence and perceived knowledge, benefits, and barriers to the MedDiet in the U.S. A cross-sectional study was conducted on 1447 participants in the U.S., and responses were sorted into geographic groups: the SB, California (CA), and all other US states (OtherUS). Linear models and multivariable linear regression analysis was used for data analysis. Convenience, sensory factors, and health were greater barriers to the MedDiet in the SB group, but not the OtherUS group (p < 0.05). Weight loss was considered a benefit of the MedDiet in the SB (p < 0.05), while price and familiarity were found to be less of a benefit (p < 0.05). Respondents with a bachelor’s degree or greater education had greater total MEDAS scores (p < 0.05) and obese participants had a lower MedDiet adherence score (p < 0.05). Our results identify key barriers and benefits of the MedDiet in the SB which can inform targeted MedDiet intervention studies.

The use of psychological methodologies in cardiovascular disease interventions promoting a Mediterranean style diet: A systematic review

AIMS

To evaluate theory-based psychological approaches that have been effective in promoting behavior change in interventions promoting a Mediterranean style diet (MD) for the reduction of cardiovascular disease (CVD) risk.

DATA SYNTHESIS

A systematic review of primary research articles using PRISMA recommendations was conducted. References were retrieved using keyword searches from MEDLINE via PUBMED and included studies targeted participants at high risk for CVD. Two hundred and ninety one studies were reviewed; however, only six met the inclusionary criteria. Three articles describe the same intervention; therefore, only four were included. Included studies incorporated social cognitive theory, social learning theory, goal-system theory, social ecological theory, selfdetermination theory, and the transtheoretical model of behavior change. Overall, studies were nutrition interventions in clinical settings with participants at high risk for or with CVD.

CONCLUSIONS

Results from use of the social cognitive theory and self-determination theory in increasing MD adherence for the reduction of CVD risk and events are encouraging. However, we encourage future long-term interventions focusing on dietary behavior change to provide not only an in-depth description of the psychological methodologies used but also how these methodologies were implemented in order ascertain the most effective theory for promoting dietary behavior change towards patterns of a MD.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this.

OBJECTIVES

To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression.

MAIN RESULTS

We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5g/d LCn3 to > 5 g/d (16 RCTs gave at least 3g/d LCn3).Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs) and ALA may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence with greater effects in trials at low summary risk of bias), and probably reduces risk of arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, except LCn3 reduced triglycerides by ˜15% in a dose-dependant way (high-quality evidence).

AUTHORS' CONCLUSIONS

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event and arrhythmia risk.

Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear.

OBJECTIVES

To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence.

MAIN RESULTS

We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants), high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality.

AUTHORS' CONCLUSIONS

This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via TG reduction.

Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear.

OBJECTIVES

To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence.

MAIN RESULTS

We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake slightly reduces total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants) and probably slightly decreases triglycerides (MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably causes slight weight gain (MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality.

AUTHORS' CONCLUSIONS

This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via lipid reduction, but increasing PUFA probably slightly increases weight.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this.

OBJECTIVES

To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression.

MAIN RESULTS

We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet.Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and it may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence), and probably reduces risk of CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs), and arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, although LCn3 slightly reduced triglycerides and increased HDL. ALA probably reduces HDL (high- or moderate-quality evidence).

AUTHORS' CONCLUSIONS

This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.

Trial to Encourage Adoption and Maintenance of a Mediterranean Diet (TEAM-MED): Protocol for a Randomised Feasibility Trial of a Peer Support Intervention for Dietary Behaviour Change in Adults at High Cardiovascular Disease Risk

Adoption of a Mediterranean diet (MD) reduces cardiovascular disease (CVD) risk. However, interventions to achieve dietary behaviour change are typically resource intensive. Peer support offers a potentially low-cost approach to encourage dietary change. The primary objective of this randomised controlled trial is to explore the feasibility of peer support versus a previously tested dietetic-led intervention to encourage MD behaviour change, and to test recruitment strategies, retention and attrition in order to inform the design of a definitive trial. A total of 75 overweight adults at high CVD risk who do not follow a MD (Mediterranean Diet Score (MDS ≤ 3)) will be randomly assigned to either: a minimal intervention (written materials), a proven intervention (dietetic support, written materials and key MD foods), or a peer support intervention (group-based community programme delivered by lay peers) for 12 months. The primary end-point is change in MDS from baseline to 6 months (adoption of MD). Secondary end-points include: change in MDS from 6 to 12 months (maintenance of MD), effects on nutritional biomarkers and CVD risk factors, fidelity of implementation, acceptability and feasibility of the peer support intervention. This study will generate important data regarding the feasibility of peer support for ease of adoption of MD in an 'at risk' Northern European population. Data will be used to direct a larger scale trial, where the clinical efficacy and cost-effectiveness of peer support will be tested.

