Mark J. Brekke

The eating pattern assessment tool: A simple instrument for assessing dietary fat and cholesterol intake☆

OBJECTIVE This study describes the development of the self-administered Eating Pattern Assessment Tool (EPAT), which is designed to assess dietary fat and cholesterol intake and aid patients and health professionals in achieving control of blood cholesterol levels. DESIGN Test-retest reliability of the instrument over five visits and concurrent validity testing compared with 4-day food records. SETTING AND SAMPLE The instrument was tested at multiple sites of a large manufacturing corporation using 436 adult volunteers with approximately equal proportions of men and women from three socioeconomic levels. MAIN OUTCOME MEASURE Development of the EPAT centered on creating an instrument that was simple and easy to use in a primary-care setting, that would provide a reliable assessment of intake of dietary fat and cholesterol among adults, and that would measure frequency of consumption of foods from high-fat and low-fat categories. ANALYSES Test-retest reliability for repeated use was estimated by between-visit Pearson product-moment correlations of EPAT section scores. Concurrent validity was assessed by using product-moment correlation between EPAT section scores and mean daily B-scores obtained from 4-day food records. RESULTS Test-retest reliability estimates were 0.91 between all adjacent pairs of visits and 0.83 between visits 1 and 5 (4 months). Validity was 0.56. APPLICATIONS/CONCLUSIONS The EPAT is a simple, quick, self-administered tool using an easy scoring method for accurately assessing fat and cholesterol intake. It is a reliable and valid substitute for more time-consuming food records. EPAT also provides an efficient way to monitor eating patterns of patients over time and is arranged to provide an educational message that reinforces the consumption of recommended types and numbers of servings of low-fat foods.

Self-reported weight, weight goals, and weight control strategies of a Midwestern population

OBJECTIVE To elicit from individuals in a population their current weight and height, weight goals, and weight control strategies to aid in design of effective interventions to prevent and treat obesity. SUBJECTS AND METHODS By random digit dial telephone survey, 1224 adult residents of Olmsted County, Minnesota, were contacted between February 28 and May 5, 2000. They self-reported weights and weight goals and described physical characteristics associated with their desire to lose weight. RESULTS Among the 1224 respondents, 65.6% of men and 47.9% of women reported that they were overweight (body mass index [BMI], 25.0-29.9 kg/m2) or obese (BMI, > or =30.0 kg/m2). Only 0.4% of men and 3.7% of women reported that they were underweight (BMI, <18.5 kg/m2). Of the respondents 72.6% of men and 85.1% of women reported that they were either trying to lose or not gain weight. The average weight loss goal for individuals trying to lose weight was 23.4 pounds for men and 28.0 pounds for women. Only one third of individuals trying to lose weight and one fifth of individuals trying not to gain weight reported using the recommended approach of combining energy restriction with at least 150 minutes of exercise per week. CONCLUSIONS The prevalence of overweight and obesity in the population and the underutilization of combining both restricting energy intake and exercising at least 150 minutes per week for weight control is high. Like the majority of people in the United States, the majority of people in Olmsted County desire to control their weight. The community has responded with plans to help residents meet their goals, although efficacy and outcomes remain to be determined.

A Comparison of Two Methods to Recruit Physicians to Deliver Smoking Cessation Interventions

To address the problem of recruiting physicians to deliver smoking cessation interventions, Doctors Helping Smokers included a trial of physician recruitment strategies. In round 1 of Doctors Helping Smokers, three types of informational materials were mailed directly to 1110 family physicians. The physicians were asked to return a postcard if they were interested in participating in a 1-month trial of a smoking cessation intervention. Response did not differ among the three conditions; overall, 9.8% of physicians (95% confidence limits [CL], 8.0, 11.6) responded and 6.0% (95% CL, 4.6, 7.4) eventually participated in the intervention trial. The same procedure was repeated for round 2 of Doctors Helping Smokers with direct mailing to all general internists and cardiologists (n = 1108) on the mailing list of the Minnesota Medical Association. Five percent (95% CL, 3.7, 6.3) of the internists responded and 2.7% (95% CL, 1.7, 3.7) participated in the trial. Recruitment for round 3 made use of repeated face-to-face recruitment efforts at the physicians office through a managed-care organization that held contracts with the physicians clinic to provide care for its enrollees. Six months after the initiation of round 3, 59% (95% CL, 49%, 67%) of the 126 primary care physicians reported that they were giving their patients smoking cessation advice and completing the smoking intervention records. Eighteen months after the initiation of round 3, 56% (95% CL, 47%, 65%) of the 116 primary care physicians who remained in the practice reported continued activity in the project.

The CardioVision 2020 Baseline Community Report Card

OBJECTIVE To establish baseline data for the CardioVision 2020 program, a collaborative project in Olmsted County, Minnesota, organized to reduce cardiovascular disease rates by altering 5 health-related items: (1) eliminating tobacco use and exposure, (2) improving nutrition, (3) increasing physical activity, (4) lowering serum cholesterol level, and (5) controlling blood pressure. SUBJECTS AND METHODS Data about tobacco use, diet, and physical activity were collected by random digit dial interview and follow-up questionnaire from a sample of the population. Blood pressure data were collected from medical records at Mayo Clinic, and serum cholesterol data were derived from the Mayo Clinic laboratory database. Data were stratified into 6 age groups. RESULTS A total of 624 women and 608 men responded to the questionnaire. Population blood pressure data were available for 1,956 women and 1,084 men. Population serum cholesterol data were available for 17,042 women and 12,511 men. Except for women in the 30- to 39-year-old age group, less than 10% of the population sampled met 4 or 5 goals. Conversely, about 90% of the population met at least 1 goal, and about 80% met 1, 2, or 3 of the goals. CONCLUSION The data from the Olmsted County population indicate considerable opportunity to reduce this populations burden of cardiovascular disease.

