Linda Lillington

Dietary Intake and Counseling, Weight Maintenance, and the Course of HIV Infection

OBJECTIVE To define relationships among dietary intake and counseling, weight maintenance, and the clinical course of patients infected with the human immunodeficiency virus (HIV). DESIGN A prospective cohort study in an HIV clinic in a county hospital. SUBJECTS HIV-infected patients (68 with and 40 without acquired immunodeficiency syndrome [AIDS]) who had a good performance status and no chronic diarrhea were assessed at entry to the study and after 6 months. The following assessments were made: energy and nutrient intake based on 7-day food records, anthropometric measurements, immunologic function as lymphocyte T-cell subpopulations (ratio of CD4 to CD8), and serum cholesterol level. Patients were monitored to determine clinical outcome. INTERVENTION All patients received standardized dietary counseling designed to address identified intake deficiencies and maintain body weight. MAIN OUTCOME MEASURES Changes in energy and nutrient intake, body weight, and clinical outcome (ie, time to AIDS-defining illness and overall survival time). STATISTICAL ANALYSES PERFORMED Group differences (HIV group vs AIDS group) were sought using chi 2 analyses and Students t test. A multivariate regression model was used to determined the best predictors of clinical outcome. RESULTS At baseline, total energy intake (based on 30 kcal/kg usual body weight) was adequate in both HIV and AIDS patients (101 +/- 4% and 103 +/- 5% [mean +/- standard deviation] of need, respectively). Despite dietary counseling and continued maintenance of energy intake, body weight, serum cholesterol level, and CD4 level progressively decreased. Consequently, saturated fat intake was found to be inversely related (P < .01) to serum cholesterol level. Clinical outcome (after 3.5 years) was associated with baseline ratio of CD4 to CD8 (P < .001), weight (P < .01), and serum cholesterol level (P < .001). Multivariate analysis related ratio of CD4 to CD8 (P < .001) and weight maintenance (P < .001) to favorable outcome in the final model. APPLICATIONS Weight loss in patients with HIV infection is independently prognostic of clinical outcome, and development of hypocholesterolemia is not favorable for clinical outcome. Because weight loss progresses despite conventional dietary counseling to identify energy need, interventions earlier in the disease course should be considered along with increased target levels for energy intake.

Tobacco interventions by oncology nurses in clinical practice

Tobacco use is an important risk factor in cancer, cancer recurrence, and increased treatment morbidity, but limited information is available about interventions for tobacco cessation used in oncology clinical practice. In 1996, the Agency for Health Care Policy Research (AHCPR) published the first evidence‐based smoking cessation guideline for use by health professionals. Using the AHCPR guideline as a framework, the authors describe the frequency of tobacco interventions provided by oncology nurses.

Changes in food sources of dietary fat in response to an intensive low-fat dietary intervention: Early results from the Women's Health Initiative

OBJECTIVE To evaluate changes in food sources of dietary fat made by participants in the Womens Health Initiative Low-Fat Dietary Modification Trial. DESIGN This study compares sources of dietary fat intake, estimated by a food frequency questionnaire, between intervention and control participants at baseline, 1 year (year 1) and 2 years (year 2) after randomization. The outcome measure was intake of fat in grams per day. Results are given on consumption of fat from six food groups and the intervention effect, defined as mean change in the intervention group minus the change in controls, controlling for baseline fat intake. PARTICIPANTS 5,004 intervention and 7,426 control postmenopausal women in 40 clinical centers across the United States. RESULTS At baseline, the major sources of fat were added fats, such as butter, oils, and salad dressings (25%); meats (21%); and desserts (13%). From baseline to year 1, the intervention group reduced fat by 24.3 g/day compared with the control group. Reductions came primarily from added fats (9.1 g/day), meats (4.6 g/day), and desserts (3.9 g/day). White people reduced added fats more than other race/ethnicity groups did, white and Hispanic people were more likely to reduce fat intake from milk and cheese compared with other groups, and Hispanics reduced fat from mixed dishes more than did other race/ethnicity groups (P<.05 for all). APPLICATIONS/CONCLUSIONS These data indicate that women in the Womens Health Initiative dietary change intervention made substantial changes in food choices. These results can facilitate future low-fat interventions, and also offer clinical applications, by identifying foods that may be refractory to change.

Recent implications of weight loss inlung cancer management

Successful lung cancer management has been hindered by the limited efficacy of dietary and pharmacologic interventions to prevent or reverse cancer-associated weight loss. The addition of total parenteral nutrition to chemotherapy in early trials was associated with survival detriment. Dietary counseling and enteral supplement use are common strategies that, when evaluated in randomized trials, do not improve anthropometrics or clinical outcome in lung cancer. Pharmacologic agents including corticosteroids, cyproheptadine, growth hormone, hydrazine sulfate, dronabinol, and pentoxyphylline also have failed to improve even anthropometric parameters in this condition. Megestrol acetate use is associated with appetite stimulation and non-fluid weight gain but, when evaluated in small cell lung cancer patients receiving defined chemotherapy, failed to improve global quality of life, and survival and was associated with toxicity. New strategies for nutrition-based interventions in lung cancer cachexia must consider their potential influence on tumor growth as well as on nutritional status. Recent lung cancer prognostic analyses have identified gender differences in outcome and weight loss that suggest potential targets for combined hormonal and nutrition interventions. Emerging information regarding the influence of specific fatty acids on tumor growth and cachexia development have identified additional approaches for future evaluation.