The Effectiveness of Brief Information and Self-Efficacy-Based Interventions in Influencing Snack Choices in Homeless Individuals

BACKGROUND

Homeless adults frequently experience poor nutrition. Research suggests raising self-efficacy and nutritional knowledge can increase healthy eating but that the choice of specific behavioral change techniques (BCTs) is also critical. This study investigated how BCTs, operationalized to increase nutrition knowledge and self-efficacy, might influence the choice of homeless adults when presented with a "healthy" and an "unhealthy" snack.

METHODS

A total of 125 homeless adults were randomly allocated to watch 1 of 4 brief films: "control," "[nutrition] information only," "self-efficacy" (aimed at increasing self-efficacy and general healthy eating knowledge), and "enhanced self-efficacy" (as "self-efficacy," but the presenter identified themselves as a homeless adult). Post-film, participants were invited to choose between a healthy and an unhealthy snack. Data were analyzed using ANOVA and chi square.

RESULTS

Participants in the "enhanced self-efficacy" condition were significantly more likely to choose the healthy option compared to those in the control condition; for the "self-efficacy" condition, the difference was marginally significant. Perceived knowledge and self-efficacy were significantly associated and those with high self-efficacy were significantly more likely to choose a healthy snack regardless of condition.

CONCLUSION

Homeless adults are more likely to make healthy snack choices if their nutritional self-efficacy is increased through encouragement by a peer.

How dietary evidence for the prevention and treatment of CVD is translated into practice in those with or at high risk of CVD: a systematic review

OBJECTIVE

CVD is a leading cause of mortality and morbidity, and nutrition is an important lifestyle factor. The aim of the present systematic review was to synthesise the literature relating to knowledge translation (KT) of dietary evidence for the prevention and treatment of CVD into practice in populations with or at high risk of CVD.

DESIGN

A systematic search of six electronic databases (CINAHL, Cochrane, EMBASE, MEDLINE, PsycINFO and Scopus) was performed. Studies were included if a nutrition or dietary KT was demonstrated to occur with a relevant separate measureable outcome. Quality was assessed using a tool adapted from two quality checklists.

SUBJECTS

Population with or at high risk of CVD or clinicians likely to treat this population.

RESULTS

A total of 4420 titles and abstracts were screened for inclusion, with 354 full texts retrieved to assess inclusion. Forty-three articles were included in the review, relating to thirty-five separate studies. No studies specifically stated their aim to be KT. Thirty-one studies were in patient or high-risk populations and four targeted health professionals. Few studies stated a theory on which the intervention was based (n 10) and provision of instruction was the most common behaviour change strategy used (n 26).

CONCLUSIONS

KT in nutrition and dietary studies has been inferred, not stated, with few details provided regarding how dietary knowledge is translated to the end user. This presents challenges for implementation by clinicians and policy and decision makers. Consequently a need exists to improve the quality of publications in this area.

Effect of nutrition care provided by primary health professionals on adults' dietary behaviours: a systematic review

BACKGROUND

'Nutrition care' refers to any practice conducted by a health professional to support a patient to improve their dietary behaviours. Better understanding about the effectiveness of nutrition care is required to identify ways to enhance success of future interventions.

OBJECTIVE

Systematically review literature that investigated the effect of nutrition care provided by primary health professionals on adult patients' dietary behaviours.

METHODS

The systematic review included all studies published between January 2000 and January 2015 that involved nutrition care by one or more primary health professionals to adult patients and incorporated at least one quantified food-related outcome measure (e.g. daily intake of vegetables in grams, weekly servings of lean meats). After data extraction, the methodological quality of each study was appraised using the Mixed Methods Appraisal Tool.

RESULTS

Twenty-one studies, totalling 12497 participants were included. The design, intensity, theoretical underpinning and follow-up period of interventions were diverse. Twelve studies found significant improvements in participants' dietary behaviours, such as increased daily consumption of fruit, vegetables, high-fibre bread and fish. However, seven studies did not identify any improvement in dietary behaviours; one observed equal improvements among participants in the intervention and control groups and one found a reduction in participants' daily fruit and vegetable intake.

