Adapting the telephone assessment and skill-building kit to the telehealth technology preferences of stroke family caregivers.

Family caregivers exhibit a wide variety of needs and concerns while providing care to stroke survivors after discharge to the home setting. We report the results of two related studies utilizing a multimethod design in which stroke family caregivers (N = 12; N = 10) were interviewed using open-ended questions, followed by written caregiver ratings regarding the types of telehealth technologies they preferred for the telephone assessment and skill-building kit (TASK III). Qualitative data were analyzed using content analysis procedures with a provisional "start list" of codes in a matrix template based on the types of telehealth technologies in the rating forms. Descriptive statistics were used to analyze ratings with response scales ranging from 1 = strongly disagree to 5 = strongly agree. Average ratings for the telehealth technologies for the TASK III resource guide were obtained for the mailed hard copy binder (M = 3.58-4.13; SD = 0.35-1.00), an interactive website (https://www.task3web.com/; M = 3.86-4.17; SD = .72-1.07), an eBook (M = 3.17-3.67; SD = 0.84-1.17), and a USB drive (M = 3.75-4.00; SD = .82-.96). Average ratings for the telehealth technologies for the TASK III calls with the nurse were obtained for the use of a telephone (M = 4.36-5.00; SD = 0.00-0.89), FaceTime on an iOS device (e.g., iPhone or iPad; M = 3.73-4.40; SD = 0.79-0.98), or online videoconferencing (M = 3.17-3.50; SD = 0.82-1.47). Qualitative data revealed a wide variety of preferences for each type of telehealth technology, with advantages and disadvantages of each. The findings underscored the importance of offering multiple telehealth technology options to stroke family caregivers. Future studies are recommended that employ randomized control trial methodology to test theoretically-based interventions that are based on stroke family caregiver preferences for telehealth technologies.

Environmental changes to control obesity: a randomized controlled trial in manufacturing companies.

PURPOSE: To determine the effects of an environmental intervention on obesity, disease risk factors, and dietary intake in an employee population. DESIGN: Randomized controlled community trial. SETTING: Eight manufacturing companies in Kentucky with ∼150 to 350 employees each. SUBJECTS: Randomly selected employees. INTERVENTION: Multicomponent environmental intervention that included employee advisory committees, point-of-decision prompts, walking paths, cafeteria/vending changes, and educational materials. MEASURES: Height; weight; body fat; blood pressure; fasting lipids, glucose and insulin; and dietary intake were assessed prior to and 3, 6, and 12 months after initiation of the intervention. ANALYSIS: Mixed-model repeat-measure analyses of covariance were used to analyze data collected over the study period. Categorical data were analyzed in contingency tables. A p value of .05 was used to judge statistical significance. RESULTS: There were no intervention effects for outcome variables, with the exception of lower intake of saturated fat and dietary cholesterol in the intervention group compared to the control group. Over the course of the study, changes in anthropometry and biomeasures were similar in both groups. CONCLUSIONS: Findings indicate that subtle environmental changes alone may not impact employees' weight and health; however, such institutional-level approaches may be essential to support healthy lifestyle habits that are initiated by more intensive efforts. Academic researchers should continue to partner with employers and practitioners to develop, implement, and evaluate innovative health promotion strategies including environmental interventions.

Adiponectin changes in relation to the macronutrient composition of a weight-loss diet.

