The validity of dietary assessment in general practice

Feasibility of a virtual multimodal prehabilitation intervention for patients with cancer undergoing surgery

BACKGROUND AND AIMS

Current prehabilitation programs are often limited by poor recruitment and attrition rates. Remote delivery of prehabilitation may reduce barriers to participation and maximize program retention. We aimed to assess the feasibility (uptake, retention, fidelity), preliminary effectiveness, and acceptability of delivering a technology-supported prehabilitation program remotely to oncologic surgical candidates.

METHODS

This was a one-arm pragmatic feasibility study aiming to follow patients for 4-6 weeks preoperatively and 8 weeks postoperatively. All patients received a home-based aerobic and resistance exercise program, with psychosocial counselling as needed. Those at risk of malnutrition received nutritional counselling and supplements to meet personalized energy and protein targets. Adherence was assessed using an exercise watch and a mobile application for dietary assessment. In addition, we assessed physical effects, with change in 6-min walking distance of 20m defined as clinically meaningful recovery, and post-operative complications. Acceptability was assessed using a convergence mixed-methods approach.

RESULTS

A total of 28 participants were included (median 69, IQR 9.5 years; 12/28, 43 % males). Rate of recruitment was 47 %, retention was 78 %, and attendance was 86-93 %. Participants walked an average of 8168 (SD: 4685) steps per day preoperatively and 6809 (SD: 4819) steps per day postoperatively. They consumed on average 21.6 kcal/kg of ideal body weight (IBW) and 1.1 g protein/kg IBW during the first week of the intervention. Participants demonstrated significant improvements in remote physical tests before surgery (arm strength: +9.7 [5.7, 13.6] repetitions in arm curl, p < 0.001; leg strength: +3.2 [1.4, 4.9] sit-to-stand repetitions in 30 s, p = 0.001; endurance: +19.4 [12.7, 26.1] repetitions in the 2-min step test, p < 0.001). The majority (16/22, 73 %) achieved clinically meaningful recovery at 8 weeks postoperatively. All participants attested to the acceptability of exercising with remote supervision.

CONCLUSION

A technology-assisted prehabilitation program delivered remotely is feasible and could lead to physical benefits for a surgical cancer population.

Physical Health in Clinical High Risk for Psychosis Individuals: A Cross-Sectional Study

BACKGROUND

The clinical high risk for psychosis (CHR-P) phase represents an opportunity for prevention and early intervention in young adults, which also could focus on improving physical health trajectories.

METHODS

We conducted a RECORD-compliant clinical register-based cohort study. The primary outcome was to describe the physical health of assessed CHR-P individuals, obtained via Electronic Health Records at the South London and Maudsley (SLaM) NHS Foundation Trust, UK (January 2013-October 2020).

RESULTS

The final database included 194 CHR-P subjects (46% female). Mean age was 23.70 ± 5.12 years. Percentage of tobacco smokers was 41% (significantly higher than in the age-matched general population [24%]). We found that 49% of subjects who consumed alcohol had an AUDIT-C (Alcohol Use Disorder Identification Test) score above 5 (hazardous drinking), with an average score of 4.94 (significantly higher than in the general population [2.75]). Investigating diet revealed low fiber intake in most subjects and high saturated fat intake in 10% of the individuals. We found that 47% of CHR-P subjects met the UK recommended physical activity guidelines (significantly lower than in the general population [66%]). Physical parameters (e.g., weight, heart rate, blood pressure) were not significantly different from the general population.

CONCLUSIONS

This evidence corroborates the need for monitoring physical health parameters in CHR-P subjects, to implement tailored interventions that target daily habits.

Personality, Risk Perceptions, and Health Behaviors: A Two-Wave Study on Reciprocal Relations in Adults

The aim of the study was to examine reciprocal associations between risk perceptions for cardiovascular disease and health behaviors (i.e., physical activity, fruit/vegetable consumption), while accounting for key personality characteristics in middle-aged adults. Participants (N = 297; M (SD) age = 51 (6.95); 72.4% female) completed online questionnaires assessing risk perceptions, physical activity, fruit/vegetable consumption, and personality (conscientiousness and neuroticism) on two occasions, one week apart. Physical activity did not have a statistically significant effect on risk perception over time (b = -0.00, p = 0.227). However, fruit and vegetable consumption (b = -0.19, p = 0.006) and neuroticism (b = 0.22, p = 0.001) predicted risk perception. Risk perception did not have a significant effect on physical activity (b = -343.86, p = 0.147) or fruit/vegetable consumption (b = -0.08, p = 0.144) over time; however, neuroticism had significant and negative effects on physical activity (b = -520.84, p = 0.029) and fruit/vegetable consumption (b = -0.20, p = 0.001). High levels of neuroticism in middle age may hinder engagement in physical activity and consumption of fruit/vegetable behaviors and should therefore be targeted accordingly to increase protective health behaviors and reduce incidence of cardiovascular disease.

Changes in dietary fat intake and associations with mental health in a UK public sample during the COVID-19 pandemic

Background

Consumption of unhealthy foods may have changed during the COVID-19 pandemic. This study explored how dietary fat intake was impacted in a sample of the UK public who were social distancing during the COVID-19 pandemic.

Methods

Data were collected from a UK COVID-19 online survey. Fat intake was measured using the Dietary Instrument for Nutrition Education questionnaire. Anxiety and depressive symptoms were assessed using Becks’ Anxiety and Depression Inventories, while the short-form Warwick-Edinburgh Mental Well-being Scale assessed mental well-being. Differences between individuals who increased versus decreased fat intake were explored using chi-square or independent sample t-tests. Association between fat intake and mental health was explored using adjusted linear regression models.

Results

Eight hundred and eighty-seven adults were included. Approximately, 34% recorded medium-to-high levels of fat consumption during social distancing. Around 48% reported decreased fat intake during social distancing compared to usual levels, while 41.3% documented increased fat intake. Fat intake was not significantly associated (P > 0.05) with any measures of mental health.

Conclusions

A higher proportion of a sample of UK adults social distancing during the COVID-19 pandemic recorded decreased fat intake when compared to levels prior to social distancing. There appeared to be no associations between fat intake and mental health.

Socioeconomically Disadvantaged Groups and Metabolic Syndrome in European Adolescents: The HELENA Study

PURPOSE

Psychosocial stressors derived from socioeconomic disadvantages in adolescents can result in higher risk of metabolic syndrome (MetS). We aimed to examine whether socioeconomic disadvantages were associated with MetS independent of lifestyle and whether there was a dose-response relationship between the number of cumulated socioeconomic disadvantages and risk of MetS.

METHODS

This study included 1,037 European adolescents (aged 12.5-17.5 years). Sociodemographic variables and lifestyle were assessed by self-reported questionnaires. Disadvantaged groups included adolescents with low-educated parents, low family affluence, migrant origin, unemployed parents, and nontraditional families. MetS risk score was calculated as the sum of sex- and age-specific z-scores of waist circumference, blood pressure, lipids, and insulin resistance. Linear mixed-effects models adjusted for sex, age, pubertal status, and lifestyle were used to study the association between social disadvantages and MetS risk score.

RESULTS

Adolescents with low-educated mothers showed a higher MetS score (.54 [.09-.98]; β estimate and 99% confidence interval) compared to those with high-educated mothers. Adolescents who accumulated more than three disadvantages (.69 [.08-1.31]) or with missing information on disadvantages (.72 [.04-1.40]) had a higher MetS risk score compared to nonsocioeconomically disadvantaged groups. Stronger associations between socioeconomic disadvantages and MetS were found in male than in female adolescents.

CONCLUSIONS

Adolescents with low-educated mothers or with more than three socioeconomic disadvantages had a higher MetS risk, independent of lifestyle, potentially due to higher psychosocial stress exposure. Policy makers should focus on improving low-educated familiesa and more disadvantaged families' knowledge on nutrition and physical activity to help them cope better with stress.

Examining the use of the FIGO Nutrition Checklist in routine antenatal practice: multistakeholder feedback to implementation

Objective

To gain insights from pregnant women and obstetricians on the utility of the FIGO Nutrition Checklist in antenatal practice.