CONCLUSION

Interventions involving nutrition care provided by primary health professionals have the potential to improve patients' dietary behaviours. However, the consistency and clinical significance of intervention outcomes are unclear. Further consideration of factors that may influence the effectiveness of interventions, but not traditionally measured, are required.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

BACKGROUND

To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).

METHODS

A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.

RESULTS

52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.

CONCLUSION

Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

Background

People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.

Methods

Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.

The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.

Results

52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.

Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.

Conclusion

Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.

The social and behavioural pathway of dental caries experience among Jewish adults in Jerusalem

AIMS

To report dental caries status, related health behaviours and social determinants among a representative sample of adults residing in Jerusalem.

METHODS

This cross-sectional study was conducted using a stratified sample of 254 Jewish and married adults aged 35-44 years in Jerusalem. Dental caries status was examined according to DMFT, percentage of caries-free persons and of people maintaining all their natural teeth (no teeth missing due to caries). The results were analysed by the independent variables and interpreted by weighted caries scores for the total Jerusalem population.

RESULTS

The mean age was 38.63 years. Weighted DMFT was found to be 10.59; 6.8% of the population were caries-free; 67.1% demonstrated maintenance of all natural teeth. Level of education was the distal factor, associated with number of natural teeth, DMFT and untreated decay. Mediating behavioural determinants included dental attendance, plaque level and sugar consumption.

DISCUSSION

The findings of this study demonstrated that caries experience among Jewish married adults in Jerusalem was moderate with low unmet dental caries needs. Additionally, data confirmed that a low level of education was a strong distal social determinant of caries experience, which affected dental health status via a pathway mediated by behavioural factors.

Impact of nutrition education on university students' fat consumption

PURPOSE

University science students who have taken a nutrition course possess greater knowledge of fats than do those who have not; whether students apply this knowledge to their diet is unknown. We measured and compared science students' total and saturated fat intake in the first and fourth years, and evaluated whether taking a nutrition course influenced fat consumption.

METHODS

A sample of 269 first- and fourth-year science students at a small undergraduate university completed a survey with both demographic questions and a semi-quantitative food frequency questionnaire about fats in the diet. Data were analyzed using chi-square tests and independent-sample t-tests.

RESULTS

Fourth-year science students consumed fewer grams of total and saturated fat than did first-year science students (p<0.001). Science students who had taken a nutrition course consumed fewer grams of total and saturated fat than did those who had not (p<0.001).

CONCLUSIONS

Taking a nutrition course may decrease first-year students' fat consumption, which may improve diet quality and decrease the risk of chronic disease related to fat consumption.

Global cardiovascular disease prevention: a call to action for nursing: multilevel policies

This section, multilevel policies, reviews the impact that has been and can be made by health policy changes at multiple levels, strategies and resources for increasing adherence to population prevention recommendations, and how changes at the microlevel and macrolevel of the environment can provide opportunities and rewards for healthy behaviors and disincentives for unhealthy behaviors. Policies that support primary prevention of cardiovascular disease require the participation of numerous stakeholders at multiple levels, such as governmental and regulatory agencies. Such policy changes support a healthy lifestyle, as in designated smoke-free areas; laws that mandate that food purveyors reduce sodium and fat content or, eliminate trans-fats; and availability of safe parks and bike and walking trails; and also provide a supportive environment that in turn reinforces adherence to primary prevention. Health-related policies have a major impact at the societal level in both developed and developing countries; thus, it is important to understand the role that policy plays in promoting a healthier lifestyle and the prevention of cardiovascular disease. This section discusses how health policies can impact primary prevention and adherence to healthful recommendations, with examples focused on physical activity and diet.

Effectiveness of small-group interactive education vs. lecture-based information-only programs on motivation to change and lifestyle behaviours. A prospective controlled trial of rehabilitation inpatients

OBJECTIVE

Although patient education may promote motivation to change health behaviours, the most effective method has not yet been determined.

METHODS

This prospective, controlled trial compared an interactive, patient-oriented group program with lectures providing only information. We evaluated motivational stages of change and self-reported behaviours in three domains (sports, diet, relaxation) at four times up to one year (60% complete data) among 753 German rehabilitation inpatients (mean age 50 years, 52% male) with orthopaedic (59%) or cardiologic disorders (10%) or diabetes mellitus (31%).

