Joan W. Rupp

A Family Approach to Cardiovascular Risk Reduction: Results from The San Diego Family Health Project:

The effectiveness of a family-based cardiovascular disease risk reduction intervention was evaluated in two ethnic groups. Participants were 206 healthy, volunteer low-to-middle-income Mexican-American and non-Hispanic white (Anglo-American) families (623 individuals), each with a fifth or a sixth-grade child. Families were recruited through elementary schools. Half of the families were randomized to a year-long educational intervention designed to decrease the whole familys intake of high salt, high fat foods, and to increase their regular physical activity. Eighty-nine percent of the enrolled families were measured at the 24-month follow-up. Both Mexican- and Anglo-American families in the experimental groups gained significantly more knowledge of the skills required to change dietary and exercise habits than did those in the control groups. Experimental families in both ethnic groups reported improved eating habits on a food frequency index. Anglo families reported lower total fat and sodium intake. There were no significant group differences in reported physical activity or in tested cardiovascular fitness levels. Significant differences for Anglo-American experimental vs. control adult subjects were found for LDL cholesterol. Significant intervention-control differences ranging from 2.2 to 3.4 mmHg systolic and/or diastolic blood pressure were found in all subgroups. Direct observation of diet and physical activity behaviors in a structured environment suggested generalization of behavior changes. There was evidence that behavior change persisted one year beyond the completion of the intervention program. It is concluded that involvement of families utilizing school based resources is feasible and effective. Future studies should focus on the most cost-effective methods of family involvement, and the potential for additive effects when family strategies are combined with other school health education programs.

Results of Language for Health: Cardiovascular Disease Nutrition Education for Latino English-as-a-Second-Language Students

This report presents the final evaluation of Language for Health, part of a federally funded initiative to develop heart disease prevention interventions for low-literate populations. Language for Health specifically intervened with recent immigrants enrolled in English-as-a-second-language classes, incorporating nutritional behavior change materials into English-language curricula. Latino participants (n = 732) were exposed to either nutrition education or stress management classes (attention-placebo group) designed specifically for low-English-literate adults. Participants completed physiological measures assessing blood pressure, total and high-density lipoprotein (HDL) cholesterol, waist and hip circumference, and weight. Self-report surveys were administered to collect students’ nutrition-related knowledge, attitudes, self-reported fat avoidance behaviors, and demographic information. Data were collected at baseline, 3-month posttest, and 6-month follow-up. Results indicated long-term effects of the intervention on nutrition knowledge and fat avoidance, yet only short-term effects on total cholesterol: HDL ratio and systolic blood pressure.

Practical nutrition assessment in primary care settings

BACKGROUND Poor dietary and physical activity habits account for 300,000 deaths per year. Interventions in the primary care setting offer promise for effecting change on a broad scale. However, to conduct counseling, primary care providers need quick, accurate, and efficient assessment tools that are practical for a health care setting. METHODS We reviewed 18 dietary measures for use in primary care that were brief (less than 50 items) and easy to administer, score, and interpret. The macronutrients assessed by the measure and the psychometric properties, if given, are reported. RESULTS In general, reliability and validity coefficients were slightly lower than more detailed instruments (i.e., food frequency questionnaires, diet recall); however, they are acceptable within this clinical setting. CONCLUSIONS Providers can benefit from using these tools to assess current dietary patterns and to guide patient counseling. Future measures should focus on additional nutritional topics (e.g., calcium deficiency) and sensitivity to change over time.

Direct observation of physical activity and dietary behaviors in a structured environment: Effects of a family-based health promotion program

The effects of cardiovascular risk reduction are typically assessed by self-reported behavior change and physiological outcomes. There is a need to enhance evaluation protocols by including direct observation measures of targeted health behaviors. To improve the evaluation of a family-based diet and physical activity change program, families were observed during a planned visit to the San Diego Zoo. This standardized environment afforded many options for dietary intake and physical activity. Thirty families who had participated in a 1-year intervention program and 30 control families were observed. Caucasian and Mexican-American families were equally represented. Observations in this standard environment discriminated between intervention and control families, and the findings indicated that intervention effects generalized to this novel setting. Intervention families consumed fewer calories, ate less sodium, and walked further than did control families. Ethnic differences were noted.