Methods

Women were recruited from the antenatal department of a large tertiary‐level university maternity hospital in Dublin, Ireland, between October and December 2019. Participants completed the FIGO Nutrition Checklist before their routine antenatal appointment. Obstetricians and women were encouraged to discuss the FIGO Nutrition Checklist during the clinical visit. Completed FIGO Nutrition Checklists were collected after appointments. Acceptability was assessed through questionnaires.

Results

The majority (80.0%) of women answered “No” to at least one diet quality question, indicating a potential nutritional risk. While none of the participating obstetricians routinely discussed nutrition with women, all agreed that using the Checklist encouraged them to address nutrition with pregnant women. Nearly every woman (99.0%) found the Checklist quick to complete; however, all participating obstetricians felt there was not enough time to discuss it in routine practice. Despite this, most obstetricians and pregnant women recommended the FIGO Nutrition Checklist for use.

Conclusion

The FIGO Nutrition Checklist is acceptable for use in routine antenatal practice in tertiary care settings. It helped identify potentially at‐risk women during early pregnancy and facilitated conversations related to optimum diet.

The FIGO Nutrition Checklist is acceptable to pregnant women and may capture high‐risk weight or dietary practices in pregnancy that would otherwise go untreated.

The Active Brains Digital Intervention to Reduce Cognitive Decline in Older Adults: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Increasing physical activity, improving diet, and performing brain training exercises are associated with reduced cognitive decline in older adults.

OBJECTIVE

In this paper, we describe a feasibility trial of the Active Brains intervention, a web-based digital intervention developed to support older adults to make these 3 healthy behavior changes associated with improved cognitive health. The Active Brains trial is a randomized feasibility trial that will test how accessible, acceptable, and feasible the Active Brains intervention is and the effectiveness of the study procedures that we intend to use in the larger, main trial.

METHODS

In the randomized controlled trial (RCT), we use a parallel design. We will be conducting the intervention with 2 populations recruited through GP practices (family practices) in England from 2018 to 2019: older adults with signs of cognitive decline and older adults without any cognitive decline. Trial participants were randomly allocated to 1 of 3 study groups: usual care, the Active Brains intervention, or the Active Brains website plus brief support from a trained coach (over the phone or by email). The main outcomes are performance on cognitive tasks, quality of life (using EuroQol-5D 5 level), Instrumental Activities of Daily Living, and diagnoses of dementia. Secondary outcomes (including depression, enablement, and health care costs) and process measures (including qualitative interviews with participants and supporters) will also be collected. The trial has been approved by the National Health Service Research Ethics Committee (reference 17/SC/0463).

RESULTS

Results will be published in peer-reviewed journals, presented at conferences, and shared at public engagement events. Data collection was completed in May 2020, and the results will be reported in 2021.

CONCLUSIONS

The findings of this study will help us to identify and make important changes to the website, the support received, or the study procedures before we progress to our main randomized phase III trial.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number 23758980; http://www.isrctn.com/ISRCTN23758980.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18929.

Maternal Pregnancy Diet Quality Is Directly Associated with Autonomic Nervous System Function in 6-Month-Old Offspring

BACKGROUND

Many pregnant women are consuming diets of poor overall quality. Although many studies have linked poor prenatal diet quality to an increased risk of specific diseases in offspring, it is not known if exposure to poor prenatal diet affects core neurophysiological regulatory systems in offspring known to lie upstream of multiple diseases.

OBJECTIVE

We aimed to examine the association between prenatal diet quality and autonomic nervous system (ANS) function in infants at 6 mo of age.

METHODS

Data from 400 women (aged >18 y, with uncomplicated pregnancies) and their infants participating in the Maternal-Infant Research on Environmental Chemicals-Infant Development cohort were used to investigate links between prenatal diet quality and infant ANS function at 6 mo of age. Prenatal diet quality was assessed using the Healthy Eating Index (2010), calculated from a validated FFQ completed by women during the first trimester. Infant ANS function was measured using 2 assessments of heart rate variability (HRV) including root mean square of successive differences (RMSSD) and SD of N-N intervals (SDNN). Associations were analyzed before and after adjustment for socioeconomic status, maternal depression symptoms, maternal cardiometabolic dysfunction, breastfeeding, and prenatal smoking.

RESULTS

Poorer prenatal diet quality was associated with lower infant HRV assessed using RMSSD (B: 0.07; 95% CI: 0.01, 0.13; R2 = 0.013) and SDNN (B: 0.18; 95% CI: 0.02, 0.35; R2 = 0.011). These associations remained significant after adjustment for confounding variables [RMSSD: B: 0.09; 95% CI: 0.003, 0.18; squared semipartial correlation (sp2) = 0.14 and SDNN B: 0.24; 95% CI: 0.0, 0.49; sp2 = 0.13].

CONCLUSIONS

In a large cohort study, poorer prenatal diet quality was associated with lower offspring HRV, a marker of decreased capacity of the ANS to respond adaptively to challenge. Therefore, poor prenatal diet may play a significant role in the programming of multiple organ systems and could increase general susceptibility to disease in offspring.

Is there an association between perceived social support and cardiovascular health behaviours in people with severe mental illnesses?

PURPOSE

People with severe mental illnesses (SMI) have an increased risk of cardiovascular disease (CVD). Research in the general population suggests that social support may protect against increased CVD morbidity and mortality; however, this may not apply to those with SMI. We aimed to explore the association between perceived social support and attendance at primary care nurse CVD risk reduction clinic appointments and CVD risk-reducing behaviours in an SMI population with elevated CVD risk factors.

METHODS

We used longitudinal and cross-sectional data from a randomised controlled trial on 326 adults with SMI recruited via 76 general practices in England. Multilevel regression analysis estimated the effect of perceived social support on attendance at CVD risk reduction clinic appointments over 6 months, and adherence to CVD medication, physical activity, diet, smoking and alcohol use at baseline, adjusted by age, sex, ethnicity, deprivation, psychiatric diagnosis and employment.

RESULTS

Perceived social support predicted greater appointment attendance in unadjusted (IRR = 1.005; 1.000-1.010; p = 0.05) but not adjusted analysis (IRR = 1.003; 0.998-1.009; p = 0.25). Perceived social support was associated with greater adherence to medication; for each 1% increase in social support, there was a 4.2% increase in medication adherence (OR = 1.042; 1.015-1.070; p = 0.002). No association was found between greater perceived social support and greater physical activity, lower sedentary behaviour, healthier diet, lower alcohol use or being a non-smoker.

CONCLUSIONS

Social support may be an important facilitator for CVD medication adherence and is potentially important for primary care appointment attendance; however, alternative strategies might be needed to help people with SMI engage in physical activity, healthier diets and to reduce their smoking and alcohol use.

A systematic review of reviews identifying UK validated dietary assessment tools for inclusion on an interactive guided website for researchers: www.nutritools.org

Background: Health researchers may struggle to choose suitable validated dietary assessment tools (DATs) for their target population. The aim of this review was to identify and collate information on validated UK DATs and validation studies for inclusion on a website to support researchers to choose appropriate DATs.Design: A systematic review of reviews of DATs was undertaken. DATs validated in UK populations were extracted from the studies identified. A searchable website was designed to display these data. Additionally, mean differences and limits of agreement between test and comparison methods were summarized by a method, weighting by sample size.Results: Over 900 validation results covering 5 life stages, 18 nutrients, 6 dietary assessment methods, and 9 validation method types were extracted from 63 validated DATs which were identified from 68 reviews. These were incorporated into www.nutritools.org. Limits of agreement were determined for about half of validations. Thirty four DATs were FFQs. Only 17 DATs were validated against biomarkers, and only 19 DATs were validated in infant/children/adolescents.Conclusions: The interactive www.nutritools.org website holds extensive validation data identified from this review and can be used to guide researchers to critically compare and choose a suitable DAT for their research question, leading to improvement of nutritional epidemiology research.

Promoting and inhibiting factors for the use of validated dietary assessment questionnaires in health check-up counseling: from occupational health nurses and dietitians' perspective

A validated questionnaire is not typically used for dietary assessment in health check-up counseling provided by occupational health nurses in Japan. We conducted a qualitative study to investigate the barriers and promoting factors affecting the use of validated questionnaires. Ten occupational health nurses and three registered dietitians, working at a health insurance society, were recruited for this study using an open-ended, free description questionnaire. Inhibiting factors, such as "Feeling of satisfaction with the current method," "Recognition of importance," and "Sense of burden from the questionnaire", and as promoting factors, "Feeling the current method is insufficient", "Recognition of importance," "Reduction in the feeling of burden after the answer," "Expectation of and reaction to the result," and "Expectation for the effect of the counseling" were noted. Since a standardized dietary assessment method in health counseling might be desirable for the harmonization of work with diseases prevention in an occupational field, findings in this study could propose appropriate targets to reduce confusion in health professionals' concerning the use of validated questionnaires.