RESULTS

We found improvements between baseline and follow up regarding each outcome (p<.001) in both groups. At the end of rehabilitation, participants of the interactive group, as compared to the lectures, showed more advanced motivation regarding diet (p<.10) and sports (p=.006). Interactive group patients reported healthier diets both after 3 months (p=0.013) and 12 months (p=0.047), more relaxation behaviours (p=.029) after 3 months and higher motivation for sports after 12 months (p=.08).

CONCLUSIONS

The superior effectiveness of the interactive group was only partly confirmed.

PRACTICE IMPLICATIONS

This short, 5-session interactive program may not be superior to lectures to induce major sustainable changes in motivation.

Taking Action Together: a YMCA-based protocol to prevent type-2 diabetes in high-BMI inner-city African American children

Background

Associated with a tripling in obesity since 1970, type 2 diabetes mellitus (T2DM) in children has risen 9-10 fold. There is a critical need of protocols for trials to prevent T2DM in children.

Methods/Design

This protocol includes the theory, development, evaluation components and lessons learned from a novel YMCA-based T2DM prevention intervention designed specifically for high-BMI African American children from disadvantaged, inner-city neighborhoods of Oakland, California. The intervention was developed on the basis of: review of epidemiological and intervention studies of pediatric T2DM; a conceptual theory (social cognitive); a comprehensive examination of health promotion curricula designed for children; consultation with research, clinical experts and practitioners and; input from community partners. The intervention, Taking Action Together, included culturally sensitive and age-appropriate programming on: healthy eating; increasing physical activity and, improving self esteem.

Discussion

Evaluations completed to date suggest that Taking Action Together may be an effective intervention, and results warrant an expanded evaluation effort. This protocol could be used in other community settings to reduce the risk of children developing T2DM and related health consequences.

Trial registration

ClinicalTrials.gov NCT01039116.

Adoption and maintenance of a Mediterranean diet in patients with coronary heart disease from a Northern European population: a pilot randomised trial of different methods of delivering Mediterranean diet advice

BACKGROUND

A Mediterranean diet has been shown to protect against coronary heart disease (CHD). Adherence to a Mediterranean diet can be assessed using a Mediterranean diet score. The primary aim of this pilot study was to examine whether CHD patients in a Northern European population would adopt and maintain a Mediterranean diet, with a secondary aim of comparing the effectiveness of different methodologies aimed at improving compliance.

METHODS

Sixty-one patients with a diagnosis of CHD were randomised to one of three groups: either to receive conventional dietetic advice for CHD or advice to implement a Mediterranean-style diet using either behavioural counselling or nutritional counselling. Patients received a follow-up assessment at 6 months (adoption) and a subset of patients was followed up at 12 months (maintenance). The primary outcome measure was the between-group difference in the mean change in Mediterranean diet score (MDS).

RESULTS

The change in MDS was not significantly different between groups. However, all three groups reported a significant within-group increase in MDS (P < 0.01) at 6 and 12 months follow-up.

CONCLUSIONS

All three groups made dietary changes towards a Mediterranean diet, but behavioural counselling did not have significant additional benefit over nutritional counselling in initiating and maintaining dietary change, and neither method offering specific Mediterranean diet advice had any significant benefit in terms of improvement in MDS over conventional dietetic practice.

The Mediterranean diet as a nutrition education, health promotion and disease prevention tool

Objective

While epidemiological research on the protective role of the Mediterranean diet (MD) is highly publicised, little is known about MD education interventions. This exploratory study aimed to provide insight into methodology and effectiveness of the MD as a nutrition education and health promotion tool.

Design and setting

Two searches were conducted within PubMed using the terms ‘Mediterranean diet’ and ‘Education’ or ‘Intervention’. Abstracts yielded were screened for distinct studies in which participants were instructed on the application of MD principles in their diet. Four studies met this criterion. These were further analysed for sample/target population, and intervention design, duration, tools, evaluative measures/tests and outcomes.

Results

Interventions targeted both healthy and at-risk populations and lasted between 12 weeks to 1 year, including follow-up. They used individual counselling, tailored computer-based counselling, group education, internet-based education, cookery classes and printed materials. Outcomes were measured using food diaries, FFQ, questionnaires on psychosocial factors and on usage of the educational tools, as well as anthropometrics and biomarkers. Interventions showed statistically significant increases in participants’ intake of vegetables, legumes, nuts, fruit, whole grains, seeds, olive oil and dietary PUFA and MUFA, and statistically significant decreases in total cholesterol, ox-LDL-cholesterol, total:HDL-cholesterol ratio, insulin resistance, BMI, body weight and waist circumference.

