Anne N. Thorndike

A 2-Phase Labeling and Choice Architecture Intervention to Improve Healthy Food and Beverage Choices

OBJECTIVES We assessed whether a 2-phase labeling and choice architecture intervention would increase sales of healthy food and beverages in a large hospital cafeteria. METHODS Phase 1 was a 3-month color-coded labeling intervention (red = unhealthy, yellow = less healthy, green = healthy). Phase 2 added a 3-month choice architecture intervention that increased the visibility and convenience of some green items. We compared relative changes in 3-month sales from baseline to phase 1 and from phase 1 to phase 2. RESULTS At baseline (977,793 items, including 199,513 beverages), 24.9% of sales were red and 42.2% were green. Sales of red items decreased in both phases (P < .001), and green items increased in phase 1 (P < .001). The largest changes occurred among beverages. Red beverages decreased 16.5% during phase 1 (P < .001) and further decreased 11.4% in phase 2 (P < .001). Green beverages increased 9.6% in phase 1 (P < .001) and further increased 4.0% in phase 2 (P < .001). Bottled water increased 25.8% during phase 2 (P < .001) but did not increase at 2 on-site comparison cafeterias (P < .001). CONCLUSIONS A color-coded labeling intervention improved sales of healthy items and was enhanced by a choice architecture intervention.

Traffic-Light Labels and Choice Architecture Promoting Healthy Food Choices

BACKGROUND Preventing obesity requires maintenance of healthy eating behaviors over time. Food labels and strategies that increase visibility and convenience of healthy foods (choice architecture) promote healthier choices, but long-term effectiveness is unknown. PURPOSE Assess effectiveness of traffic-light labeling and choice architecture cafeteria intervention over 24 months. DESIGN Longitudinal pre-post cohort follow-up study between December 2009 and February 2012. Data were analyzed in 2012. SETTING/PARTICIPANTS Large hospital cafeteria with a mean of 6511 transactions daily. Cafeteria sales were analyzed for (1) all cafeteria customers and (2) a longitudinal cohort of 2285 hospital employees who used the cafeteria regularly. INTERVENTION After a 3-month baseline period, cafeteria items were labeled green (healthy); yellow (less healthy); or red (unhealthy) and rearranged to make healthy items more accessible. MAIN OUTCOME MEASURES Proportion of cafeteria sales that were green or red during each 3-month period from baseline to 24 months. Changes in 12- and 24-month sales were compared to baseline for all transactions and transactions by the employee cohort. RESULTS The proportion of sales of red items decreased from 24% at baseline to 20% at 24 months (p<0.001), and green sales increased from 41% to 46% (p<0.001). Red beverages decreased from 26% of beverage sales at baseline to 17% at 24 months (p<0.001); green beverages increased from 52% to 60% (p<0.001). Similar patterns were observed for the cohort of employees, with the largest change for red beverages (23%-14%, p<0.001). CONCLUSIONS A traffic-light and choice architecture cafeteria intervention resulted in sustained healthier choices over 2 years, suggesting that food environment interventions can promote long-term changes in population eating behaviors.

Depressive Symptoms and Smoking Cessation After Hospitalization for Cardiovascular Disease

BACKGROUND Although smoking cessation is essential for prevention of secondary cardiovascular disease (CVD), many smokers do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. We hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital. METHODS This was a planned secondary analysis of data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up. The effect of depressive symptoms on smoking cessation was assessed using multiple logistic regression and survival analyses. RESULTS Twenty-two percent of smokers had moderate to severe depressive symptoms (BDI >or= 16) during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge (P= .007; incidence rate ratio, 2.40; 95% confidence interval, 1.48-3.78) than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37% vs 15%; adjusted odds ratio, 3.02; 95% confidence interval, 1.28-7.09) and 1-year follow-up (27% vs 10%; adjusted odds ratio, 3.77; 95% confidence interval, 1.31-10.82). We estimate that 27% of the effect of the BDI score on smoking cessation was mediated by nicotine withdrawal symptoms. CONCLUSIONS Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. The relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.

Physicians' missed opportunities to address tobacco use during prenatal care

Smoking cessation during pregnancy reduces the risk of adverse perinatal outcomes and leads to long-term cessation for at least some women smokers. Prenatal care offers repeated opportunities for smoking status identification and smoking cessation counseling. Using cross-sectional data from the 1991-1996 National Ambulatory Medical Care Survey, we assessed how frequently physicians caring for pregnant women identified pregnant womens smoking status and provided counseling to pregnant smokers. Data were available from 793 physicians reporting on 5,622 office visits by pregnant patients from 1991 through 1996. Physicians identified pregnant womens smoking status at 81% of visits but provided smoking counseling at only 23% of visits by pregnant smokers. Physicians were less likely to identify smoking status of non-White pregnant women but no less likely to counsel non-White smokers. These results indicate a clear need to improve quality of care provided to pregnant women who use tobacco.

