Julie T. Schaefer

A Review of Interventions that Promote Eating by Internal Cues

Traditional diet programs that encourage individuals to consciously restrict their dietary intake have not only been ineffective in terms of weight outcomes, but have also been counterproductive, promoting psychological distress and unhealthy eating behaviors. Nondiet approaches shift the focus away from weight outcomes to the improvement of health outcomes and psychological well-being. One such approach, intuitive eating, promotes dietary intake based on internal cues of hunger and fullness, body acceptance, and making behavior choices based on health as well as enjoyment. Several studies have implemented such ideas into intervention programs. The purpose of our review was to examine the physical and psychological effects of these programs. Twenty interventions were identified. Overall, studies had positive results, demonstrating improvements in eating habits, lifestyle, and body image as measured by dietary restraint, restrictive dieting, physical activity, body satisfaction, and drive for thinness. Participants also experienced improved psychological health as measured by depression, ineffectiveness, anxiety, self-esteem, negative affect, and quality of life. Several improvements were sustained through follow-up periods as long as 2 years. Completion rates were as high as 92% in nondieting groups. In addition, improvements in eating behaviors and maintaining a nondiet approach, increased self-esteem, and decreased body dissatisfaction were sustained long-term. Overall, studies that encourage individuals to eat intuitively help participants abandon unhealthy weight control behaviors, improve metabolic fitness, increase body satisfaction, and improve psychological distress. Results from our review favor the promotion of programs that emphasize a nonrestrictive pattern of eating, body acceptance, and health rather than weight loss.

Cognitive Function in Heart Failure Is Associated With Nonsomatic Symptoms of Depression But Not Somatic Symptoms.

Background:Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others. Objective:The aim of this study was to identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF. Methods:Participants were 326 HF patients (40.5% women, 26.7% non-white race-ethnicity, aged 68.6 ± 9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnaire-9. Somatic and nonsomatic subscale scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and clinical factors were conducted. Results:Regressions revealed that Patient Health Questionnaire-9 total was associated with attention (&bgr; = −.14, P = .008) and executive function (&bgr; = −.17, P = .001). When analyzed separately, the nonsomatic subscale, but not the somatic symptoms subscale (P values ≥ .092), was associated with attention scores (&bgr; = −.15, P = .004) and memory (&bgr; = −.11, P = .044). Both nonsomatic (&bgr; = −.18, P < .001) and somatic (&bgr; = −.11, P = .048) symptoms were related to executive function. When included together, only the nonsomatic symptom cluster was associated with attention (&bgr; = −.15, P = .020) and executive function (&bgr; = −.19, P = .003). Conclusions:Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression. Clinical Implications:These findings suggest that screening explicitly for nonsomatic depressive symptoms may be warranted and that the mechanisms underlying the depression-cognitive function relationship in HF are not solely related to sleep or appetite disturbance. Thus, interventions that target patients’ somatic symptoms only (eg, poor appetite or fatigue) may not yield maximum cognitive benefit compared with a comprehensive treatment that targets depressed mood, anhedonia, and other nonsomatic symptoms.

Association Between Poorer Cognitive Function and Reduced Objectively Monitored Medication Adherence in Patients With Heart Failure.

Background—Subclinical cognitive impairment is prevalent in heart failure (HF); however, its role in important clinical outcomes, such as HF treatment adherence, is unclear. Given the complex polypharmacy in HF treatment, cognitive deficits may be important in predicting medication management. Thus, the objective of the current study was to examine the impact of cognitive function on medication adherence among community-dwelling patients with HF using objective assessments. Methods and Results—A prospective observational cohort design of 309 community-dwelling patients with HF (59.7% male, 68.7±9.7 years) and no history of dementia or neurological disease. Cognition was assessed using a neuropsychological battery at baseline. Medication adherence was objectively measured for 21 days using an electronic pillbox. Regression analyses tested whether attention, executive function, or memory predicted 21-day medication adherence. In unadjusted analyses, lower scores on all 3 cognitive domains predicted poorer medication adherence (&bgr;=0.52–85; P=0.001–0.009). After adjusting for demographic, clinical, and psychosocial variables, memory continued to predict medication adherence (&bgr;=0.51; P=0.008), whereas executive function (&bgr;=0.24; P=0.075) and attention were no longer a predictor (&bgr;=0.34; P=0.131). Conclusions—Poorer cognitive function, especially in regard to memory, predicted reduced medication adherence among patients with HF and no history of dementia. This effect remained after adjustment for factors known to predict adherence, such as depressed mood, social support, and disease severity level. Future studies should examine the link from cognitive impairment and medication nonadherence to clinical outcomes (eg, hospitalization and mortality). Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01461629.