Conclusions

MD education interventions may be cost-effective strategies for helping to protect against and treat a variety of health problems in different populations. Details of such interventions need to be publicised internationally. This introductory review could help inform the design of future targeted MD nutrition education.

Bowel health to better health: a minimal contact lifestyle intervention for people at increased risk of colorectal cancer

Colorectal cancer screening forms part of Scotland's cancer reduction strategy. Screened participants, who had undergone colonoscopy and had adenoma(s) removed, were invited to participate in the bowel health to better health (BHBH) programme. BHBH tested the hypothesis that a minimal contact lifestyle intervention could prove effective in promoting changes in diet and activity. Baseline and follow-up questionnaires on lifestyle and psycho-social measures were undertaken in adults randomised to BHBH or a comparison group (CG). The 3-month intervention comprised personalised lifestyle advice, goal-setting and social support to promote increases in physical activity, fibre, fruit and vegetables. Response rate to BHBH was 51 %. BHBH participants (n 32) increased their intake of fibre (DINE FFQ scores 30 (sd 11)-41 (sd 13)) significantly (P < 0.001) more than the CG (n 30; 31 (sd 8)-30 (sd 11). No significant differences between the groups were detected for changes in fruits, vegetables and moderate activity. At baseline, only one participant from each study arm, met the target recommendations for fibre, fruit and vegetable intakes and physical activity. At follow up a significant number of BHBH participants, 15 (47 %) compared to 4 (13 %) of the CG were achieving all three lifestyle recommendations (chi2 (1, n 62) = 8.196, P = 0.006). If sustained, the positive behaviour change achieved through this intervention has the potential to impact on the progression of chronic disease risk including CVD.

A randomised trial of three counselling strategies for lifestyle changes in patients with hypercholesterolemia treated with ezetimibe on top of statin therapy (TWICE)

AIMS

To compare the impact of three patient counselling strategies for lifestyle changes and to assess the safety and efficacy of ezetimibe on top of statin therapy in hypercholesterolemic high risk patients.

METHODS

Open, cluster randomized 3-parallel group trial. Physicians were randomized between patient motivation on: diet or physical exercise or both. Counselling was adapted to the patient's baseline Prochaska stage of change. High cardiovascular risk patients, with LDL-C above or equal to 3 mmol/L despite statin therapy for at least 3 months, were enrolled. Ezetimibe (10mg/day) and patient counselling were started at the same time. Target goal was defined as total cholesterol less than 5 mmol/L and LDL-C above 3 mmol/L.

RESULTS

Overall 428 physicians enrolled 1,496 patients. At baseline, LDL-C was 3.9+/-0.9 mmol/L and total cholesterol was 6.1+/-1.1 mmol/L. LDL-C decreased by -30.4+/-19.3% and 869 (62%) patients achieved target goal. No difference was shown between randomisation groups. However, improvements in diet consumption patterns were more easily obtained than improvement in physical activity stage of change in non-active patient at baseline.

CONCLUSIONS

The marked short-term impact (-30%) on LDL-C, although similar between the three groups, slightly exceeds usual LDL-C reductions achieved by this dose of ezetimibe. Decreasing fat consumption seems easier than increasing physical activity. This study confirms the good efficacy, short-term tolerability and safety of ezetimibe on top of statins.

Baseline correlates of insulin resistance in inner city high-BMI African-American children

To characterize the influence of diet-, physical activity-, and self-esteem-related factors on insulin resistance in 8- 10-year-old African-American (AA) children with BMI greater than the 85th percentile who were screened to participate in a community-based type 2 diabetes mellitus (T2DM) prevention trial. In 165 subjects, fasting glucose- and insulin-derived values for homeostasis model assessment of insulin resistance (HOMA-IR) assessed insulin resistance. Body fatness was calculated following bioelectrical impedance analysis, and fitness was measured using laps from a 20-m shuttle run. Child questionnaires assessed physical activity, dietary habits, and self-esteem. Pubertal staging was assessed using serum levels of sex hormones. Parent questionnaires assessed family demographics, family health, and family food and physical activity habits. Girls had significantly higher percent body fat but similar anthropometric measures compared with boys, whereas boys spent more time in high-intensity activities than girls. Scores for self-perceived behavior were higher for girls than for boys; and girls desired a more slender body. Girls had significantly higher insulin resistance (HOMA-IR), compared with boys (P < 0.01). Adjusting for age, sex, pubertal stage, socioeconomic index (SE index), and family history of diabetes, multivariate regression analysis showed that children with higher waist circumference (WC) (P < 0.001) and lower Harter's scholastic competence (SC) scale (P = 0.044) had higher insulin resistance. WC and selected self-esteem parameters predicted insulin resistance in high-BMI AA children. The risk of T2DM may be reduced in these children by targeting these factors.

