Robert P. Magner

Number of 24-hour diet recalls needed to estimate energy intake

PURPOSE Twenty-four-hour diet recall interviews (24HRs) are used to assess diet and to validate other diet assessment instruments. Therefore it is important to know how many 24HRs are required to describe an individuals intake. METHOD Seventy-nine middle-aged white women completed seven 24HRs over a 14-day period, during which energy expenditure (EE) was determined by the doubly labeled water method (DLW). Mean daily intakes were compared to DLW-derived EE using paired t tests. Linear mixed models were used to evaluate the effect of call sequence and day of the week on 24HR-derived energy intake while adjusting for education, relative body weight, social desirability, and an interaction between call sequence and social desirability. RESULTS Mean EE from DLW was 2115 kcal/day. Adjusted 24HR-derived energy intake was lowest at call 1 (1501 kcal/day); significantly higher energy intake was observed at calls 2 and 3 (2246 and 2315 kcal/day, respectively). Energy intake on Friday was significantly lower than on Sunday. Averaging energy intake from the first two calls better approximated true energy expenditure than did the first call, and averaging the first three calls further improved the estimate (p=0.02 for both comparisons). Additional calls did not improve estimation. CONCLUSIONS Energy intake is underreported on the first 24HR. Three 24HRs appear optimal for estimating energy intake.

Lifestyle behaviours and weight among hospital-based nurses

AIMS The purpose of this study was to (i) describe the weight, weight-related perceptions and lifestyle behaviours of hospital-based nurses, and (ii) explore the relationship of demographic, health, weight and job characteristics with lifestyle behaviours. BACKGROUND The obesity epidemic is widely documented. Worksite initiatives have been advocated. Nurses represent an important part of the hospital workforce and serve as role models when caring for patients. METHODS A sample of 194 nurses from six hospitals participated in anthropometric measurements and self-administered surveys. RESULTS The majority of nurses were overweight and obese, and some were not actively involved in weight management behaviours. Self-reported health, diet and physical activity behaviours were low, although variable by gender, age and shift. Reports of co-worker norms supported low levels of healthy behaviours. CONCLUSIONS Findings reinforce the need to address the hospital environment and culture as well as individual behaviours for obesity control. IMPLICATIONS FOR NURSING MANAGEMENT Nurse managers have an opportunity to consider interventions that promote a climate favourable to improved health habits by facilitating and supporting healthy lifestyle choices (nutrition and physical activity) and environmental changes. Such efforts have the potential to increase productivity and morale and decrease work-related disabilities and improve quality of life.

Effect of mindfulness training on asthma quality of life and lung function: a randomised controlled trial

Background This study evaluated the efficacy of a mindfulness training programme (mindfulness-based stress reduction (MBSR)) in improving asthma-related quality of life and lung function in patients with asthma. Methods A randomised controlled trial compared an 8-week MBSR group-based programme (n=42) with an educational control programme (n=41) in adults with mild, moderate or severe persistent asthma recruited at a university hospital outpatient primary care and pulmonary care clinic. Primary outcomes were quality of life (Asthma Quality of Life Questionnaire) and lung function (change from baseline in 2-week average morning peak expiratory flow (PEF)). Secondary outcomes were asthma control assessed by 2007 National Institutes of Health/National Heart Lung and Blood Institute guidelines, and stress (Perceived Stress Scale (PSS)). Follow-up assessments were conducted at 10 weeks, 6 and 12 months. Results At 12 months MBSR resulted in clinically significant improvements from baseline in quality of life (differential change in Asthma Quality of Life Questionnaire score for MBSR vs control: 0.66 (95% CI 0.30 to 1.03; p<0.001)) but not in lung function (morning PEF, PEF variability and forced expiratory volume in 1 s). MBSR also resulted in clinically significant improvements in perceived stress (differential change in PSS score for MBSR vs control: −4.5 (95% CI −7.1 to −1.9; p=0.001)). There was no significant difference (p=0.301) in percentage of patients in MBSR with well controlled asthma (7.3% at baseline to 19.4%) compared with the control condition (7.5% at baseline to 7.9%). Conclusions MBSR produced lasting and clinically significant improvements in asthma-related quality of life and stress in patients with persistent asthma, without improvements in lung function. Clinical Trial Registration Number Asthma and Mindfulness-Based Reduction (MBSR) Identifier: NCT00682669. clinicaltrials.gov.