Adiponectin is an adipose-derived protein with beneficial metabolic effects. Low adiponectin is associated with obesity and related diseases. Significant weight loss increases adiponectin, reducing disease risk. This study compared the effects of two weight-loss diets with different macronutrient compositions on adiponectin. Eighty-one obese women in two cohorts were randomized to a low-fat (LF) or a low-carbohydrate (LC) diet. All subjects underwent equivalent weight-loss intervention, with weight and other measures assessed at baseline and after 6 (cohort I) or 4 (cohort II) months. Body fat was measured by dual energy X-ray absorptiometry. Adiponectin was measured by radioimmunoassay. Diet intake was assessed using 24-h recalls and 3-day diet records. Data were analyzed via t-tests and repeated-measures factorial ANOVA using time, diet, and replicate (cohort I vs. cohort II) as factors. Age, weight, body fat, BMI, adiponectin, and diet were similar at baseline. Following intervention, macronutrient composition of the diet was vastly different between the groups, reflecting the assigned diet. Both groups lost weight and body fat (P < 0.001), with effect in LC dieters greater than LF dieters (-9.1 kg vs. -4.97 kg weight, P < 0.05 and -5.45 kg vs. -2.62 kg fat, P < 0.001). Adiponectin increased in the LC (+1.92 mcg/ml, P < 0.01), but not the LF (+0.86 mcg/ml, P = 0.81), group. There was no correlation between weight loss and increase in adiponectin. These results confirm that diet-induced loss of weight and body fat is associated with increased adiponectin concentrations. This effect is evident with weight loss of 10% or more, and may be greater with LC diets.

Challenges of a worksite health promotion project.

It is estimated that American employers spend more than $900 billion annually on health care and that obesity-attributable health care expenditures total $75 billion. The authors discuss a yearlong health promotion research project aimed at obesity and involving eight small manufacturing companies. Three hundred forty-one employees randomly selected at the intervention and control worksites were followed at baseline and at 3, 6, and 12 months for anthropometric measures, lifestyle behaviors, absences, and work performance. The authors conclude that although the worksite offers unique opportunities to develop health promotion programs, these efforts are not without challenges due to the tensions regarding the need to protect and promote health for the population, the increasing concerns over health care costs and access, and the priority to maintain individuals' rights and privacy.

One-year comparison of a high-monounsaturated fat diet with a high-carbohydrate diet in type 2 diabetes.

OBJECTIVE: The purpose of this study was to compare the effects of high-monounsaturated fatty acid (MUFA) and high-carbohydrate (CHO) diets on body weight and glycemic control in men and women with type 2 diabetes. RESEARCH DESIGN AND METHODS: Overweight/obese participants with type 2 diabetes (n = 124, age = 56.5 +/- 0.8 years, BMI = 35.9 +/- 0.3 kg/m2, and A1C = 7.3 +/- 0.1%) were randomly assigned to 1 year of a high-MUFA or high-CHO diet. Anthropometric and metabolic parameters were assessed at baseline and after 4, 8, and 12 months of dieting. RESULTS: Baseline characteristics were similar between the treatment groups. The overall retention rate for 1 year was 77% (69% for the high-MUFA group and 84% for the high-CHO group; P = 0.06). Based on food records, both groups had similar energy intake but a significant difference in MUFA intake. Both groups had similar weight loss over 1 year (-4.0 +/- 0.8 vs. -3.8 +/- 0.6 kg) and comparable improvement in body fat, waist circumference, diastolic blood pressure, HDL cholesterol, A1C, and fasting glucose and insulin. There were no differences in these parameters between the groups. A follow-up assessment of a subset of participants (n = 36) was conducted 18 months after completion of the 52-week diet. These participants maintained their weight loss and A1C during the follow-up period. CONCLUSIONS: In individuals with type 2 diabetes, high-MUFA diets are an alternative to conventional lower-fat, high-CHO diets with comparable beneficial effects on body weight, body composition, cardiovascular risk factors, and glycemic control.

Benefits of high-protein weight loss diets: enough evidence for practice?

PURPOSE OF REVIEW: High-protein diets, often with carbohydrate restriction, are quite popular among overweight Americans pursuing strategies for weight control. Recently, well designed clinical trials have evaluated the anthropometric and metabolic effects of these diets. This review focuses on the impact of high-protein diets on energy expenditure and satiety; the diets' effects on weight loss, body composition, cardiovascular risk, and glycemic control; and potential detrimental consequences of high-protein intake. RECENT FINDINGS: Current evidence indicates that protein-induced energy expenditure and satiety contribute to weight control. Randomized, controlled trials continue to show comparable, if not superior, effects of high-protein diets compared with lower protein diets on weight loss, preservation of lean body mass, and improvement in several cardiovascular risk factors for up to 12 months. Evidence that chronic high-protein intake affects glucose metabolism is inconclusive at present. Further study of the long-term safety of diets with varying amounts of protein is warranted. SUMMARY: On the basis of patients' metabolic profiles and preferences, practitioners can recommend individualized, nutrient-rich diets within current nutritional guidelines for weight control. Diets moderately increased in protein and modestly restricted in carbohydrate and fat, particularly saturated fat, may have beneficial effects on body weight, body composition, and associated metabolic parameters. Key issues must be resolved regarding the long-term compliance and safety of chronic high-protein intake.