Attitudes of Olmsted County, Minnesota, residents about tobacco smoke in restaurants and bars

OBJECTIVE To determine the attitudes of Olmsted County, Minnesota, adults about environmental tobacco smoke in restaurants, bars, and nightclubs. SUBJECTS AND METHODS In this population survey,2014 adults were contacted by random digit dial methods between February 28 and May 5, 2000, and asked to participate in a telephone survey; 1224 (61%) consented. RESULTS For the 57% (95% confidence interval [CI], 54%-60%) of the study population that reported exposure to environmental tobacco smoke, the most frequently reported sites of exposure were restaurants (44% [95% CI, 41%-48%]), work (21% [95% CI, 18%-24%]), and bars (19% [95% CI, 16%-22%]). Seventy-two percent (95% CI, 69%-74%) of respondents said that they would select a smoke-free restaurant over one where smoking is permitted, and 70% (95% CI, 67%-72%) said that they would select a smoke-free bar over one where smoking is permitted. The majority of respondents said that they would not dine out or visit bars or nightclubs more often or less often if all restaurants, bars, and nightclubs were smoke-free. CONCLUSIONS Olmsted County residents prefer smoke-free restaurants, bars, and nightclubs.

Dietary Intake of Fruits, Vegetables, and Fat in Olmsted County, Minnesota

OBJECTIVE To assess self-reported dietary intake in the adult population of Olmsted County, Minnesota. SUBJECTS AND METHODS We conducted a random-digit-dial telephone survey between March 1 and April 21, 1999, of 1232 adults residing in Olmsted County, Minnesota. We then mailed a structured questionnaire to the survey respondents and achieved a response rate of 732 individuals. Percentages of individuals and predictors of those who meet recommendations for intake of fruits and vegetables and for dietary fats were determined by using chi2 tests of general association and multivariate logistic regression. RESULTS Only 16% of the population of Olmsted County reported meeting standard dietary recommendations for consuming both 5 or more servings of fruits and/or vegetables per day and no more than 30% of calories from fat. Fifty-one percent of the population was meeting neither recommendation. Women were more likely than men to report meeting both goals (22% vs 8%, P<.001), but still more women were meeting neither goal than were meeting both goals (40% vs 22%, P<.001). Multivariate logistic regression revealed the following factors to predict adherence to both goals: female sex, lower body mass index, nonsmoker, history of high cholesterol, and daily physical activity. CONCLUSION Few individuals in Olmsted County are meeting national recommendations for intake of fruits, vegetables, and dietary fat. More effective interventions are needed to improve dietary habits in all subgroups of this community.

Opportunities to prevent sudden out-of-hospital death due to coronary heart disease in a community

BACKGROUND Intervening successfully to reduce the burden of sudden out-of-hospital death due to coronary heart disease (OHCD) requires knowledge of where these deaths occur and whether they are observed by bystanders. METHODS To establish the proportion of OHCDs that were witnessed and where they occurred, we reviewed the coroners notes and medical records of a previously-described sample of OHCD cases among residents of Olmsted County, Minnesota. This cohort (n=113) consisted of a 10% random sample of all Olmsted County residents who died out-of-hospital between 1981 and 1994 and whose deaths were attributed to coronary heart disease. RESULTS Excluding deaths in nursing homes (n=27), 71 (83%) of the deaths occurred in private homes and 15 (17%) occurred in public places. The event was not witnessed in 59% of deaths occurring in private homes and in 20% of deaths occurring in public places. The presence or absence of a bystander could not be established for 10% of deaths in private homes and 7% of deaths in public areas. CONCLUSIONS A significant proportion of OHCDs occur in private homes and are not witnessed. Prevention of unwitnessed deaths will require programs that result in primary prevention and/or calls to first responders at the time of impending cardiac arrest.

Design and development of a coronary heart disease decision support tool

We are developing a decision support tool to help clinicians and policy makers estimate the impact of various coronary heart disease (CHD) treatments on disease outcomes for populations. We have created seven modules that correspond to states commonly encountered with CHD, that is, congestive heart failure, tachyarrhythmia, stable angina pectoris, acute coronary syndrome, bradycardia, postmyocardial infarction, and postcoronary artery bypass grafting, and a healthy individual module. Within each module, we created event-decision- intervention-outcome flow pathways to simulate risk of a clinical event and the expected outcome as the result of a particular intervention. We will combine disease state probability estimates based on the experience of the Olmsted County, Minnesota, population and estimates of intervention efficacy based on clinical trial data to estimate the impact of interventions on a population. We plan to make this tool available to the public through the internet.

Feasibility of Simulating Physicians?? Judgments of Patient Severity

This article reports on adopting Gustafsons multiattribute utility method to develop a specific momentary severity index (vis-à-vis severity over time) for nontraumatic chest pain patients. A panel of physicians identified an appropriate set of indicators for the index. Three mathematic models were generated on the basis of these indicators with each model predicting no less than 81% of the variance in overall scores of 96 simulated patients with chest pain. High interrater reliability (0.94) was demonstrated. Congruent validity coefficients between the three model scores and the overall scores vary between 0.71 and 0.92 depending on how the panel physicians are grouped. Results indicate the feasibility of simulating physician judgments regarding patient severity in chest-pain-related cases.

The Potential Impact of CardioVision 2020 and Three Other Risk Factor Scenarios on Population Rates of Coronary Heart and Cardiovascular Disease: A Call to Action

Background: We are implementing CardioVision 2020—a comprehensive, population-wide initiative—in Olmsted County, Minnesota to reduce the population burden of coronary heart disease (CHD) and cardiovascular (CVD) disease. In this analysis we compare disease incidence rates expected with CardioVision 2020 to three other scenarios.