Step Ahead A Worksite Obesity Prevention Trial Among Hospital Employees

BACKGROUND The worksite represents a promising venue in which to address the issue of obesity. DESIGN Pair-matched, cluster-RCT. Data were collected from 2005 to 2008 and analyzed in 2008. SETTING/PARTICIPANTS A random sample of 806 employees was selected to represent the workforce of six hospitals in central Massachusetts. INTERVENTION The 2-year ecologic intervention sought to prevent weight gain through changes in worksite weight-related norms using strategies targeted at the organization, interpersonal environment, and employees. MAIN OUTCOME MEASURES The primary outcome was change in BMI at the 12- and 24-month follow-ups. Change in perceptions of organizational commitment to employee health and normative coworker behaviors were secondary outcomes. RESULTS There was no impact of the intervention on change in BMI from baseline to 12 (beta=0.272; 95% CI=-0.271, 0.782) or 24 months (beta=0.276; 95% CI=-0.338, 0.890) in intention-to-treat analysis. When intervention exposure (scale=0 to 100) was used as the independent variable, there was a decrease of 0.012 BMI units (95% CI=-0.025, 0.001) for each unit increase in intervention participation at the 24-month follow-up. Employees in intervention sites reported significantly greater improvements in perceptions of organizational commitment to employee health at 12 and 24 months compared to control sites, but there was no impact on perceptions of normative coworker behaviors. CONCLUSIONS The intervention had a dose-response relationship with BMI, with positive effects proportional to extent of participation. Although the intervention was able to change organizational perceptions, successfully improving changes in actual and perceived social norms may be needed to achieve population-level impact in complex worksite organizations.

A school nurse-delivered intervention for overweight and obese adolescents.

BACKGROUND Models are needed for implementing weight management interventions for adolescents through readily accessible venues. This study evaluated the feasibility and efficacy of a school nurse-delivered intervention in improving diet and activity and reducing body mass index (BMI) among overweight and obese adolescents. METHODS Six high schools were randomized to either a 6-session school nurse-delivered counseling intervention utilizing cognitive-behavioral techniques or nurse contact with provision of information. Eighty-four overweight or obese adolescents in grades 9 through 11 completed behavioral and physiological assessments at baseline and 2- and 6-month follow-ups. RESULTS At 2 months, intervention participants ate breakfast on more days/week (difference = 1.01 days; 95% CI: 0.11, 1.92), and had a lower intake of total sugar (difference = -45.79 g; 95% CI: -88.34, -3.24) and added sugar (difference = -51.35 g; 95% CI: -92.45, -10.26) compared to control participants. At 6 months, they were more likely to drink soda ≤ one time/day (OR 4.10; 95% CI: 1.19, 16.93) and eat at fast food restaurants ≤ one time/week (OR 4.62; 95% CI: 1.10, 23.76) compared to control participants. There were no significant differences in BMI, activity, or caloric intake. CONCLUSION A brief school nurse-delivered intervention was feasible, acceptable, and improved selected obesogenic behaviors, but not BMI.

Translational research at community health centers: challenges and successes in recruiting and retaining low-income Latino patients with type 2 diabetes into a randomized clinical trial.