Can a Simple Dietary Index Derived from a Sub-Set of Questionnaire Items Assess Diet Quality in a Sample of Australian Adults?

Large, longitudinal surveys often lack consistent dietary data, limiting the use of existing tools and methods that are available to measure diet quality. This study describes a method that was used to develop a simple index for ranking individuals according to their diet quality in a longitudinal study. The RESIDential Environments (RESIDE) project (2004-2011) collected dietary data in varying detail, across four time points. The most detailed dietary data were collected using a 24-item questionnaire at the final time point (n = 555; age ≥ 25 years). At preceding time points, sub-sets of the 24 items were collected. A RESIDE dietary guideline index (RDGI) that was based on the 24-items was developed to assess diet quality in relation to the Australian Dietary Guidelines. The RDGI scores were regressed on the longitudinal sub-sets of six and nine questionnaire items at T4, from which two simple index scores (S-RDGI1 and S-RDGI2) were predicted. The S-RDGI1 and S-RDGI2 showed reasonable agreement with the RDGI (Spearman's rho = 0.78 and 0.84; gross misclassification = 1.8%; correct classification = 64.9% and 69.7%; and, Cohen's weighted kappa = 0.58 and 0.64, respectively). For all of the indices, higher diet quality was associated with being female, undertaking moderate to high amounts of physical activity, not smoking, and self-reported health. The S-RDGI1 and S-RDGI2 explained 62% and 73% of the variation in RDGI scores, demonstrating that a large proportion of the variability in diet quality scores can be captured using a relatively small sub-set of questionnaire items. The methods described in this study can be applied elsewhere, in situations where limited dietary data are available, to generate a sample-specific score for ranking individuals according to diet quality.

People with a body mass index ⩾30 under-report their dietary intake: A systematic review

Under-reporting of total energy intake is a common and well-known source of measurement error in dietary assessment, and evidence suggests that this bias is particularly significant in obese individuals. After a multi-stage selection process of eligible papers, this literature review appraised 34 papers detailing the accuracy of self-reported dietary intake in people with an obese body mass index (BMI ⩾ 30). The available literature to date shows that having a body mass index ⩾30 is associated with significant under-reporting of food intake. Future research should look into identifying effective techniques to reduce this bias in clinical practice.

Can a dietary quality score derived from a short-form FFQ assess dietary quality in UK adult population surveys?

Objective

To devise a measure of diet quality from a short-form FFQ (SFFFQ) for population surveys. To validate the SFFFQ against an extensive FFQ and a 24 h diet recall.

Design

Population-based cross-sectional survey.

Setting

East Leeds and Bolton in Northern England.

Subjects

Adults (n1999) were randomly selected from lists of those registered with a general practitioner in the study areas, contacted by mail and asked to complete the SFFFQ. Responders were sent a longer FFQ to complete and asked if they would take part in a telephone-based 24 h diet recall.

Results

Results from 826 people completing the SFFFQ, 705 completing the FFQ and forty-seven completing the diet recall were included in the analyses. The dietary quality score (DQS), based on fruit, vegetable, oily fish, non-milk extrinsic sugar and fat intakes, showed significant agreement between the SFFFQ and the FFQ (κ=0·38,P<0·001). The DQS for the SFFFQ and the diet recall did not show significant agreement (κ=0·04,P=0·312). A number of single items on the SFFFQ predicted a ‘healthy’ DQS when calculated from the FFQ. The odds of having a healthy diet were increased by 27 % (95 % CI 9, 49 %,P<0·001) for an increase in fruit of 1 portion/d and decreased by 67 % (95 % CI 47, 79 %,P<0·001) for an increase in crisps of 1 portion/d.

Conclusions

The SFFFQ has been shown to be an effective method of assessing diet quality. It provides an important method for determining variations in diet quality within and across different populations.

Diet and physical activity intervention in colorectal cancer survivors: a feasibility study

Purpose

Evidence that lifestyle factors are associated with better outcomes in colorectal cancer (CRC) survivors highlights the need for behaviour change interventions. This study examined feasibility and acceptability, and provided an indication of behavioural impact, of a telephone-based, multimodal health behaviour intervention for CRC survivors.

Method

Participants were recruited from five London hospitals. Patients (n = 29) who had recently completed treatment for CRC participated in a 12 week intervention. Behavioural goals were to increase physical activity (PA) and fruit and vegetable (F&V) intake, and reduce consumption of red/processed meat and alcohol. Self-report measures of PA and diet were completed in all patients, supplemented by objective measures in a sub-set.

Results

Uptake of the study when patients were approached by a researcher was high (72%), compared with 27% contacted by letter. Methods for identifying eligible patients were not optimal. Study completion rate was high (79%), and completers evaluated the intervention favourably. Significant improvements were observed in objectively-measured activity (+70 min/week; p = .004). Gains were seen in diet: +3 F&V portions a day (p < .001), −147 g of red meat a week (p = .013), −0.83 portions of processed meat a week (p = .002). Changes in serum vitamin levels were not statistically significant, but the small sample size provides limited power. Clinically meaningful improvement in quality of life (p < .001) was observed.

Conclusion

An intervention combining print materials and telephone consultations was feasible and acceptable, and associated with improvements in PA, diet and quality of life.

South Asian individuals at high risk of type 2 diabetes have lower plasma vitamin C levels than white Europeans

Individuals of South Asian origin are at high risk of developing type 2 diabetes; the relationship between this risk and diet remains to be investigated fully. Furthermore, fruit and vegetable intake remains low throughout the world and previous data suggest that intake is associated with risk of diabetes. The aim of this research study was to compare plasma vitamin C concentrations, measured as a biomarker for fruit and vegetable intake, in South Asian and white European individuals. Participants recruited as part of the Let's Prevent Diabetes Study provided samples for the quantification of plasma vitamin C. We compared vitamin C levels by ethnicity using multiple regression, both unadjusted and adjusted for confounders, including glycaemic status. Mean plasma vitamin C was significantly lower in the South Asian participants compared with white European participants (34.5 (sd 19·8) v. 39·9 (sd 22·1) µmol/l, respectively; P ≤ 0·0001). Significantly fewer South Asian individuals consumed five portions of fruit and vegetables per d, as determined by a plasma vitamin C concentration of ≥ 50 µmol/l (23·2 % (n 58) v. 31·4 % (n 558); P = 0·01). Vitamin C reflects habitual fruit and vegetable consumption; thus results suggest that South Asians have lower fruit and vegetable intake. However, it cannot be excluded that vitamin C is utilised differently. Dietary advice specifically targeting the South Asian population should be developed.

Fruit and vegetable intake and the association with glucose parameters: a cross-sectional analysis of the Let's Prevent Diabetes Study

BACKGROUND

Dietary recommendations for the prevention of type 2 diabetes mellitus include the message to consume 400 g fruit and vegetables per day. Measurement of habitual diet is inherently difficult, yet errors due to self-report can be eliminated by the use of nutritional biomarkers. The aim of this study was to determine plasma vitamin C concentrations as a biomarker for fruit and vegetable intake in individuals identified at high risk of diabetes. Fruit and vegetables may confer benefit via their antioxidant capacity, thus we also measured urinary F₂-isoprostanes as a marker for oxidative stress.

SUBJECTS/METHODS

Participants recruited from a high-risk population as part of a diabetes prevention trial provided fasting blood samples and a spot urine sample for the quantification of plasma vitamin C and F₂-isoprostanes, respectively. We compared glycaemic parameters by the increments of the standard deviation of plasma vitamin C using multiple regression models.

RESULTS

Mean plasma vitamin C of participants was 39.3 μmol/l (s.d. 21.8). In the unadjusted model, 1 s.d. plasma vitamin C was significantly and inversely associated with HbA1c, fasting and 2 h blood glucose (P ≤ 0.0001). Relationships remained significant after adjustment for demographic variables and confounding factors. No significant association was observed between plasma vitamin C and urinary F₂-isoprostanes.