Reducing the fat content of ground beef in a school foodservice setting

OBJECTIVE The objective was to develop and test the nutrient results of a two-step defatting procedure with ground beef in a school foodservice setting as part of the Eat Smart school lunch component of the Child and Adolescent Trial for Cardiovascular Health (CATCH). SETTING AND DESIGN The procedure was tested in a school foodservice setting to determine the effect of cooking, draining, and subsequent rinsing with hot water on nutrient composition of ground beef. Samples of raw; cooked and drained; and cooked, drained, and rinsed ground beef were collected and chemically analyzed for total fat, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol, iron, and niacin content. RESULTS The results indicated that the total fat and the saturated, monounsaturated, and polyunsaturated fatty acids were significantly reduced 31% to 35% from cooking and draining (P < .005) and reduced by an additional 25% to 30% from rinsing (P < .0001). Cholesterol content was not affected. Iron content increased after the cooking and rinsing, although not significantly. Niacin content significantly decreased during rinsing by 28% (P < .005), but the mean value of the cooked, drained, and rinsed ground beef still met the criteria of the Food and Drug Administration for a good source of niacin. APPLICATION The two-step defatting procedure developed for use in a school foodservice setting lowers the total fat and saturated fatty acid content of ground beef without substantially reducing its nutritional quality.

Attendance at Health Promotion Programs: Baseline Predictors and Program Outcomes

As part of a family cardiovascular health promotion project, 111 Mexican-American and 95 Anglo-American families with fifth- or sixth-grade children were assigned to either a primary prevention program involving 18 sessions or to a control condition. This article evaluates predictors of attendance at the year long sequence of sessions in the intervention group. In addition it considers the relationship between attendance and program outcomes. Low baseline scores on physical activity and cardiovascular fitness measures were associated with higher attendance for both children and adults. High initial health knowledge and self-motivation were also associated with attendance. Multiple regression analysis showed that adult attendance was significantly predicted by a model including completion of a three-day food record, low exercise, higher socioeconomic status, family adaptability, and self-motivation. Attendance was correlated with greater knowledge gains and larger reductions in blood pressure. The results indicate that motivated families who are in greater need of conditioning attended more sessions in a health promotion program.

Relationship between self-monitoring of diet and exercise change and subsequent risk factor changes in children and adults

Self-monitoring is often used in health behaviour change programs; but it is not known to what extent self-monitoring data are valid and useful in predicting changes in cardiovascular disease (CVD) risk. Subjects included 72 Anglo adults, 68 Anglo children, 80 Mexican-American adults and 94 Mexican-American children. Subjects were families with fifth and sixth grade children who participated in an 18-session family-based diet and exercise change program designed to reduce CVD risk. During the intervention, each participant self-monitored diet and aerobic physical activity. Families were measured at baseline, 3, 12, and 24 months. For adults, self-monitored changes in diet correlated with changes in body mass index, systolic blood pressure, total cholesterol and LDL 1 and 2 years later. Correlations between self-monitored diet and diet-related risk factor changes were not observed among children. Correlations between self-monitored exercise and subsequent risk factor changes were not observed among adults. For children, self monitored changes in aerobic physical activity correlated significantly with changes in VO2Max and HDL/LDL ratio 1 and 2 years later. Thus, this study provides some support for the predictive validity of diet self-monitoring in adults and exercise self-monitoring in children.

A randomized trial of cardiovascular risk factor reduction: patterns of attrition after randomization and during follow-up.

