Victor J. Stevens

Branched-chain amino acid levels are associated with improvement in insulin resistance with weight loss.

Aims/hypothesisInsulin resistance (IR) improves with weight loss, but this response is heterogeneous. We hypothesised that metabolomic profiling would identify biomarkers predicting changes in IR with weight loss.MethodsTargeted mass spectrometry-based profiling of 60 metabolites, plus biochemical assays of NEFA, β-hydroxybutyrate, ketones, insulin and glucose were performed in baseline and 6xa0month plasma samples from 500 participants who had lost ≥4xa0kg during Phase I of the Weight Loss Maintenance (WLM) trial. Homeostatic model assessment of insulin resistance (HOMA-IR) and change in HOMA-IR with weight loss (∆HOMA-IR) were calculated. Principal components analysis (PCA) and mixed models adjusted for race, sex, baseline weight, and amount of weight loss were used; findings were validated in an independent cohort of patients (nu2009=u200922).ResultsMean weight loss was 8.67u2009±u20094.28xa0kg; mean ∆HOMA-IR was −0.80u2009±u20091.73, range −28.9 to 4.82). Baseline PCA-derived factor 3 (branched chain amino acids [BCAAs] and associated catabolites) correlated with baseline HOMA-IR (ru2009=u20090.50, pu2009<u20090.0001) and independently associated with ∆HOMA-IR (pu2009<u20090.0001). ∆HOMA-IR increased in a linear fashion with increasing baseline factor 3 quartiles. Amount of weight loss was only modestly correlated with ∆HOMA-IR (ru2009=u20090.24). These findings were validated in the independent cohort, with a factor composed of BCAAs and related metabolites predicting ∆HOMA-IR (pu2009=u20090.007).Conclusions/interpretationA cluster of metabolites comprising BCAAs and related analytes predicts improvement in HOMA-IR independent of the amount of weight lost. These results may help identify individuals most likely to benefit from moderate weight loss and elucidate novel mechanisms of IR in obesity.

Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.

OBJECTIVESnPrimary care medical clinics are good settings for smoking interventions. This study extends this strategy with a smokeless tobacco intervention delivered by dentists and dental hygienists in the course of routine dental care.nnnMETHODSnMale users of moist snuff and chewing tobacco (n = 518) were identified by questionnaire in clinic waiting rooms and then randomly assigned to either usual care or intervention. The intervention included a routine oral examination with special attention to the part of the mouth in which tobacco was kept and an explanation of the health risks of using smokeless tobacco. After receiving unequivocal advice to stop using tobacco, each patient viewed a 9-minute videotape, received a self-help manual, and was briefly counseled by the dental hygienist.nnnRESULTSnLong-term success was defined as no smokeless tobacco use at both 3- and 12-month follow-ups, with those lost to follow-up counted as smokeless tobacco users. The intervention increased the proportion of patients who quit by about one half (12.5% vs 18.4%, P < .05).nnnCONCLUSIONSnThese results demonstrate the efficacy of a brief dental office intervention for the general population of smokeless tobacco users.

Effect of lifestyle modifications on blood pressure by race, sex, hypertension status, and age

Recommendations for control of high blood pressure (BP) emphasize lifestyle modification, including weight loss, reduced sodium intake, increased physical activity, and limited alcohol consumption. The Dietary Approaches to Stop Hypertension (DASH) dietary pattern also lowers BP. The PREMIER randomized trial tested multicomponent lifestyle interventions on BP in demographic and clinical subgroups. Participants with above-optimal BP through stage 1 hypertension were randomized to an Advice Only group or one of two behavioural interventions that implement established recommendations (Est) or established recommendations plus DASH diet (Est plus DASH). The primary outcome was change in systolic BP at 6 months. The study population was 810 individuals with an average age of 50 years, 62% women, 34% African American (AA), 95% overweight/obese, and 38% hypertensive. Participants in all the three groups made lifestyle changes. Mean net reductions in systolic (S) BP in the Est intervention were 1.2 mmHg in AA women, 6.0 in AA men, 4.5 in non-AA women, and 4.2 in non-AA men. The mean effects of the Est Plus DASH intervention were 2.1, 4.6, 4.2, and 5.7 mmHg in the four race–sex subgroups, respectively. BP changes were consistently greater in hypertensives than in nonhypertensives, although interaction tests were nonsignificant. The Est intervention caused statistically significant BP reductions in individuals over and under age 50. The Est Plus DASH intervention lowered BP in both age groups, and significantly more so in older individuals. In conclusion, diverse groups of people can adopt multiple lifestyle changes that can lead to improved BP control and reduced CVD risk.

Premier: a clinical trial of comprehensive lifestyle modification for blood pressure control: rationale, design and baseline characteristics

PURPOSEnTo describe PREMIER, a randomized trial to determine the effects of multi-component lifestyle interventions on blood pressure (BP).nnnMETHODSnParticipants with above optimal BP through stage 1 hypertension were randomized to: 1) a behavioral lifestyle (BLS) intervention that implements established recommendations, 2) a BLS intervention that implements established recommendations plus the DASH diet, or 3) an advice only standard of care group. The two BLS interventions consist of group and individual counseling sessions for 18 months. The primary outcome is systolic BP at 6 months. Additional outcomes include diastolic BP and homocysteine at 6 months; systolic and diastolic BP at 18 months; fasting lipids, glucose and insulin at 6 and 18 months; and effects in subgroup.nnnCONCLUSIONnResults from the PREMIER trial will provide scientific rationale for implementing multi-component behavioral lifestyle intervention programs to control BP and prevent CVD.