CONCLUSION

The data adds to the evidence that small lifestyle changes may influence glucose regulation. The role that fruit and vegetables independently have should be investigated further.

A preliminary investigation into the use of denture adhesives combined with dietary advice to improve diets in complete denture wearers

OBJECTIVES

To investigate how nutritional advice and denture adhesives may be associated with eating healthier foods.

METHODS

35 edentulous subjects (13 males and 22 females, mean age 73.9 years (55-84 years)), wearing complete dentures more than one year old, completed validated questionnaires analysing saturated fat, protein, Vitamin C, the number of servings of fruit/vegetables. In addition subjects completed the NDNS and OHIP Edent questionnaires. At baseline, nutritional information and the use of denture adhesive was provided. Subjects returned after 30 consecutive days and the questionnaires were repeated. A Wilcoxon signed rank test was used to test the effect of the denture adhesive on diet and on quality of life measures.

RESULTS

The subjects increased mean intake from 2.2 portions of fruit/vegetables a day to 3.6. Fat and saturated fats were reduced from 23.2g to 11.3g and Vitamin C intake increased by 34.4mg. All were statistically significant (p<0.0001). There was a statistically significant improvement over the 30-day treatment period in subjects' ability as measured by using OHIP Edent scores to bite (p=0.017) and chew a range of foods (p=0.007).

CONCLUSION

Within the confines of the study, use of simple dietary advice and denture adhesives improved diet.

CLINICAL SIGNIFICANCE

The results of this pilot study suggest that denture fixatives may improve dietary behaviour of complete denture wearers.

Walking away from type 2 diabetes: trial protocol of a cluster randomised controlled trial evaluating a structured education programme in those at high risk of developing type 2 diabetes

BACKGROUND

The prevention of type 2 diabetes is a recognised health care priority globally. Within the United Kingdom, there is a lack of research investigating optimal methods of translating diabetes prevention programmes, based on the promotion of a healthy lifestyle, into routine primary care. This study aims to establish the behavioural and clinical effectiveness of a structured educational programme designed to target perceptions and knowledge of diabetes risk and promote a healthily lifestyle, particularly increased walking activity, in a multi-ethnic population at a high risk of developing type 2 diabetes.

DESIGN

Cluster randomised controlled trial undertaken at the level of primary care practices. Follow-up will be conducted at 12, 24 and 36 months. The primary outcome is change in objectively measured ambulatory activity. Secondary outcomes include progression to type 2 diabetes, biochemical variables (including fasting glucose, 2-h glucose, HbA1c and lipids), anthropometric variables, quality of life and depression.

METHODS

10 primary care practices will be recruited to the study (5 intervention, 5 control). Within each practice, individuals at high risk of impaired glucose regulation will be identified using an automated version of the Leicester Risk Assessment tool. Individuals scoring within the 90th percentile in each practice will be invited to take part in the study. Practices will be assigned to either the control group (advice leaflet) or the intervention group, in which participants will be invited to attend a 3 hour structured educational programme designed to promote physical activity and a healthy lifestyle. Participants in the intervention practices will also be invited to attend annual group-based maintenance workshops and will receive telephone contact halfway between annual sessions. The study will run from 2010-2014.

DISCUSSION

This study will provide new evidence surrounding the long-term effectiveness of a diabetes prevention programme run within routine primary care in the United Kingdom.

TRIAL REGISTRATION

ClinicalTrials.Gov identifier: NCT00941954.

Bath Breakfast Project (BBP)--examining the role of extended daily fasting in human energy balance and associated health outcomes: study protocol for a randomised controlled trial [ISRCTN31521726]

BACKGROUND

Current guidance regarding the role of daily breakfast in human health is largely grounded in cross-sectional observations. However, the causal nature of these relationships has not been fully explored and what limited information is emerging from controlled laboratory-based experiments appears inconsistent with much existing data. Further progress in our understanding therefore requires a direct examination of how daily breakfast impacts human health under free-living conditions.

METHODS/DESIGN

The Bath Breakfast Project (BBP) is a randomised controlled trial comparing the effects of daily breakfast consumption relative to extended fasting on energy balance and human health. Approximately 70 men and women will undergo extensive laboratory-based assessments of their acute metabolic responses under fasted and post-prandial conditions, to include: resting metabolic rate, substrate oxidation, dietary-induced thermogenesis and systemic concentrations of key metabolites/hormones. Physiological and psychological indices of appetite will also be monitored both over the first few hours of the day (i.e. whether fed or fasted) and also following a standardised test lunch used to assess voluntary energy intake under controlled conditions. Baseline measurements of participants' anthropometric characteristics (e.g. DEXA) will be recorded prior to intervention, along with an oral glucose tolerance test and acquisition of adipose tissue samples to determine expression of key genes and estimates of tissue-specific insulin action. Participants will then be randomly assigned either to a group prescribed an energy intake of ≥3000 kJ before 1100 each day or a group to extend their overnight fast by abstaining from ingestion of energy-providing nutrients until 1200 each day, with all laboratory-based measurements followed-up 6 weeks later. Free-living assessments of energy intake (via direct weighed food diaries) and energy expenditure (via combined heart-rate/accelerometry) will be made during the first and last week of intervention, with continuous glucose monitors worn both to document chronic glycaemic responses to the intervention and to verify compliance.

Performance of a short percentage energy from fat tool in measuring change in dietary intervention studies

Measurement of percentage energy from fat is important in surveillance of populations and in epidemiologic studies examining relationships between diet and disease as well as for behavioral intervention studies seeking to change dietary behavior. The NCI percentage energy from fat screener (PFat) has adequately predicted percentage of energy from fat compared with 24-h recalls (24HR) in cross-sectional analyses. However, the instrument has not been evaluated for its ability to assess change of percentage energy from fat over time or in response to interventions to change dietary intake of fat. The objective of this analysis is to evaluate the performance of the PFat in assessing change in percentage energy intake from fat in a behavioral intervention setting. Four individual sites participating in the Behavior Change Consortium Nutrition Working Group administered both the PF at and multiple 24HR at baseline and follow-up to 278 participants. A measurement error model was used to assess agreement between the PFat and 24HR at baseline and follow-up. The PFat was consistent with 24HR in finding there was no significant change in percentage energy from fat as a result of the intervention. Both male and female participants in the intervention group demonstrated a significant increase in the correlation between PFat and 24HR from baseline to follow-up. Percentage energy from fat measured by PFat may be useful to provide estimates of change in mean intake of populations over time in longitudinal studies. Further methodologic research is called for in interventions producing significant changes and in diverse populations with adequate sample size.

Illness representations among patients with type 2 diabetes and their partners: relationships with self-management behaviors

OBJECTIVE

There is accumulating evidence to indicate that the illness representations of significant others are important for understanding patients' responses to chronic disease. The aims of the present study were to (a) assess the illness representations of patients with type 2 diabetes and their partners, (b) determine the extent of agreement between patient and partner representations, and (c) examine whether partners' representations mediate the relationships between patients' representations and their prospective self-management behaviors.

METHODS

Patients' and partners' representations of diabetes were assessed with the Revised Illness Perception Questionnaire [Moss-Morris R, Weinman J, Petrie K, Horne R, Cameron LD, Buick, D. The revised illness perception questionnaire (IPQ-R). Psychol Health 2002;17:116] at baseline (n=164). Self-management behaviors were assessed 12 months later with self-report measures of physical activity, medication, and a food frequency questionnaire.

RESULTS

Patients scored lower on the illness coherence dimension, indicating that they reported a poorer understanding of the condition (t=-2.66, df=163, P=.009) relative to their partners. Patients demonstrated higher scores for personal control than their partners (t=2.01, df=163, P=.046). Mediational analyses indicated that partners' perceived timeline of diabetes partially mediated the relationship between patients' representations and their self-management behaviors including physical activity and dietary intake. In addition, partners' personal control representations partially mediated the relationship between patients' representations and physical activity.

CONCLUSION

It was demonstrated that patient-partner dyads generally share similar representations of type 2 diabetes and perceived control over the condition. Furthermore, there was evidence that partners' representations partially mediated the relationships between patients' representations and their prospective self-management behaviors.