Purpose To describe methods used to recruit and retain low-income Latinos in a randomized clinical trial (RCT) of a diabetes self-management intervention at 5 community health centers (CHCs) in Massachusetts. Methods Consent from primary care providers (PCPs) was obtained to screen their patients. Trained site research coordinators (SRCs) screened, recruited, and enrolled participants following a multistep process (medical record reviews, PCP approval, a patient eligibility interview) and provided support for retention efforts. Assessment staff were trained in motivational strategies to facilitate retention and received ongoing support from a retention coordinator. Electronic tracking systems facilitated recruitment and retention activities. Results Of an initial pool of 1176 patients, 1034 were active at the time of screening, 592 (57%) were eligible by medical record review, and 487 received PCP approval (92% of reviewed patients). Of these, 293 patients completed the patient screening interview (60% of patients with PCP approval, and 76% of those reached), and 276 were eligible. Sixteen percent of all active patients refused participation, and 8% of contacted patients were unreachable. Two hundred fifty-two patients were randomized after completion of baseline assessments. Clinical, behavioral, and psychosocial assessment completion rates were 92%, 77%, and 86% at 12-month follow-up, respectively, and 93% of patients completed at least one study assessment at 12 months. Conclusions CHCs are a prime setting for translation research aimed to eliminate diabetes health disparities. Successful recruitment and retention efforts must address institutional/organizational, research team, and patient-related challenges. References 1. US Department of Health and Human Services, Centers for Disease Control and Prevention. 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Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care. 1998; 21:1230-1235. 6. Franklin GM, Kahn LB, Baxter J, Marshall JA, Hamman RF. Sensory neuropathy in non-insulin-dependent diabetes mellitus: the San Luis Valley Diabetes Study. Am J Epidemiol . 1990;131:633-643. 7. Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2006. Rockville, MD: Agency for Healthcare Research and Quality; 2006. Available at: http://www.ahrq.gov/ qual/nhdr06/nhdr06.htm. Accessed January 12, 2010. 8. National Institute of Diabetes and Digestive and Kidney Diseases, National Diabetes Information Clearinghouse (NDIC). National diabetes statistics. Available at: http://diabetes.niddk.nih.gov/dm/ pubs/statistics/index.htm. Accessed January 12, 2010. 9. US Department of Health and Human Services, Office of Minority Research. Diabetes and Hispanic Americans. 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Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic health and nutrition examination survey 1982-1984. Diabetes Care. 1991;14(7 Suppl):528-538. 19. Lemon SC, Zapka JG, Estabrook B, Benjamin E. Challenges to research in urban community health centers. Am J Public Health. 2006;96:626-628. 20. Handley MA, Hammer H, Schillinger D. Navigating the terrain between research and practice: a Collaborative Research Network (CRN) case study in diabetes research. J Am Board Fam Med. 2006;19:85-92. 21. Piatt GA, Orchard TJ, Emerson S. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29:811-817. 22. Frayne SM, Burns RB, Hardt EJ, Rosen AK, Moskowitz MA. The exclusion of non-English-speaking persons from research. J Gen Intern Med. 1996;11:39-43. 23. Durant RW, Davis RB, St George M, Williams IC, Blumenthal C, Corbie-Smith GM. Participation in research studies: factors associated with failing to meet minority recruitment goals. Ann Epidemiol. 2007;17:634-642. 24. Centers for Disease Control and Prevention, Department of Health and Human Services. Diabetes data and trends. Available at: http:www.cdc.gov/diabetes/statistics/prev/national/. Accessed March 31, 2010. 25. Surani S, Aguillar R, Komari V, Surani A, Subramanian S. Influence of Hispanic ethnicity in prevalence of diabetes mellitus in sleep apnea and relationship to sleep phase. Postgrad Med. 2009;121:108-112. 26. Link CL, McKinlay JB. Disparities in the prevalence of diabetes: is it race/ethnicity or socioeconomic status? Results from the Boston Area Community Health (BACH) survey. Ethn Dis. 2009;19:288-292. 27. Bryson CL, Ross HJ, Boyko EJ, Young BA. Racial and ethnic variations in albuminuria in the US Third National Health and Nutrition Examination Survey (NHANES III) population: associations with diabetes and level of CKD. 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PDA-assisted low glycemic index dietary intervention for type II diabetes: a pilot study

Background:Epidemiological and dietary intervention studies suggest that a low-glycemic index (GI) diet is beneficial for blood glucose control; however, long-term clinical utility of the low GI diet has not been fully investigated.Objectives:To evaluate the feasibility and efficacy of a nutritionist-delivered low-GI dietary intervention, with the support of a personal digital assistant (PDA), for adult patients with poorly controlled type II diabetes.Method:The low-GI intervention consisted of six counseling sessions and the use of a PDA-based food database with GI scores for 6 months. Study outcomes included feasibility measures, glycosylated hemoglobin levels (HbA1c), GI and glycemic load (GL) score of self-reported dietary intake, body weight, depression and quality of life (QOL). Measures were obtained at baseline, 3 and 6 months.Results:Of 31 adult patients approached, 15 met study eligibility criteria and were enrolled in the study. Thirteen patients (87%) completed all study assessments. Findings included decreases in average HbA1c (−0.5% P=0.02), body weight, hip circumference, blood pressure, dietary GI and daily caloric intake. Diabetes impact scores also decreased. All but one participant completed all components of the intervention. There were mixed reports regarding the usefulness of the PDAs; however, participants offered helpful suggestions for further development.Conclusions:Results of this pilot study support the feasibility of implementing a nutritionist-delivered, PDA-assisted low-GI dietary intervention for patients with poorly controlled type II diabetes. Encouraging initial efficacy data require further testing in the context of a randomized clinical trial.