Plasma glycosylphosphatidylinositol-specific phospholipase D predicts the change in insulin sensitivity in response to a low-fat but not a low-carbohydrate diet in obese women.

Although circulating glycosylphosphatidylinositol-specific phospholipase D (GPI-PLD), a minor high-density lipoprotein-associated protein, is elevated in patients with insulin resistance or high triglycerides, no information is available on the effect of weight loss or changes in insulin sensitivity on circulating GPI-PLD levels. The objective of the study was to determine the effect of weight loss and changes in insulin sensitivity on plasma GPI-PLD levels. Forty-two nondiabetic obese women were included in the study, which involved a 3-month dietary intervention randomizing patients to a low-fat or a low-carbohydrate diet. The study's main outcome measures were plasma GPI-PLD levels and insulin sensitivity as estimated by the homeostasis model assessment. The very low carbohydrate diet group lost more weight after 3 months (-7.6 +/- 3.2 vs -4.2 +/- 3.5 kg, P < .01), although the decrease in insulin resistance was similar between groups. Weight loss with either diet did not alter plasma GPI-PLD levels. However, baseline GPI-PLD levels correlated with the change in insulin sensitivity in response to the low-fat diet, whereas baseline insulin sensitivity correlated with the change in insulin sensitivity in response to the low-carbohydrate diet. Plasma GPI-PLD may serve as a clinical tool to determine the effect of a low-fat diet on insulin sensitivity.

Obesity and presenteeism: the impact of body mass index on workplace productivity.

OBJECTIVE: To examine whether obesity is associated with increased presenteeism (health-related limitations at work). METHODS: Randomly selected manufacturing employees (n = 341) were assessed via height and weight measures, demographic survey, wage data, and the Work Limitations Questionnaire. The Work Limitations Questionnaire measures productivity on four dimensions. Analyses of variance and analyses of covariance were computed to identify productivity differences based on body mass index (BMI). RESULTS: Moderately or extremely obese workers (BMI > or =35) experienced the greatest health-related work limitations, specifically regarding time needed to complete tasks and ability to perform physical job demands. These workers experienced a 4.2% health-related loss in productivity, 1.18% more than all other employees, which equates to an additional $506 annually in lost productivity per worker. CONCLUSIONS: The relationship between BMI and presenteeism is characterized by a threshold effect, where extremely or moderately obese workers are significantly less productive than mildly obese workers.

Weight loss and metabolic benefits with diets of varying fat and carbohydrate content: separating the wheat from the chaff.

With the rising prevalence of both obesity and diabetes, the contributing role of diet to the prevention and treatment of these conditions has become a major focus of research, clinical practice, and public policy. There has been intense debate over which dietary regimens might be most effective for weight loss, with interest centered on the potential for specific dietary macronutrients to affect body composition, metabolism, and overall health. This Review addresses two regimens with distinct macronutrient prescriptions that have been widely touted as being beneficial for weight loss and/or metabolic profile: diets low in carbohydrate and diets high in monounsaturated fat. Although data from recent randomized, controlled trials suggest these popular diets may be useful for weight control, cardiovascular health, and glycemic control, longer studies of the efficacy and safety of varying macronutrient content are needed to strengthen the evidence base for nutritional recommendations. Until more support for specific macronutrient combinations is available, practitioners can recommend an array of diets with moderate amounts of macronutrients, tailored to individual needs and preferences.

Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials.