Identification and correlates of weight loss in adolescents in a national sample

OBJECTIVE

Little is known about behaviors associated with successful weight loss during adolescence. The first objective of the current study was to identify meaningful weight loss, weight maintenance, and weight gain in male and female adolescents. The second objective of this study was to apply these methods to U.S. adolescents from the National Health and Nutrition Survey 1999 to 2002 data and to identify factors associated with these weight change outcomes.

RESEARCH METHODS AND PROCEDURES

The current analyses include 1726 (female, 836; male, 890) 16- to 18-year-old adolescents who completed the questionnaire components and interview for either the 1999-2000 or the 2001-2002 National Health and Nutrition Survey study. Dietary intake, physical activity, and dieting attitudes were compared across the weight loss (L), maintain (M), and gain (G) groups in the entire sample and in a subset of adolescents who are overweight and at-risk-for-overweight (> or = 85th percentile).

RESULTS

The tested method for identifying weight L, M, and G groups has both theoretical and statistical validity and, when applied to the sample, showed the expected direction of changes in weight. Results suggest that more overall physical activity, more vigorous exercise, and less sedentary activity are associated with being in the L group in both the full sample and the overweight and at-risk-for-overweight sample. In addition, fewer teens in the L groups endorsed efforts at trying to lose weight, compared with the M and G groups.

DISCUSSION

This study provides a method to determine successful adolescent weight loss for researchers and provides useful concrete information about successful weight loss for clinicians and others who work with adolescents.

Pathways from deprivation to health differed between individual and neighborhood-based indices

OBJECTIVE

To explore the role of behavioral and psychosocial factors in explaining the social gradient in self-rated health as defined either by an individual or a neighborhood deprivation index.

STUDY DESIGN AND SETTING

Data were from the baseline survey of the UK Flexible Sigmoidoscopy trial. Recruitment through general practices was stratified to generate a socioeconomically diverse sample (N=5,253, aged 55-64). Assessments included an individual and neighborhood deprivation index, each of which were categorized in four levels; three behavioral and three psychosocial factors; and self-rated health.

RESULTS

Neighborhood deprivation was more strongly related to behavioral than to psychosocial factors, whereas individual deprivation was strongly related to both. The social gradient in poor self-rated health (odds in most compared to least deprived group) was 6.5 for individual and 4.2 for the neighborhood deprivation index. Behavioral and psychosocial variables explained, respectively, 7% and 11% of the individual deprivation gradient and 11% and 4% of the neighborhood gradient. The psychosocial pathway did not significantly mediate the neighborhood deprivation effect on self-rated health.

CONCLUSION

Intermediary pathways of the social gradient in self-rated health differed between individual and neighborhood-based deprivation indices, suggesting at least partly independent influences on poor health of individual and neighborhood-level deprivation.

Structured patient education: the diabetes X-PERT Programme makes a difference

AIMS

To develop a patient-centred, group-based self-management programme (X-PERT), based on theories of empowerment and discovery learning, and to assess the effectiveness of the programme on clinical, lifestyle and psychosocial outcomes.

METHODS

Adults with Type 2 diabetes (n = 314), living in Burnley, Pendle or Rossendale, Lancashire, UK were randomized to either individual appointments (control group) (n = 157) or the X-PERT Programme (n = 157). X-PERT patients were invited to attend six 2-h group sessions of self-management education. Outcomes were assessed at baseline, 4 and 14 months.

RESULTS

One hundred and forty-nine participants (95%) attended the X-PERT Programme, with 128 (82%) attending four or more sessions. By 14 months the X-PERT group compared with the control group showed significant improvements in the mean HbA1c (- 0.6% vs. + 0.1%, repeated measures anova, P < 0.001). The number needed to treat (NNT) for preventing diabetes medication increase was 4 [95% confidence interval (CI) 3, 7] and NNT for reducing diabetes medication was 7 (95% CI 5, 11). Statistically significant improvements were also shown in the X-PERT patients compared with the control patients for body weight, body mass index (BMI), waist circumference, total cholesterol, self-empowerment, diabetes knowledge, physical activity levels, foot care, fruit and vegetable intake, enjoyment of food and treatment satisfaction.

CONCLUSIONS

Participation in the X-PERT Programme by adults with Type 2 diabetes was shown at 14 months to have led to improved glycaemic control, reduced total cholesterol level, body weight, BMI and waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction.

Estimating dietary intakes from a brief questionnaire: A simulation study of reliability in a molecular epidemiologic study of pancreatic and biliary diseases

INTRODUCTION

Brief dietary questionnaires may be useful in research or clinical settings where in-depth assessments are inefficient or impractical. We conducted a simulation study to assess the reliability of a brief food frequency questionnaire (bFFQ) for capturing dietary intakes relative to a detailed survey.

SUBJECTS AND METHODS

The bFFQ was used in a study of patients with pancreatic and biliary diseases in eastern Spain (n = 605). The structured interview included a section probing the frequency of intakes of 14 food groups, using 4 response categories. Data from a 93-item semi-quantitative food frequency questionnaire (SFFQ) with 9 response categories (n = 1337) was used to: (1) develop estimates of nutrient intakes for each food group, and (2) to simulate how intakes would have been estimated using the bFFQ. The simulation allowed to assess effects of aggregating foods and using abbreviated frequency categories.

RESULTS

Correlations between actual and simulated intake frequencies exceeded 0.70 for 10 food groups; modest correlations (0.43-0.56) were observed for groups assessed less well using abbreviated frequency categories. Correlations exceeded 0.60 for most nutrients. Concordance was lower for several nutrients, notably retinol, for which substantial proportions were contributed by groups combining foods with highly variable levels of these compounds.

CONCLUSIONS

Intake estimates from the bFFQ may be useful in exploratory analyses of the role of diet in bilio-pancreatic diseases and related etiopathogenic events. Estimates for some nutrients may be less reliable, and should be interpreted with particular caution.

The feasibility and utility of grocery receipt analyses for dietary assessment

Objective

To establish the feasibility and utility of a simple data collection methodology for dietary assessment.

Design

Using a cross-sectional design, trained data collectors approached adults (~20 – 40 years of age) at local grocery stores and asked whether they would volunteer their grocery receipts and answer a few questions for a small stipend ($1).

Methods

The grocery data were divided into 3 categories: "fats, oils, and sweets," "processed foods," and "low-fat/low-calorie substitutions" as a percentage of the total food purchase price. The questions assessed the shopper's general eating habits (eg, fast-food consumption) and a few demographic characteristics and health aspects (eg, perception of body size).

Statistical Analyses Performed. Descriptive and analytic analyses using non-parametric tests were conducted in SAS.

Results

Forty-eight receipts and questionnaires were collected. Nearly every respondent reported eating fast food at least once per month; 27% ate out once or twice a day. Frequency of fast-food consumption was positively related to perceived body size of the respondent (p = 0.02). Overall, 30% of the food purchase price was for fats, oils, sweets, 10% was for processed foods, and almost 6% was for low-fat/low-calorie substitutions. Households where no one was perceived to be overweight spent a smaller proportion of their food budget on fats, oils, and sweets than did households where at least one person was perceived to be overweight (p = 0.10); household where the spouse was not perceived to be overweight spent less on fats, oils, and sweets (p = 0.02) and more on low-fat/low-calorie substitutions (p = 0.09) than did households where the spouse was perceived to be overweight; and, respondents who perceived themselves to be overweight spent more on processed foods than did respondents who did not perceive themselves to be overweight (p = 0.06).

Conclusion

This simple dietary assessment method, although global in nature, may be a useful indicator of dietary practices as evidenced by its association with perceived weight status.

Ethnicity and Nutrition of Adolescent Girls in Hawaii

OBJECTIVE

To describe the ethnicity and nutrition of adolescent girls in Hawaii.

DESIGN

This was a cross-sectional survey.

SUBJECTS

Girls, aged 9 to 14 years, were identified from the membership files of Kaiser Permanente Hawaii, a large Hawaii health maintenance organization.

MAIN OUTCOME MEASURES

Nutrient and food group intakes were compared against recommended intakes, physical activity levels, and anthropometric measurements of height, weight, body mass index (BMI), and subscapular and iliac skinfold thicknesses.