The PHLAME firefighters' study: feasibility and findings.

OBJECTIVEnTo assess efficacy of 2 worksite health promotion interventions.nnnMETHODSnRandomly assign 3 fire stations to (a) team-based curriculum, (b) individual counselor meetings, and (c) control.nnnRESULTSnBoth interventions were feasible and acceptable, and they resulted in significant reductions in LDL cholesterol. The team approach significantly increased coworker cohesion, personal exercise habits, and coworkers healthy behaviors. The one-on-one strategy significantly increased dietary self-monitoring, decreased fat intake, and reduced depressed feelings.nnnCONCLUSIONSnAlthough both interventions promoted healthy behaviors, specific outcomes differed and reflected their conceptual underpinnings. The team-based curriculum is innovative and may enlist influences not accessed with individual formats.

Recruitment of Older Participants in Frailty/Injury Prevention Studies

Despite the lifelong health benefits of physical activity, frailer older adults have typically been excluded from studies promoting more active lifestyles. This study documents the recruitment process and costs from a multisite study to identify effective strategies for recruiting older adults in frailty/injury prevention research. Randomized controlled clinical trials were conducted at 7 sites; an 8th site was a compliance study. Interventions reflected center- and home-based health promotion programs. Site objectives, eligibility criteria, and contact and screening methods were obtained from manuals of operation. Recruitment results (number screened, eligibility rates, randomized to screened ratios) were ascertained from recruitment data. Sites furnished estimated recruitment costs (nonlabor expenses, investigator and staff time, fringe benefits) up to signing the consent form. The sites targeted diverse populations and sample sizes. The majority revised recruitment methods to meet their recruitment goals. Most sites estimated costs of recruitment at over

Trials of Hypertension Prevention, phase II structure and content of the weight loss and dietary sodium reduction interventions

300 per participant randomized. Recruitment costs were affected by staff time spent alleviating concerns about participants health, essential interactions with family members, and arranging for transportation. Neither frailty nor intervention intensity was found to be a major predictor of recruitment outcomes. Recruitment expense was associated with selection criteria and frailty status of the target population. Older people can be successfully recruited into beneficial health promotion programs, but it is often challenging. In planning health promotion studies, investigators need to be aware of the numbers of older people they may need to screen and different strategies for increasing recruitment success.

Dental office practices for tobacco users: independent practice and HMO clinics.

Identifying effective, nonpharmacologic means of preventing or significantly delaying the onset of hypertension would be a major advance in the primary prevention of cardiovascular disease. In the first phase of the Trials of Hypertension Prevention (TOHP I), adults with high-normal diastolic blood pressure were randomly assigned to one of seven nonpharmacologic interventions. Only weight loss and reduction of dietary sodium proved to be effective strategies for reducing blood pressure. The second phase of TOHP (TOHP II) will test the effectiveness of weight loss, reduction of dietary sodium, and their combination of lowering blood pressure and preventing the onset of hypertension over a 3- to 4-year follow-up period. This article describes the three interventions used in TOHP II, methods used to maintain continued participation in this long-term trial, and protocol enhancements designed to maximize intervention effectiveness.

Does methodology affect the ability to monitor tobacco control activities? implications for HEDIS and other performance measures

Surveys of independent dental practitioners and health maintenance organization (HMO) dentists and their adult male patients in Oregon found that cessation information and advice was being given to tobacco-using patients, especially smokeless tobacco users, and that the tobacco users surveyed expressed interest in obtaining help to quit. Oral health providers expressed an interest in further training in how to help their tobacco-using patients to quit.

Physical Activity, Cardiorespiratory Fitness, and their Relationship to Cardiovascular Risk Factors in African Americans and Non-African Americans With Above-Optimal Blood Pressure

BACKGROUNDnIt is unclear whether methodological differences in sample size, survey methods, and analysis approach significantly affect the ability to accurately monitor tobacco control activities and to make rate comparisons.nnnMETHODSnQuestionnaires were sent to 64,764 members of nine health plans in diverse settings soon after their visit to a primary care clinician. Of these 41,677 completed responses were received. We compared responses received by mail and by telephone follow-up for the percentage of smokers, characteristics of smokers, and their rates of reporting physician cessation counseling.nnnRESULTSnOverall, 10.2% were current cigarette smokers, but the proportion was 8.6% for mail responders and 17.2% for phone follow-up responders. Smokers identified by phone follow-up were different from mail responders in most demographic and smoking characteristics and their reports of clinical smoking cessation activities differed for six of nine clinician smoking cessation actions. Calculating advice rates as a proportion of visits produced lower rates with more dispersion among plan rates than doing so without accounting for visit variation.nnnCONCLUSIONSnSmoking surveys using only mailed questionnaires dramatically undersample smokers, especially in some demographic groups. Comparisons of tobacco counseling among health plans can be improved by ensuring an adequate sample size and response rate and by analyzing by frequency of quit advice.