Background The Preventive Cardiology Center compared two intensities of behavior modification for cardiovascular disease (CVD) risk factors in persons at risk and their families. Characteristics of drop-outs both before and after intervention were compared with subjects who completed the 6-month trial. Methods A total of 333 individuals of all ages were enrolled in the study and randomly assigned by family to a single-session (‘skills’ group — low-intensity) or a five-session (‘practice’ group — high intensity) intervention. Baseline and follow-up assessments included a personal and family health questionnaire, nutritional intake survey, and clinic visit to obtain blood pressure, lipids, and height and weight data. Results Two hundred and forty adults over 18 years of age were randomly assigned to one of the two intervention groups, Of these, 68 subjects (28.3%) did not participate in the intervention. Multivariate analysis revealed that these ‘early drop-outs’ were significantly more likely to be non-white and to have had a lower LDL cholesterol. Of the 172 subjects attending the intervention, 70 (40.7%) did not attend the 6-month follow-up (‘late drop-outs’), Multivariate analysis revealed that, compared with follow-up attendees, non-attendees were significantly more likely to be white and to be current smokers. Conclusions Both early and late drop-outs in a randomized trial of CVD risk reduction were significantly different than continuing participants in several key factors. These differences suggest the use of caution in both interpreting and making generalizations about behavioral trials of risk factor reduction when attrition is high.

Development of a Protocol to Assess Dietary Intake Among Hispanics who Have Low Literacy Skills in English

Hispanic adults who had low literacy in English (n = 14.3) and who attended community college English-as-a-Second-Language (ESL) classes, completed 24-hour dietary recalls using version 2.5 of the computerized Minnesota Nutrition Data System (NDS), which included many Hispanic foods. The purposes of our study were to assess the appropriateness of NDS for a Hispanic group who had low literacy in English, to describe the development and implementation of training procedures for NDS interviewers, and to discuss the special problems that occurred using the enhanced version of NDS. Further, nutrient, intakes for the study population, as calculated using NDS, were compared with nutrient estimates from the Hispanic Health and Nutrition Examination Survey (HHANES). Results suggest that version 2.5 of NDS is a useful tool for collecting dietary information for Hispanics who have low literacy in English. Challenges encountered during data collection for this study could be categorized into three types: regional differences in foods, food preparation differences, and lack of appropriate options in NDS for preparation methods. Generally, the study group and HHANES participants had similar intakes, although the study group tended to have a more healthful nutrition profile. Overall, findings indicate that NDS is a promising assessment tool for nutrition practitioners who work with Hispanics who have low literacy in English. Continued improvements to the NDS system can correct its shortcomings related to regional/ cultural food differences.

Effects of a preventive cardiology curriculum on behavioral cardiovascular risk factors and knowledge of medical students

We evaluated a Preventive Cardiology Academic Award (PCAA) program designed to integrate preventive cardiology concepts into the medical school curriculum. Diet, preventive cardiology knowledge, preventive cardiology attitudes, exercise behavior, and body mass index were compared at entrance to medical school and during the graduation year. Complete data were available on 94 students (65 men and 29 women). Similar data from students who graduated in 1987, prior to the introduction of the PCAA curriculum, served as a control. Women showed a significant enhancement in attitude towards cardiovascular disease (CVD) prevention, while both men and women significantly increased their knowledge about CVD prevention. The frequency of planned physical activity decreased significantly in both sexes and men showed a significant increase in body mass index. Men significantly reduced total calories, percent of calories from fat and saturated fat and dietary cholesterol and increased fiber intake. In women, the only significant reduction was in total calories. In comparison to the control class that did not have the program, men receiving the PCAA curriculum reduced dietary cholesterol, dietary fat, saturated fat and monounsaturated fat. Changes in these dietary parameters were nonsignificant for women in comparison to the control class women. Additional analyses showed no systematic secular trends in dietary or other variables in classes entering from 1986 to 1990. We conclude that the PCAA curriculum changes have favorably affected the preventive cardiology knowledge, attitudes and diet of medical students.