Social Support From the Athletic Trainer and Symptoms of Depression and Anxiety at Return to Play

CONTEXT Few empirical studies have examined social support from athletic trainers (ATs) and its buffering effect during injury recovery. OBJECTIVE To examine the effect of social support received from ATs during injury recovery on reported symptoms of depression and anxiety at return to play among a cohort of collegiate athletes. DESIGN Cohort study. SETTING Two Big 10 Conference universities. PATIENTS OR OTHER PARTICIPANTS A total of 594 injuries sustained by 387 collegiate athletes (397 injuries by 256 males, 197 injuries by 131 females) on 9 sports teams. MAIN OUTCOME MEASURE(S) Data were collected during the 2007-2011 seasons. Social support was measured using the 6-item Social Support Questionnaire. Symptoms of depression were assessed using the Center for Epidemiological Studies Depression Scale. Anxiety was measured by the State-Trait Anxiety Inventory. We used generalized estimation equation regression models to examine the effect of the social support from ATs on the odds of symptoms of depression and anxiety at return to play. RESULTS In 84.3% (n = 501) of injury events, injured athletes received social support from ATs during their recovery. Of these, 264 (53.1%) athletes reported being very satisfied with this social support. Whether or not athletes received social support from ATs during recovery did not affect the symptoms of depression or anxiety experienced at return to play. However, compared with athletes who were dissatisfied with the social support received from ATs, athletes who were very satisfied or satisfied with this social support were 87% (95% confidence interval = 0.06, 0.30) and 70% (95% confidence interval = 0.13, 0.70) less likely to report symptoms of depression at return to play, respectively. Similar results were observed for anxiety. CONCLUSIONS Our findings support the buffering effect of social support from ATs and have important implications for successful recovery in both the physical and psychological aspects for injured athletes.

What is your patient's cognitive profile? Three distinct subgroups of cognitive function in persons with heart failure

PURPOSE The aim of this study was to determine whether patients with heart failure (HF) have distinct profiles of cognitive impairment. BACKGROUND Cognitive impairment is common in HF. Recent work found three cognitive profiles in HF patients-(1) intact, (2) impaired, and (3) memory-impaired. We examined the reproducibility of these profiles and clarified mechanisms. METHODS HF patients (68.6 ± 9.7 years; N=329) completed neuropsychological testing. Composite scores were created for cognitive domains and used to identify clusters via agglomerative-hierarchical cluster analysis. RESULTS A 3-cluster solution emerged. Cluster 1 (n=109) had intact cognition. Cluster 2 (n=123) was impaired across all domains. Cluster 3 (n=97) had impaired memory only. Clusters differed in age, race, education, SES, IQ, BMI, and diabetes (ps ≤ .026) but not in mood, anxiety, cardiovascular, or pulmonary disease (ps ≥ .118). CONCLUSIONS We replicated three distinct patterns of cognitive function in persons with HF. These profiles may help providers offer tailored care to patients with different cognitive and clinical needs.