Tobacco: An Emerging Topic in nursing Research

BackgroundTobacco use is the leading cause of preventable death in the United States. Since the first Surgeon General’s Report in 1964 on the health risks of tobacco use, overwhelming evidence regarding increased tobacco-attributable morbidity and mortality has been reported. The purpose of this review was to explore nursing research contributions to this public health issue by evaluating the emergence of publications focused on tobacco in a leading nursing research journal. ObjectivesThe specific aims of this review were to determine, among data-based articles published in Nursing Research (1952–2000), how often tobacco use was included (a) in sample descriptions, (b) as a variable potentially associated with study outcomes, and (c) as a finding. Additionally, the frequency of publication of research instruments developed to study tobacco use was evaluated. MethodsData-based articles (n = 1,705) and research briefs (n = 197) were evaluated. Inter-rater reliability (100%) was established by the re-review of 20% of the issues in each decade. ResultsA total of 40 data-based articles (2% of those reviewed) either included tobacco use in the sample description only (n = 11), as an independent or mediating variable (n = 11), or as a finding (n = 18). The majority (53%) of the articles were published since 1990; and 71% of the outcome studies were published within the past 5 years. One study focused on tobacco use among youth, and 1 of 197 instrument articles reviewed focused on tobacco. None of the studies reviewed addressed prevention of tobacco use or strategies to decrease exposure to second-hand smoke. ConclusionsThis review demonstrates that the cessation of tobacco use is emerging as a topic for nursing research, reflecting the increased public health attention on this topic. Increased research efforts are needed in the areas of tobacco cessation and prevention of tobacco use. Researchers should be encouraged to consider tobacco use as a variable potentially affecting outcomes in other research studies.

Breast Cancer Chemoprevention Tamoxifen: Current Issues and Future Prospective

Intervention clinical trials are under way to address whether tamoxifen can prevent breast cancer development. This effort is based on laboratory evidence that tamoxifen interferes with the initiation and promotion of mammary cancer, clinical evidence of decreased breast cancer incidence in the opposite breast of women participating in tamoxifen adjuvant breast cancer trials, and a favorable toxicity profile of tamoxifen providing reasonable assurance of drug safety when used in a population without cancer. The apparently favorable effects of tamoxifen on lipid metabolism and bone mineral density provide additional impetus to this evaluation. Potentially life threatening toxicity of thromboembolism and development of a second cancer remain concerns. With respect to implications of such clinical trials, even upon successful study completion, difficult issues will remain; these issues include the potential for interaction between tamoxifen and dietary fat reduction (also proposed as potential breast cancer prevention), the cost and cost‐effectiveness of wide scale (or selective) implementation of positive results, and the generalizability of study results to socioeconomically disadvantaged and racial and ethnic minority populations that historically have been under‐represented in medical clinical trials. These important issues should be addressed concurrently as large‐scale prevention trials go forward to optimize the practical utility of efficacy data obtained.

Is Insurance a More Important Determinant of Healthcare Access Than Perceived Health? Evidence from the Women's Health Initiative

Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Womens Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.

Altered metabolism and mortality in patients with colon cancer receiving chemotherapy

To identify the metabolic effects of 5-fluorouracil and hydrazine sulfate therapy, 22 patients with colon cancer were admitted prospectively to a Clinical Research Center for serial measurement of counter-regulatory hormones, fasting hepatic glucose production (HGP), intravenous glucose tolerance test, plasma leucine appearance (LA) and leucine oxidation. Combined therapy was associated with a significant reduction in fasting glucose level (98 ± 2 mg/dL to 94 ± 2, P < 0.025) without a significant fall in fasting HGP (2.09 ± 0.11 mg/kg/min versus 2.03 ± 0.13; P > 0.05). The decreased fasting glucose value was associated with a mild but not statistically improved glucose disposal rate in response to the intravenous glucose tolerance test (1.34 ± 0.07 %/min vs 1.47 ± 0.11, P = 0.15). Plasma leucine appearance was significantly reduced after 2 months of therapy (63.3 ± 3.0 μmol/kg/hr vs 57.1 ± 3.9 μmol/kg/hr; P < 0.025), but leucine oxidation (11.5 ± 1.1 μmol/kg/hr vs 11.2 ± 1.1 μmol/kg/hr) was not altered. Despite the fact that plasma triiodothyronine concentrations significantly increased with therapy, it was not associated with plasma LA. Half of the patients with cancer died 14 ± 4 months after the study, and the other half were alive 58 ± 2 months later. Survival time can be estimated with 59% accuracy using plasma LA, HGP, carcino-embryonic antigen, and insulin concentration. Multiple regression analysis identified that plasma LA was related directly to length of survival time, and baseline HGP, carcino-embryonic antigen, and insulin concentration were related inversely to length of survival. Unlike an elevated HGP seen in cancer cachexia, based on the association of a higher plasma LA and longer survival rate, an elevation in plasma LA may not be an unfavorable response to cancer. Further research is required to validate the predictability of baseline metabolic markers with survival rate in the cancer population.