Prevention of Weight Gain Following a Worksite Nutrition and Exercise Program: A Randomized Controlled Trial

BACKGROUND Many employers are now providing wellness programs to help employees make changes in diet and exercise behaviors. Improving health outcomes and reducing costs will depend on whether employees sustain lifestyle changes and maintain a healthy weight over time. PURPOSE To determine if a 9-month maintenance intervention immediately following a 10-week worksite exercise and nutrition program would prevent regain of the weight lost during the program. DESIGN RCT. SETTING/PARTICIPANTS In 2008, a total of 330 employees from 24 teams completed a 10-week exercise and nutrition program at a large hospital worksite and were randomized by team to maintenance or control (usual care) for 9 months. INTERVENTION Internet support with a website for goal-setting and self-monitoring of weight and exercise plus minimal personal support. MAIN OUTCOME MEASURES Weight loss, percentage weight loss, time spent in physical activity, and frequency of consumption of fruits/vegetables, fatty foods, and sugary foods at 1 year compared to baseline. One-year follow-up was completed in 2010, and data were analyzed in 2011. RESULTS At 1 year, 238 subjects (72%) completed follow-up assessments. Mean baseline BMI was 27.6 and did not differ between intervention and control. Compared to baseline, both groups lost weight during the 10-week program and maintained 65% of weight loss at 1 year (p<0.001). There was no difference in weight loss between groups at the end of the 10-week program (4.8 lbs vs 4.3 lbs, p=0.53 for group X time interaction) or end of maintenance at 1 year (3.4 lbs vs 2.5 lbs, p=0.40 for group X time interaction). All subjects had improvements in physical activity and nutrition (increased fruits/vegetables and decreased fat and sugar intake) at 1 year but did not differ by group. CONCLUSIONS An intensive 10-week team-based worksite exercise and nutrition program resulted in moderate weight loss and improvements in diet and exercise behaviors at 1 year, but an Internet-based maintenance program immediately following the 10-week program did not improve these outcomes. TRIAL REGISTRATION This study is registered at clinicaltrials.gov NCT00707577.

Use of nicotine replacement therapy to reduce or delay smoking but not to quit: prevalence and association with subsequent cessation efforts

Objective: To assess the prevalence of nicotine replacement therapy (NRT) use for purposes other than quitting smoking and examine the relation of this non-standard NRT use (NSNRT) with subsequent smoking cessation efforts. Design: A population based cohort study of adult smokers who were interviewed by telephone at baseline (2001–2) and at two year follow-up. The association between NSNRT use to cut down on smoking or to delay smoking before baseline and cessation attempts and smoking outcomes at two year follow-up was assessed using logistic regression to adjust for multiple potential confounding factors. Setting: Massachusetts, USA. Subjects: 1712 adult smokers in Massachusetts who were selected using a random digit dial telephone survey. Main outcome measures: Quit attempt in 12 months before follow-up, NRT use at quit attempt in 12 months before follow-up, smoking cessation by follow-up, or 50% reduction in cigarettes smoked per day between baseline and follow-up. Results: 18.7% of respondents reported ever having used NSNRT. In a multiple logistic regression analysis, there was no statistically significant association between past NSNRT use and quit attempts (ORcut down  = 0.89, 95% CI 0.59 to 1.33; ORdelay  = 1.29, 95% CI 0.73 to 2.29), smoking cessation (ORcut down  = 0.74, 95% CI 0.43 to 1.24; ORdelay  = 1.22, 95% CI 0.60 to 2.50) or 50% reduction in cigarettes smoked per day (ORcut down  = 0.93, 95% CI 0.62 to 1.38; ORdelay  = 0.80, 95% CI 0.43 to 1.49) at follow-up. Past use of NRT to cut down on cigarettes was associated with use of NRT at a follow-up quit attempt (ORcut down  = 2.28, 95% CI 1.50 to 3.47) but past use of NRT to delay smoking was not (ORdelay  = 1.25, 95% CI 0.67 to 2.34). Conclusions: Use of NRT for reasons other than quitting smoking may be more common than was previously estimated. This population based survey finds no strong evidence that NRT use for purposes other than quitting smoking is either harmful or helpful.