STATISTICAL ANALYSIS PERFORMED

Asian girls, girls of mixed ethnicity, and white girls were compared using analysis of variance.

RESULTS

Although Asian girls weighed the least and were the most sedentary, white girls had the lowest BMIs. Mixed ethnicity girls had the highest weights, BMIs, and subscapular and iliac skinfold thicknesses. No significant differences were found in major macronutrient intake. However, mixed ethnicity and Asian girls had lower fiber, iron, folate, and calcium intake than white girls. All groups met recommendations for iron intake, whereas none met fiber and calcium recommendations. All girls met folate recommendations. No differences were found in intakes for tofu, soy, grains, vegetables, or fruit and nuts food groups. Mixed ethnicity girls had the highest sweetened carbonated beverage intake although overall sugar intake was highest in white girls. Asian and mixed ethnicity girls' meat intakes were higher than white girls'. Intakes of mixed ethnicity girls more closely resembled those of Asians, although they exhibited the highest BMIs.

CONCLUSIONS

These data suggest grain, vegetable, fruit, and dairy intake should be encouraged as part of a balanced diet for adolescent girls in Hawaii.

Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis

OBJECTIVES

To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs.

DESIGN

Randomised controlled trial.

SETTING

Eight general practices in south Birmingham.

PARTICIPANTS

441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg.

INTERVENTIONS

Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice).

PRIMARY OUTCOME

change in systolic blood pressure at six months and one year in both intervention and control groups.

SECONDARY OUTCOMES

change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs.

RESULTS

400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling).

CONCLUSIONS

Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

Interventions for preventing obesity in children

BACKGROUND

Obesity prevention is an international public health priority. The prevalence of obesity and overweight is increasing in child populations throughout the world, impacting on short and long-term health. Obesity prevention strategies for children can change behaviour but efficacy in terms of preventing obesity remains poorly understood.

OBJECTIVES

To assess the effectiveness of interventions designed to prevent obesity in childhood through diet, physical activity and/or lifestyle and social support.

SEARCH STRATEGY

MEDLINE, PsycINFO, EMBASE, CINAHL and CENTRAL were searched from 1990 to February 2005. Non-English language papers were included and experts contacted.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials with minimum duration twelve weeks.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty-two studies were included; ten long-term (at least 12 months) and twelve short-term (12 weeks to 12 months). Nineteen were school/preschool-based interventions, one was a community-based intervention targeting low-income families, and two were family-based interventions targeting non-obese children of obese or overweight parents. Six of the ten long-term studies combined dietary education and physical activity interventions; five resulted in no difference in overweight status between groups and one resulted in improvements for girls receiving the intervention, but not boys. Two studies focused on physical activity alone. Of these, a multi-media approach appeared to be effective in preventing obesity. Two studies focused on nutrition education alone, but neither were effective in preventing obesity. Four of the twelve short-term studies focused on interventions to increase physical activity levels, and two of these studies resulted in minor reductions in overweight status in favour of the intervention. The other eight studies combined advice on diet and physical activity, but none had a significant impact. The studies were heterogeneous in terms of study design, quality, target population, theoretical underpinning, and outcome measures, making it impossible to combine study findings using statistical methods. There was an absence of cost-effectiveness data.

AUTHORS' CONCLUSIONS

The majority of studies were short-term. Studies that focused on combining dietary and physical activity approaches did not significantly improve BMI, but some studies that focused on dietary or physical activity approaches showed a small but positive impact on BMI status. Nearly all studies included resulted in some improvement in diet or physical activity. Appropriateness of development, design, duration and intensity of interventions to prevent obesity in childhood needs to be reconsidered alongside comprehensive reporting of the intervention scope and process.

The impact of job strain on the predictive validity of the theory of planned behaviour: an investigation of exercise and healthy eating

OBJECTIVES

This study examined the impact of the job strain model on exercise and healthy eating within the framework of the Theory of Planned Behaviour.

DESIGN

Participants completed a questionnaire measuring the components of the Theory of Planned Behaviour and the job strain model. A follow-up questionnaire a week later measured behaviour.

METHOD

The questionnaires were completed by e-mail. The initial questionnaire was completed by 331 employees, and 286 follow-up questionnaires were returned.

RESULTS

Job demands affected exercise indirectly by lowering perceptions of behavioural control over exercise. However, variables from the job strain model were not related to exercise intentions or behaviour. In contrast, employees in passive jobs intended to eat more sweets and snack foods and employees in low strain jobs were more likely to realize their intentions to eat more sweets and snack foods. However, variables from the job strain model did not influence consumption of fruit and vegetables.

CONCLUSIONS

While people may consider the impact of job strain on exercise whilst making decisions about whether or not to exercise, job strain has a more direct impact on healthy eating. However, job strain may only affect consumption of so-called 'high density' foods, rather than foods such as fruit and vegetables.

Group based training for self-management strategies in people with type 2 diabetes mellitus

BACKGROUND

It has been recognised that adoption of self-management skills by the person with diabetes is necessary in order to manage their diabetes. However, the most effective method for delivering education and teaching self-management skills is unclear.

OBJECTIVES

To assess the effects of group-based, patient-centred training on clinical, lifestyle and psychosocial outcomes in people with type 2 diabetes.

SEARCH STRATEGY

Studies were obtained from computerised searches of multiple electronic bibliographic databases, supplemented by hand searches of reference lists of articles, conference proceedings and consultation with experts in the field. Date of last search was February 2003.

SELECTION CRITERIA

Randomised controlled and controlled clinical trials which evaluated group-based education programmes for adults with type 2 diabetes compared with routine treatment, waiting list control or no intervention. Studies were only included if the length of follow-up was six months or more and the intervention was at least one session with the minimum of six participants.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. A meta-analysis was performed if there were enough homogeneous studies reporting an outcome at either four to six months, 12-14 months, or two years, otherwise the studies were summarised in a descriptive manner.

MAIN RESULTS

Fourteen publications describing 11 studies were included involving 1532 participants. The results of the meta-analyses in favour of group-based diabetes education programmes were reduced glycated haemoglobin at four to six months (1.4%; 95% confidence interval (CI) 0.8 to 1.9; P < 0.00001), at 12-14 months (0.8%; 95% CI 0.7 to 1.0; P < 0.00001) and two years (1.0%; 95% CI 0.5 to 1.4; P < 0.00001); reduced fasting blood glucose levels at 12 months (1.2 mmol/L; 95% CI 0.7 to 1.6; P < 0.00001); reduced body weight at 12-14 months (1.6 Kg; 95% CI 0.3 to 3.0; P = 0.02); improved diabetes knowledge at 12-14 months (SMD 1.0; 95% CI 0.7 to 1.2; P < 0.00001) and reduced systolic blood pressure at four to six months (5 mmHg: 95% CI 1 to 10; P = 0.01). There was also a reduced need for diabetes medication (odds ratio 11.8, 95% CI 5.2 to 26.9; P < 0.00001; RD = 0.2; NNT = 5). Therefore, for every five patients attending a group-based education programme we could expect one patient to reduce diabetes medication.

AUTHORS' CONCLUSIONS

Group-based training for self-management strategies in people with type 2 diabetes is effective by improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.

Effect of normal-fat diets, either medium or high in protein, on body weight in overweight subjects: a randomised 1-year trial

BACKGROUND

We have previously reported that a fat-reduced high-protein diet had more favourable effects on body weight loss over 6 months than a medium-protein diet.

OBJECTIVE

To extend this observation by a further 6-12 months less stringent intervention and a 24 months follow-up.

DESIGN

A randomised 6 months strictly controlled dietary intervention followed by 6-12 months dietary counselling period, and a subsequent 24 months follow-up, comparing an ad libitum, fat-reduced diet (30% of energy) either high in protein (25% of energy, HP) or medium in protein (12% of energy, MP).

SUBJECTS

A total of 50 overweight and obese subjects (age: 19-55 y; BMI: 26-34 kg/m(2)).

MEASUREMENTS

Change in body weight, body composition and blood parameters.