Mediterranean diet has no effect on markers of inflammation and metabolic risk factors in patients with coronary artery disease

OBJECTIVE

Mediterranean diet is associated with decreased levels of inflammatory markers and metabolic risk factors in epidemiologic studies and recent trials on patients with metabolic syndrome. Given the recent improvements in medical treatments, it is unclear if such beneficial effects are also present in patients with coronary artery disease (CAD). We therefore investigated the effect of Mediterranean diet on markers of inflammation and metabolic risk factors in patients with treated CAD.

DESIGN

Randomized, controlled trial.

SUBJECTS

A total of 101 patients (59.4+/-8.6 years, 23% female) with established and treated CAD (80% statins).

INTERVENTIONS

Participants were assigned to a Mediterranean diet group (MG; n=48) with a 1-year program of 100 h of education, or to a written advice-only group (AG; n=53). Before and after intervention, we measured serum high-sensitivity C-reactive protein (hs-CRP), fibrinogen, fasting insulin, homocysteine, serum lipids and plasma fatty acids.

RESULTS

The Mediterranean diet program increased the intakes of fish, fruits/vegetables and moderately of canola/olive oil and increased plasma concentrations of long-chain n-3 polyunsaturated fatty acids in the MG. Median hs-CRP and mean fibrinogen, homocysteine, fasting insulin, triglycerides and serum cholesterols remained unchanged in both groups.

CONCLUSIONS

Adoption of a Mediterranean diet by patients with medically treated CAD has no effect on markers of inflammation and metabolic risk factors.

SPONSORSHIP

Alfried Krupp Foundation, Essen, Germany.

Psychosocial correlates of fruit and vegetable consumption among African American men

OBJECTIVE

To determine the best predictors of fruit and vegetable consumption among African American men age 35 years and older.

DESIGN

Data (n = 291) from a 2001 nationally representative mail survey commissioned by the American Cancer Society.

PARTICIPANTS

291 African American men age 35 years and older.

MAIN OUTCOME MEASURES

DEPENDENT VARIABLES

(1) total fruits and vegetables without fried potatoes, (2) total fruit with juice, and (3) total vegetables without fried potatoes. Independent variables included 3 blocks of predictors: (1) demographics, (2) a set of psychosocial scales, and (3) intent to change variables based on a theoretical algorithm.

ANALYSIS

Linear regression models; analysis of variance for the intent to change group. Alpha = .05.

RESULTS

Regression model for total fruits and vegetables, significant psychosocial predictors: social norms, benefits, tangible rewards, and barriers-other. Total fruit with juice: social norms, benefits, tangible rewards. Total vegetables, no fried potatoes: tangible rewards, barriers-other interests.

CONCLUSIONS AND IMPLICATIONS

For African American men, fruit consumption appears to be motivated by perceived benefits and standards set by important people in their lives; vegetable consumption is a function of extrinsic rewards and preferences for high-calorie, fatty foods. The results suggest that communications to increase fruit and vegetable consumption should be crafted to reflect differences in sources of motivation for eating fruits versus eating vegetables.

The Mediterranean diet: is it cardioprotective?

Coronary heart disease is one of the leading causes of morbidity and mortality in the United States. Dietary interventions are first-line therapy for coronary heart disease prevention and treatment. Increasing scientific evidence suggests that the traditional Mediterranean diet may reduce the risk of cardiovascular disease. The cardiovascular benefits of this whole-diet approach may outweigh those of typically prescribed low-fat diets. The burden of coronary heart disease is enormous, and nutritional approaches that optimize cardiovascular health are essential. Clinical trial evidence supporting the role of the Mediterranean diet in cardiovascular health is presented with an emphasis on the physiological effects of omega-3 fatty acids. Implications for clinical practice and future research are also discussed.