Perceptions of Worksite Support and Employee Obesity, Activity and Diet

OBJECTIVES To examine the associations of perceptions of organizational commitment to employee health and coworker physical activity and eating behaviors with body mass index (BMI), physical activity, and eating behaviors in hospital employees. METHODS Baseline data from 899 employees participating in a worksite weight-gain prevention trial were analyzed. RESULTS Greater perception of organizational commitment to employee health was associated with lower BMI. Greater perceptions of coworker healthy eating and physical activity behaviors were associated with fruit and vegetable and saturated fat consumption and physical activity, respectively. CONCLUSIONS Improving organizational commitment and facilitating supportive interpersonal environments could improve obesity control among working populations.

Effectiveness of a school nurse-delivered smoking-cessation intervention for adolescents.

OBJECTIVE: To evaluate the effectiveness of a school nurse–delivered smoking-cessation intervention in increasing abstinence among adolescent smokers. METHODS: Thirty-five high schools were pair-matched and randomly assigned to 1 of 2 conditions, each of which consisted of 4 visits with the school nurse: (1) counseling intervention using the 5 As model and cognitive-behavioral techniques; or (2) an information-attention control condition. Adolescents (n = 1068) who reported past 30-day smoking and interest in quitting completed surveys at baseline and at 3 and 12 months and provided saliva samples for biochemical validation of reported smoking abstinence. RESULTS: Intervention condition participants were almost twice as likely to be abstinent per self-report at 3 months (odds ratio: 1.90 [95% confidence interval: 1.12–3.24]; P = .017) compared with control participants; at 12 months there were no differences. The difference at 3 months was driven by quit rates in male students (15.0% [intervention] vs 4.9% [control]; odds ratio: 3.23 [95% confidence interval: 1.63–6.43]; P = .001); there was no intervention effect in female students at either time point (6.6% vs 7.0% at 3 months and 16.6% vs 15.5% at 12 months) and no intervention effect in male students at 12 months (13.9% vs 13.2%). Smoking amount and frequency decreased significantly in intervention compared with control schools at 3 but not at 12 months. CONCLUSIONS: A school nurse–delivered smoking-cessation intervention proved feasible and effective in improving short-term abstinence among adolescent boys and short-term reductions in smoking amount and frequency in both genders. Additional research is needed to enhance both cessation and maintained abstinence.

Effectiveness of Rituximab for the Treatment of Rheumatoid Arthritis in Patients with Prior Exposure to Anti-TNF: Results from the CORRONA Registry

Objective. To characterize the real-world effectiveness of rituximab (RTX) in patients with rheumatoid arthritis. Methods. Clinical effectiveness at 12 months was assessed in patients who were prescribed RTX based on the Clinical Disease Activity Index (CDAI). Change in CDAI was calculated (CDAI at 12 mos minus at initiation). Achievement of remission or low disease activity (LDA; CDAI ≤ 10) among those with moderate/high disease activity at the time of RTX initiation was compared based on prior anti-tumor necrosis factor agent (anti-TNF) use (1 vs ≥ 2) using logistic regression models. Results. Patients (n = 265) were followed for 12 months with a mean change in CDAI of −8.1 (95% CI −9.8 – −6.4). Of the 218 patients with moderate/high disease activity at baseline, patients with 1 prior anti-TNF (baseline CDAI 25.0) demonstrated a mean change in CDAI of −10.1 (95% CI −13.2 – −7.0); patients with ≥ 2 prior anti-TNF (baseline CDAI 30.0) demonstrated a mean change of −10.5 (95% CI −12.9 – −8.0). The unadjusted OR for achieving LDA/remission in patients with moderate/high disease activity at baseline exposed to ≥ 2 versus 1 prior anti-TNF was 0.40 (95% CI 0.22–0.73), which was robust to 4 different adjusted models (OR range 0.38–0.44). Conclusion. A good clinical response was observed in all patients; however, patients previously treated with 1 anti-TNF, who had lower baseline CDAI and a greater opportunity for clinical improvement compared with patients previously treated with ≥ 2 anti-TNF, were more likely to achieve LDA/remission.