Participation and cardiovascular risk reduction in a voluntary worksite nutrition and physical activity program

OBJECTIVE In a cohort of employees participating in a worksite nutrition and physical activity program, we compared program completion and changes in cardiovascular risk factors by baseline body mass index. METHODS In 2007, 774 employees enrolled in a 10 week program at a hospital in Boston, Massachusetts. Program completion and change in weight, cholesterol, and blood pressure were compared between obese (body mass index≥30), overweight (body mass index=25-29.9), and normal weight (body mass index<25) participants. RESULTS At baseline, 63% were obese or overweight and had higher blood pressure and cholesterol compared to normal weight participants. Program completion was 82% and did not differ by body mass index. Mean weight loss was 1.9 kg at end of program (p<0.001) and 0.4 kg at 1 year (p=0.002). At end of program, participants with body mass index≥30 lost 3.0% body weight vs. 2.7% for body mass index=25-29.9 and 1.7% for body mass index<25 (p<0.001), but weight loss at 1 year did not differ by body mass index. Mean cholesterol and blood pressure were lower at end of program and 1 year (all, p<0.005) but did not differ by body mass index. CONCLUSIONS Worksite programs can successfully initiate cardiovascular risk reduction among employees, but more intensive interventions are needed to make significant improvements in the health of higher risk obese employees.

Activity monitor intervention to promote physical activity of physicians-in-training: randomized controlled trial.

Background Physicians are expected to serve as role models for healthy lifestyles, but long work hours reduce time for healthy behaviors. A hospital-based physical activity intervention could improve physician health and increase counseling about exercise. Methods We conducted a two-phase intervention among 104 medical residents at a large hospital in Boston, Massachusetts. Phase 1 was a 6-week randomized controlled trial comparing daily steps of residents assigned to an activity monitor displaying feedback about steps and energy consumed (intervention) or to a blinded monitor (control). Phase 2 immediately followed and was a 6-week non-randomized team steps competition in which all participants wore monitors with feedback. Phase 1 outcomes were: 1) median steps/day and 2) proportion of days activity monitor worn. The Phase 2 outcome was mean steps/day on days monitor worn (≥500 steps/day). Physiologic measurements were collected at baseline and study end. Median steps/day were compared using Wilcoxon rank-sum tests. Mean steps were compared using repeated measures regression analyses. Results In Phase 1, intervention and control groups had similar activity (6369 vs. 6063 steps/day, p = 0.16) and compliance with wearing the monitor (77% vs. 77% of days, p = 0.73). In Phase 2 (team competition), residents recorded more steps/day than during Phase 1 (Control: 7,971 vs. 7,567, p = 0.002; Intervention: 7,832 vs. 7,739, p = 0.13). Mean compliance with wearing the activity monitor decreased for both groups during Phase 2 compared to Phase 1 (60% vs. 77%, p<0.001). Mean systolic blood pressure decreased (p = 0.004) and HDL cholesterol increased (p<0.001) among all participants at end of study compared to baseline. Conclusions Although the activity monitor intervention did not have a major impact on activity or health, the high participation rates of busy residents and modest changes in steps, blood pressure, and HDL suggest that more intensive hospital-based wellness programs have potential for promoting healthier lifestyles among physicians. Trial Registration Clinicaltrials.gov NCT01287208.

A tragic triad: coronary artery disease, nicotine addiction, and depression.

Purpose of review Despite the availability of multiple resources for treating smoking in patients with cardiovascular disease (CVD) and the well known risks of continued smoking, a majority of smokers resume smoking after hospitalization for acute CVD. Depression is common among patients with CVD and is associated with failure to follow recommendations to reduce cardiac risk. This review examines the complex relationship between smoking and depression in patients with CVD and current evidence for treating this triad. Recent findings The prevalence of depressive symptoms among smokers hospitalized with CVD is 22–24%. Smokers with depressive symptoms are more likely to return to smoking after hospital discharge compared with nondepressed smokers. Stronger nicotine withdrawal symptoms among the depressed smokers contribute to relapse. Secondary analyses suggest that bupropion SR and cognitive behavioral therapy may be effective treatments for smokers with depression and CVD. A systematic review of smoking interventions in hospitalized patients found that only intensive counseling interventions with follow-up for more than 1 month were effective for smokers with CVD. Summary Clinicians should consider screening all smokers with CVD for depression, particularly during hospitalization for an acute event. Smokers hospitalized with CVD need intensive counseling lasting more than 1 month after discharge, and smokers with depressive symptoms need even more prolonged treatment for quitting. The addition of pharmacotherapy to long-term counseling has the potential to further improve cessation rates.

Food-and-beverage environment and procurement policies for healthier work environments.

The importance of creating healthier work environments by providing healthy foods and beverages in worksite cafeterias, in on-site vending machines, and at meetings and conferences is drawing increasing attention. Large employers, federal and state governments, and hospital systems are significant purchasers and providers of food and beverages. The American Heart Association, federal government, and other organizations have created procurement standards to guide healthy purchasing by these entities. There is a need to review how procurement standards are currently implemented, to identify important minimum criteria for evaluating health and purchasing outcomes, and to recognize significant barriers and challenges to implementation, along with success stories. The purpose of this policy paper is to describe the role of food-and-beverage environment and procurement policy standards in creating healthier worksite environments; to review recently created national model standards; to identify elements across the standards that are important to consider for incorporation into policies; and to delineate issues to address as standards are implemented across the country.