A new evidence-based model for weight management in primary care: the Counterweight Programme

BACKGROUND/AIMS

Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care.

METHODS

The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit.

RESULTS

By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months.

CONCLUSION

The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Are current health behavioral change models helpful in guiding prevention of weight gain efforts?

Effective procedures are needed to prevent the substantial increases in adiposity that have been occurring among children and adults. Behavioral change may occur as a result of changes in variables that mediate interventions. These mediating variables have typically come from the theories or models used to understand behavior. Seven categories of theories and models are reviewed to define the concepts and to identify the motivational mechanism(s), the resources that a person needs for change, the processes by which behavioral change is likely to occur, and the procedures necessary to promote change. Although each model has something to offer obesity prevention, the early promise can be achieved only with substantial additional research in which these models are applied to diet and physical activity in regard to obesity. The most promising avenues for such research seem to be using the latest variants of the Theory of Planned Behavior and Social Ecology. Synergy may be achieved by taking the most promising concepts from each model and integrating them for use with specific populations. Biology-based steps in an eating or physical activity event are identified, and research issues are suggested to integrate behavioral and biological approaches to understanding eating and physical activity behaviors. Social marketing procedures have much to offer in terms of organizing and strategizing behavioral change programs to incorporate these theoretical ideas. More research is needed to assess the true potential for these models to contribute to our understanding of obesity-related diet and physical activity practices, and in turn, to obesity prevention.

Nutrient adequacy and Mediterranean Diet in Spanish school children and adolescents

OBJECTIVE

To evaluate dietary habits and nutritional status of Spanish school children and adolescents, and their relationship with the Mediterranean Diet.

DESIGN

Cross-sectional study by face-to-face interview.

SETTING

Free living children and adolescents of all Spanish regions.

SUBJECTS

A random sample of 3166 people aged 6-24 y.

METHODS

Home interviews conducted by a team of 43 dietitians included 24-h recalls (a second 24-h recall in 25% of the sample) and a short frequency questionnaire to determine the quality of the Mediterranean Diet (KIDMED).

RESULTS

The participation rate was 68%. In general, the adequacy of the Mediterranean Diet rose with increased mean intakes of the majority of vitamins and minerals and decreased percentages of inadequate intakes (&<2/3 of the RNI) for calcium, magnesium, vitamin B(6) and C in both sexes, and iron and vitamin A only in females.

CONCLUSIONS

This study demonstrates that the Mediterranean Diet contributes to nutritional quality, and also shows concomitant risks as the Mediterranean Diet deteriorates.

Patients' readiness for dietary change at the beginning of counselling: a transtheoretical model-based assessment

BACKGROUND

The purpose of this study was to explore patients' readiness for dietary change within a theoretical framework of the transtheoretical model. The patients were recently diagnosed to have type 2 diabetes or impaired glucose tolerance. We discuss the theoretical aspects of appropriate dietary counselling strategies from a standpoint of patient-specific stages of change.

METHODS

The data included 32 audiotaped diabetes counselling sessions with 16 patients conducted by two nurses. The transcribed data was analysed by using deductive content analysis.

RESULTS

The patients were at different stages of change of diabetes-affected dietary behaviour. Their stages of change varied in different dietary areas and within certain dietary habits. These stages of change could involve their overall dietary behaviour or some minor aspects of their diets.

CONCLUSIONS

Understanding patient-specific stages of change orientates health counsellors to use the most appropriate counselling strategies. The transtheoretical framework helps counsellors to perceive the total range of patients' different stages of change and their effect on the implementation of counselling. However, determining patients' stages of change through examining counselling conversations is occasionally difficult. Further qualitative research is called for.

Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force

OBJECTIVE

The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings.

DESIGN AND DATA SOURCES

We conducted a MEDLINE search from 1966 to December 2001.

STUDY SELECTION

We included randomized controlled trials of at least 3 months' duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease.

DATA EXTRACTION

One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques.

DATA SYNTHESIS

We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes.

CONCLUSIONS

Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.

Dietary interventions to prevent disease

Changing dietary behaviors to prevent chronic disease has been an important research focus for the last 25 years. Here we present a review of published articles on the results of research to identify methods to change key dietary habits: fat intake, fiber intake, and consumption of fruits and vegetables. We divided the research reviewed into sections, based on the channel through which the intervention activities were delivered. We conclude that the field is making progress in identifying successful dietary change strategies, but that more can be learned. Particularly, we need to transfer some of the knowledge from the individual-based trials to community-level interventions. Also, more research with rigorous methodology must be done to test current and future intervention options.