The association between cognitive function and objective adherence to dietary sodium guidelines in patients with heart failure

Background Although cognitive impairment is common in heart failure (HF) patients, its effects on sodium adherence recommendations are unknown. Purpose Our aim is to examine if cognitive function is associated with patient sodium adherence. Methods Sodium collection/excretion and cognitive function were assessed for 339 HF patients over a 5–8-week period. Neuropsychological testing was performed at baseline (Visit 1), whereas two 24-hour urine samples were collected within 7 weeks postbaseline. The ability to collect two 24-hour urine samples and the estimation of sodium excretion levels from these samples were used to estimate sodium adherence recommendations. Results Nearly half (47%) of the study participants (n=159) were unable to give two valid 24-hour urine samples. Participants who were unable to adhere to two valid 24-hour urine samples had significantly poorer attention and global cognition tests (P<0.044), with a trend for poorer executive function (P=0.064). Among those with valid samples, urine sodium level was not associated with global cognitive function, attention, executive function, or memory after adjusting for covariates. Female sex was associated with lower sodium excretion (all P<0.01); individuals with knowledge of sodium guidelines had less intake of sodium, resulting in excretion of less sodium (all P≤0.03). Conversely, higher socioeconomic status (SES) and body mass index (BMI) were associated with greater sodium (all P≤0.02 and P≤0.01). Conclusion Adherence to urine sodium collection was poor, especially among those with poorer cognitive function. Sodium consumption exceeded recommended amounts and was unrelated to cognitive function. Interventions for improving sodium adherence should focus on at-risk groups (high SES and BMI) and at improving knowledge of recommended salt intake.

Cognitive Function Predicts Risk for Clinically Significant Weight Gain in Adults With Heart Failure

Background: Few investigators have examined whether cognitive deficits predict poorer self-care of weight management recommendations and weight gain in adults with heart failure. Objective: The purposes of this study were (1) to examine whether cognition is associated with adherence to daily weighing and weight gain incidence and (2) to explore self-reported symptom perception and management when a weight increase occurs. Methods: In this observational study, participants completed neuropsychological testing, were given an electronic scale, and were instructed to record their weight for 21 days. Data for 301 participants were collected at baseline and 3 weeks after weight monitoring. Results: At baseline, only 35% of the enrolled respondents knew when to call their physician for increased weight gain, and 37% of the analyzed sample (n = 110/301) experienced a clinically significant weight gain. Regressions tested whether baseline attention, executive function, or memory predicted adherence to daily weighing and the likelihood of weight gain incidence. In unadjusted and adjusted covariate analyses, none of the cognitive domains predicted adherence to daily weighing (P ≥ .375); however, all 3 cognitive domains predicted an increased risk of a clinically significant weight gain (P ⩽ .05). Importantly, 65% of participants with a weight gain did not identify this symptom on self-report questions. Conclusions: Although cognitive deficits are not associated with adherence to daily weighing, adults with cognitive deficits may be at an increased risk for experiencing a clinically significant weight gain, and most do not perceive symptoms. Clinical Implications: Adults with heart failure require more than directions on self-care related to weight monitoring.

Validation of an instrument to measure registered dietitians'/nutritionists' knowledge, attitudes and practices of an intuitive eating approach.

OBJECTIVE The purpose of the present study was to develop and assess the construct validity of a tool to measure knowledge, attitudes and practices of registered dietitians/nutritionists (RD/N) regarding an intuitive eating lifestyle. DESIGN Cross-sectional study design that utilized a survey administered to a random sample and remaining full population of RD/N. SETTING A national survey conducted via online survey software. SUBJECTS A random sample of 10 % of all RD/N in the USA (n 8834) was invited to participate. Survey completion rate was 22·2 % (n 1897). After initial validation, the survey was distributed to the remaining 90 % of RD/N to confirm validation. RESULTS After removing items with insufficient factor loadings, results were consistent with a four-factor solution: (i) knowledge of intuitive eating; (ii) attitudes towards intuitive eating; (iii) traditional and restrictive practices; and (iv) non-restrictive and intuitive eating practices. Confirmatory factor analysis provided further evidence of the validity of the four factors and the factors had strong reliability. CONCLUSIONS Unlike the hypothesized three-factor solution (knowledge, attitudes and practices), validation analysis revealed that the survey measures knowledge of intuitive eating, attitudes towards intuitive eating, use of traditional and restrictive weight-management practices, and use of non-restrictive and intuitive eating practices. With the landscape of weight management and health promotion undergoing a shift towards a health centred, size acceptance approach, this instrument will provide valuable information regarding the current knowledge, attitudes and practices of RD/N and other health promotion professionals.