RESULTS

After 6 months, the HP group (n=23) achieved a greater weight loss than the MP group (n=23) (9.4 vs 5.9 kg) (P<0.01). After 12 months, 8% had dropped out in the HP vs 28% in the MP group (P<0.07). After 12 months, the weight loss was not significantly greater among the subjects in the HP group (6.2 and 4.3 kg), but they had a 10% greater reduction in intra-abdominal adipose tissue and more in the HP group (17%) lost >10 kg than in the MP (P<0.09). At 24 months, both groups tended to maintain their 12 months weight loss, but more than 50% were lost to follow-up.

CONCLUSION

A fat-reduced diet high in protein seems to enhance weight loss and provide a better long-term maintenance of reduced intra-abdominal fat stores.

Adolescent dairy consumption and physical activity associated with bone mass

BACKGROUND

This study identifies key modifiable factors influencing Asian and White adolescent bone development. Cross-sectional analysis of baseline data of cohort.

METHODS

Three hundred and twenty-three girls were examined from age-eligible girls at Kaiser Permanente Oahu in Hawaii. Girls' age, ethnicity, Tanner stage, 3-day diet record, level of physical activity, anthropometry, and calcaneal bone status were obtained by questionnaire and measurement, respectively. Lunar Achilles calcaneal was used to measure calcaneal bone mass. Multiple regression was used for analysis of factors influencing bone mass.

RESULTS

The mean age of adolescents was 11.6 +/- 1.5 years. Girls were generally ethnically mixed; the mean Asian ethnic proportion was 48% while White ethnic proportion was 43% and other ethnic proportion was 10%. Multiple regression explained 40.8% and 25.6% of the variation in calcaneal broadband ultrasound attenuation (BUA) and speed of sound (SOS), respectively, in a model where age, weight, biacromial breadth, Tanner pubic hair stage, Asian ethnicity, dairy intake, and physical activity positively influenced bone mass.

CONCLUSIONS

Tanner pubic hair stage, ethnicity, and biacromial breadth had the greatest influence on SOS; while physical activity, body weight, and dairy product intake had the greatest influence on BUA.

Randomised controlled factorial trial of dietary advice for patients with a single high blood pressure reading in primary care

OBJECTIVE

To assess the effect of brief interventions during the "watchful waiting" period for hypertension.

DESIGN

Factorial trial.

SETTING

General practice.

METHODS

296 patients with blood pressure > 160/90 mm Hg were randomised to eight groups defined by three factors: an information booklet; low sodium, high potassium salt; prompt sheets for high fruit, vegetable, fibre; and low fat.

MAIN OUTCOME MEASURES

Blood pressure (primary outcome); secondary outcomes of diet, weight, and dietary biomarkers (urinary sodium:potassium (Na:K) ratio; carotenoid concentrations).

RESULTS

Blood pressure was not affected by the booklet (mean difference (diastolic blood pressure) at one month 0.2, 95% confidence interval 1.6 to 2.0), salt (0.13; 1.7 to 2.0), or prompts (0.52; 1.3 to 2.4). The salt decreased Na:K ratio (difference 0.32; 0.08 to 0.56, P = 0.01), and the prompts helped control weight (difference 0.39 (0.85 to 0.05) kg at one month, P = 0.085; 1.2 (0.1 to 2.25) kg at six months, P = 0.03). Among those with lower fruit and vegetable consumption (< 300 g per day), prompts increased fruit and vegetable consumption and also carotenoid concentrations (difference 143 (16 to 269) mmol/l, P < 0.03) but did not decrease blood pressure.

CONCLUSION

During watchful waiting, over and above the effect of brief advice and monitoring, an information booklet, lifestyle prompts, and low sodium salt do not reduce blood pressure. Secondary analysis suggests that brief interventions-particularly lifestyle prompts-can make useful changes in diet and help control weight, which previous research indicates are likely to reduce the long term risk of stroke.

Stress and dietary practices in adolescents

Baseline data from the Health and Behavior in Teenagers Study (HABITS) were used to investigate associations between stress and dietary practices in a socioeconomically and ethnically diverse sample of 4,320 schoolchildren (mean age = 11.83 years). Male (n = 2,578) and female (n = 1,742) pupils completed questionnaire measures of stress and 4 aspects of dietary practice (fatty food intake, fruit and vegetable intake, snacking, and breakfast consumption) and also provided demographic and anthropometric data. Multivariate analyses revealed that greater stress was associated with more fatty food intake, less fruit and vegetable intake, more snacking, and a reduced likelihood of daily breakfast consumption. These effects were independent of individual (gender, weight) and social (socioeconomic status, ethnicity) factors. Stress may contribute to long-term disease risk by steering the diet in a more unhealthy direction.

Sex differences in fruit and vegetable intake in older adults

Fruits and vegetables are important components of a healthy diet, but intakes in most Western countries are well below the recommended five servings a day. Men in particular are eating too little. The aim of this study is to understand the processes underlying this gender difference. Fruit and vegetable intake, nutrition knowledge, taste preferences, attitudes to fruit and vegetable intake, and dieting status, were assessed in a simple questionnaire in 1,024 older adults attending population-based cancer screening across the UK. The results confirmed the pattern of men consuming fewer servings of fruit and vegetables daily than women (2.52 vs 3.47; p<0.01). Fewer men than women knew the current recommendations for fruit and vegetable intake, and fewer were aware of the links between fruit and vegetable consumption and disease prevention. Women rated their liking for vegetables but not fruit higher, and there were no differences in attitudes. Men were less likely to be dieting to lose weight. Multivariate analysis showed that the gender difference in intake was substantially attenuated by controlling for nutrition knowledge. There were no significant attenuating effects of preferences, attitudes or dieting status. These results indicate that men's poorer nutrition knowledge explains a significant part of their lower intake of fruit and vegetables.

Relative validity of a diet history interview in an intervention trial manipulating dietary fat in the management of Type II diabetes mellitus

BACKGROUND

This study assesses the relative validity of a diet history interview in 56 free-living individuals with Type II diabetes mellitus.

METHODS

The diet history interview was compared to a 3-day food record in a 1-year dietary intervention trial. The plausibility of energy intake data was examined throughout the trial. Paired data were compared for differences and the presence of systematic error was determined by Bland Altman analysis. Changes in accuracy and responsiveness were assessed over time.

RESULTS

The proportion of underreporters was larger in the diet history at baseline. Underrecording with the food record was more common in subjects with BMIs > 30 kg/m(2). There was no difference between paired dietary data from the two methods; however, data on fatty acids failed to correlate. These correlations improved when outliers were removed. There was no evidence of a relationship between bias and mean intake of dietary variables. Accuracy of diet history measurement did not change during the trial for energy or macronutrients, but data on protein and monounsaturated fat were both affected by BMI. The diet history was more responsive than the food record to changes in monounsaturated fatty acid intake after 3 months, but this changed at the end of the trial.

CONCLUSION

The diet history provided good estimates of energy and macronutrient intakes in a sample group with Type II diabetes mellitus. However, energy intake data revealed a high prevalence of underreporting especially in people with higher BMIs.

Estimation of fruit and vegetable intake using a two-item dietary questionnaire: a potential tool for primary health care workers

BACKGROUND AND AIM

High fruit and vegetable intake is associated with health benefits for cancer and cardiovascular disease. An increase is therefore integral in recommendations for the prevention of chronic disease. However, measuring intake requires either extensive dietary assessment or the measurement of specific bio-markers which is neither cheap nor feasible for the routine assessment of an individual's diet in a community or primary care setting. Within the context of a study evaluating a dietary counselling programme to increase fruit and vegetable intake our aim was to assess the use of a simple tool to estimate fruit and vegetable intake.

METHODS AND RESULTS

We studied associations between bio-markers [plasma ascorbic acid, beta-carotene and alpha-tocopherol 24-hour urinary potassium excretion] and a two-item fruit and vegetable consumption questionnaire in 271 subjects (105 men and 166 women), aged 18 to 70 years. After controlling for age, sex, vitamin supplement use, smoking and body mass, those reporting a daily intake of > or = 5 portions of fruit and vegetables had higher potassium excretion (difference 15.6 [95% confidence interval: 6.2 to 25.0] mmol/24 h), urinary potassium/creatinine ratio (1.2 [0.5 to 2.0]) and plasma vitamin C (10.0 [-0.9 to 20.8] mumol/L) than those reporting < or = 2.5 portions per day. beta-carotene (p = 0.04), vitamin C (p = 0.01) and potassium excretion (p < 0.001) were associated with fruit rather than vegetable intake. The two-item questionnaire had high specificity; over 3/4 of participants who reported low intake also had bio-markers below the upper third of the distribution.