Effect of an increased intake of alpha-linolenic acid and group nutritional education on cardiovascular risk factors: the Mediterranean Alpha-linolenic Enriched Groningen Dietary Intervention (MARGARIN) study

BACKGROUND

The effect of long-term increased intakes of alpha-linolenic acid (ALA; 18:3n-3) on cardiovascular risk factors is unknown.

OBJECTIVES

Our objectives were to assess the effect of increased ALA intakes on cardiovascular risk factors and the estimated risk of ischemic heart disease (IHD) at 2 y and the effect of nutritional education on dietary habits.

DESIGN

Subjects with multiple cardiovascular risk factors (124 men and 158 women) were randomly assigned in a double-blind fashion to consume a margarine rich in either ALA [46% linoleic acid (LA; 18:2n-6) and 15% ALA; n = 114] or LA (58% LA and 0.3% ALA; n = 168). An intervention group (n = 110; 50% ALA) obtained group nutritional education, and a control group (n = 172; 34% ALA) received a posted leaflet containing the standard Dutch dietary guidelines.

RESULTS

Average ALA intakes were 6.3 and 1.0 g/d in the ALA and LA groups, respectively. After 2 y, the ALA group had a higher ratio of total to HDL cholesterol (+0.34; 95% CI: 0.12, 0.56), lower HDL cholesterol (-0.05 mmol/L; -0.10, 0), higher serum triacylglycerol (+0.24 mmol/L; 0.02, 0.46), and lower plasma fibrinogen (-0.18 g/L; -0.31, -0.04; after 1 y) than did the LA group (adjusted for baseline values, sex, and lipid-lowering drugs). No significant difference existed in 10-y estimated IHD risk. After 2 y, the intervention group had lower saturated fat intakes and higher fish intakes than did the control group.

CONCLUSIONS

Increased ALA intakes decrease the estimated IHD risk to an extent similar to that found with increased LA intakes. Group nutritional education can effectively increase fish intake.

Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol

BACKGROUND

The average level of blood cholesterol is an important determinant of the risk of coronary heart disease. Blood cholesterol can be reduced by dietary means. Although dietitians are trained to provide dietary advice, for practical reasons it is also given by other health professionals and occasionally through the use of self-help resources.

OBJECTIVES

To assess the effects of dietary advice given by a dietitian compared with another health professional, or the use of self-help resources, in reducing blood cholesterol in adults.

SEARCH STRATEGY

We searched The Cochrane Library (to Issue 2 1999), MEDLINE (1966 to January 1999), EMBASE (1980 to December 1998), Cinahl (1982 to December 1998), Human Nutrition (1991 to 1998), Science Citation Index, Social Sciences Citation Index, hand searched conference proceedings on nutrition and heart disease, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials of dietary advice given by a dietitian compared with another health professional or self-help resources. The main outcome was difference in blood cholesterol between dietitian groups compared with other intervention groups.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eleven studies with 12 comparisons were included, involving 704 people receiving advice from dietitians, 486 from other health professionals and 551 people using self-help leaflets. Four studies compared dietitian with doctor, seven with self-help resources, and one compared dietitian with nurse. Participants receiving advice from dietitians experienced a greater reduction in blood cholesterol than those receiving advice only from doctors (-0.25 mmol/L (95% CI -0.37, -0.12 mmol/L)). There was no statistically significant difference in change in blood cholesterol between dietitians and self-help resources (-0.10 mmol/L (95% CI -0.22, 0.03 mmol/L)). No statistically significant differences were detected for secondary outcome measures between any of the comparisons with the exception of dietitian versus nurse for HDLc, where the dietitian groups showed a greater reduction (-0.06 mmol/L (95% CI -0.11, -0.01)). No significant heterogeneity between the studies was detected.

REVIEWER'S CONCLUSIONS

Dietitians were better than doctors at lowering blood cholesterol in the short to medium term, but there was no evidence that they were better than self-help resources. The results should be interpreted with caution as the studies were not of good quality and the analysis was based on a limited number of trials. More evidence is required to assess whether change can be maintained in the longer term. There was no evidence that dietitians provided better outcomes than nurses.