CONCLUSION

Self report of fruit and vegetable intake through a simple questionnaire is confirmed by bio-markers for those eating less than five portions of fruit and vegetables a day. Although the tool is amenable to improvements for the detection of vegetable portions, it may prove useful for monitoring dietary preventive approaches in primary care without the use of invasive and costly biochemical measurements.

Development, validation and utilisation of food-frequency questionnaires - a review

OBJECTIVE

The purpose of this review is to provide guidance on the development, validation and use of food-frequency questionnaires (FFQs) for different study designs. It does not include any recommendations about the most appropriate method for dietary assessment (e.g. food-frequency questionnaire versus weighed record).

METHODS

A comprehensive search of electronic databases was carried out for publications from 1980 to 1999. Findings from the review were then commented upon and added to by a group of international experts.

RESULTS

Recommendations have been developed to aid in the design, validation and use of FFQs. Specific details of each of these areas are discussed in the text.

CONCLUSIONS

FFQs are being used in a variety of ways and different study designs. There is no gold standard for directly assessing the validity of FFQs. Nevertheless, the outcome of this review should help those wishing to develop or adapt an FFQ to validate it for its intended use.

Interventions for preventing obesity in children

BACKGROUND

The prevalence of obesity and overweight is increasing in both adult and child populations throughout the world. Obesity in children impacts on their health in both the short and longer term, and obesity prevention is an international public health priority. However, the efficacy of prevention strategies is poorly understood.

OBJECTIVES

To assess the effectiveness of educational, health promotion and/or psychological/family/behavioural therapy/counselling/management interventions that focussed on diet, physical activity and/or lifestyle and social support, and were designed to prevent obesity in childhood.

SEARCH STRATEGY

The following databases were searched: MEDLINE, Psyclit, EMBASE, Science Citation Index, Social Science Citation Index, CINAHL, Cochrane Controlled Trials Register (CCTR) and the Cochrane Heart Group's specialised register from 1985 to July 2001. Non English language papers were included. Experts were contacted to seek additional references or unpublished studies.

SELECTION CRITERIA

RCTs and non-randomised trials with concurrent control group that observed participants for a minimum of three months were included

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten studies were included; seven were long-term (children observed for at least one year), three were shorter term (at least 3 months). Eight were school/nursery-based interventions, one was a community-based intervention targeting low-income African-American families, and one was a family-based intervention that targeted non-obese children of obese parents. The studies included were diverse in terms of study design and quality, target population, theoretical underpinning of intervention approach, and outcome measures, so it was not possible to combine study findings using statistical methods. Three of the four long-term studies that combined dietary education and physical activity interventions resulted in no difference in overweight, whereas one study reported an improvement in favour of the intervention group. In two studies of dietary education alone, a multimedia action strategy appeared to be effective but other strategies did not. The one long term study that only focussed on physical activity resulted in a slightly greater reduction in overweight in favour of the intervention group, as did two short term studies of physical activity.

REVIEWER'S CONCLUSIONS

There is limited high quality data on the effectiveness of obesity prevention programs and no generalisable conclusions can be drawn. However, concentration on strategies that encourage reduction in sedentary behaviours and increase in physical activity may be fruitful. The need for well-designed studies that examine a range of interventions remains a priority, although a number of important studies are underway.

The correlates of dietary intake among HIV-positive adults

BACKGROUND

Dietary adequacy, as distinct from weight loss, has not been examined thoroughly in a diverse cohort of HIV-infected individuals.

OBJECTIVE

An analysis was undertaken to determine the correlates of inadequate dietary intake among HIV-infected adults.

DESIGN

In a cross-sectional study of 463 men and 170 women (aged 21-70 y) with HIV infection, dietary adequacy was evaluated by using 3-d diet records.

RESULTS

Among nondieting males, whites had higher energy intakes than did nonwhites. Injection drug users consumed less energy than did nonusers. Among nondieting females, only the absence of nausea and vomiting was marginally associated with higher energy intakes. Inadequate energy intake, which occurred in 38% of this population, was independently associated with female sex among nondieters. A significant proportion of the study cohort (52%) was consuming less than the recommended dietary allowance of vitamin A. Inadequate protein intake, found in 11% of the study population, occurred more often in females, those without a caregiving adult in the household, and individuals with reduced appetite. A considerable proportion of the participants (23%) reported that they were dieting to lose weight.

CONCLUSIONS

Dietary inadequacy was strongly correlated with being in the sociodemographic groups that are at heightened risk of adverse clinical outcomes. It may be worthwhile to study dietary intake as a potential determinant of the clinical outcomes of HIV infection.

Psychosocial, lifestyle, and health status variables in predicting high attendance among adults

BACKGROUND

Increasing consultation rates have implications for the organisation of health services, the quality of care, and understanding the decision to consult. Most quantitative studies have concentrated on very high attenders--not those attending five or more times a year, who are responsible for most (60%) consultations--and have assessed neither the role of lifestyle nor patients' attitudes.

AIMS

To assess associations with higher than average attendance (five or more times ayear).

DESIGN OF STUDY

Postal questionnaire sent to a random sample.

SETTING

Four thousand adults (one per household) from six general practices.

METHOD

Data were analysed to identify predictors significantly associated with higher than average attendance.

RESULTS

The response rate was 74%. Sef-reported attendance agreed with the notes (r = 0.80, likelihood ratio for a positive test = 9.4). Higher attendance was independently predicted by the severity of ill health (COOP score = 0-7, 8-9, and 10+; adjusted odds ratios= 1, 1.72, 1.91 respectively; test for trend P<0.001) and the number of reported medical problems (COOP score = 0, 1, 2, and 3+ respectively; adjusted ORs = 1, 2.05, 2.31, 4.29; P<0.001). After controlling for sociodemographic variables, medical problems, the severity of physical ill health, and other confounders, high attendance was more likely in those with medically unexplained somatic symptoms (0, 1-2, 3-5, and 6+ symptoms respectively, ORs = 1, 1.15, 1.48, and 1.62; P<0.001); health anxiety (Whitely Index = 0, 1-5, 6-7 and 8+ respectively, ORs = 1, 1.22, 1.77, and 2.78; P<0.001); and poor perceived health ('very good', 'good', 'poor' respectively, ORs = 1, 1.61, and 2.93; P<0.001). Attendance was less likely in those with negative attitudes to repeated surgery use (OR = 0.61, 95% CI = 0.47-0.78), or to doctors (Negdoc scale <18, 18-20, and 21+ respectively; ORs = 1, 0.87, 0.67; P<0.001), in those usually trying the pharmacy first (OR = 0.61, 95% CI 0.48-0.78), and those consuming alcohol (0, 1, 2, 3+ units/day respectively; ORs = 1, 0.62, 0.41, 0.29; P<0.001). Anxiety or depression predicted perceived health, unexplained symptoms, and health anxiety.

CONCLUSION

Strategies to manage somatic symptoms, health anxiety, dealing with the causes of--or treating--anxiety and depression, and encouraging use of the pharmacy have the potential both to help patients manage symptoms and in the decision to consult. Sensitivity to the psychological factors contributing to the decision to consult should help doctors achieve a better shared understanding with their patients and help inform appropriate treatment strategies.

The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease

OBJECTIVES

This study assessed stages of change in fat intake, physical activity, and cigarette smoking during a randomized controlled trial of behavioral counseling.

METHODS

Twenty general practices (primary health care centers) were randomized to lifestyle counseling by behavioral methods or to usual health promotion. A total of 883 patients were selected for the presence of 1 or more of the following risk factors: cigarette smoking, high cholesterol, or a combination of a high body mass index and low physical activity. Stage of change (precontemplation, contemplation, preparation, and action/maintenance) was assessed at baseline and after 4 and 12 months.

RESULTS

The odds of moving to action/maintenance for behavioral intervention vs control patients at 4 months were 2.15 (95% confidence interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The likelihood of achieving action/maintenance was related to baseline stage for all 3 behaviors.

CONCLUSIONS

Brief behavioral counseling based on advice matched to stage of readiness for change may be valuable in encouraging healthy lifestyles among patients in primary care at raised risk of cardiovascular disease.