BACKGROUND: Low-carbohydrate diets have become increasingly popular for weight loss. However, evidence from individual trials about benefits and risks of these diets to achieve weight loss and modify cardiovascular risk factors is preliminary. METHODS: We used the Cochrane Collaboration search strategy to identify trials comparing the effects of low-carbohydrate diets without restriction of energy intake vs low-fat diets in individuals with a body mass index (calculated as weight in kilograms divided by the square of height in meters) of at least 25. Included trials had to report changes in body weight in intention-to-treat analysis and to have a follow-up of at least 6 months. Two reviewers independently assessed trial eligibility and quality of randomized controlled trials. RESULTS: Five trials including a total of 447 individuals fulfilled our inclusion criteria. After 6 months, individuals assigned to low-carbohydrate diets had lost more weight than individuals randomized to low-fat diets (weighted mean difference, -3.3 kg; 95% confidence interval [CI], -5.3 to -1.4 kg). This difference was no longer obvious after 12 months (weighted mean difference, -1.0 kg; 95% CI, -3.5 to 1.5 kg). There were no differences in blood pressure. Triglyceride and high-density lipoprotein cholesterol values changed more favorably in individuals assigned to low-carbohydrate diets (after 6 months, for triglycerides, weighted mean difference, -22.1 mg/dL [-0.25 mmol/L]; 95% CI, -38.1 to -5.3 mg/dL [-0.43 to -0.06 mmol/L]; and for high-density lipoprotein cholesterol, weighted mean difference, 4.6 mg/dL [0.12 mmol/L]; 95% CI, 1.5-8.1 mg/dL [0.04-0.21 mmol/L]), but total cholesterol and low-density lipoprotein cholesterol values changed more favorably in individuals assigned to low-fat diets (weighted mean difference in low-density lipoprotein cholesterol after 6 months, 5.4 mg/dL [0.14 mmol/L]; 95% CI, 1.2-10.1 mg/dL [0.03-0.26 mmol/L]). CONCLUSIONS: Low-carbohydrate, non-energy-restricted diets appear to be at least as effective as low-fat, energy-restricted diets in inducing weight loss for up to 1 year. However, potential favorable changes in triglyceride and high-density lipoprotein cholesterol values should be weighed against potential unfavorable changes in low-density lipoprotein cholesterol values when low-carbohydrate diets to induce weight loss are considered.

Diet-induced weight loss is associated with decreases in plasma serum amyloid a and C-reactive protein independent of dietary macronutrient composition in obese subjects.

Elevated levels of serum amyloid A (SAA) and C-reactive protein (CRP) have been associated with increased cardiovascular risk. Although levels of CRP decrease with weight loss, it is not known whether SAA decreases with weight loss or whether dietary macronutrient composition affects levels of either SAA or CRP. SAA and CRP levels were measured retrospectively on baseline and 3-month plasma samples from 41 obese (mean body mass index 33.63 +/- 1.86 kg/m2) women completing a randomized trial comparing a low-fat diet (n = 19) and a very low-carbohydrate diet (n = 22). For the 41 participants, there were significant decreases from baseline to 3 months in both LogSAA (P = 0.049) and LogCRP (P = 0.035). The very low-carbohydrate dieters had a significantly greater decrease in LogSAA (P = 0.04), but their weight loss also was significantly greater (-7.6 +/- 3.2 vs. -4.3 +/- 3.5 kg, P < 0.01). In this study, the decreases in inflammatory markers correlated significantly with weight loss (r = 0.44, P = 0.004 vs. LogSAA and r = 0.35, P = 0.03 vs. LogCRP). Also, change in LogSAA correlated with change in insulin resistance (r = 0.35, P = 0.03). Thus, in otherwise healthy, obese women, weight loss was associated with significant decreases in both SAA and CRP. These effects were proportional to the amount of weight lost but independent of dietary macronutrient composition.

The role of energy expenditure in the differential weight loss in obese women on low-fat and low-carbohydrate diets.

We have recently reported that obese women randomized to a low-carbohydrate diet lost more than twice as much weight as those following a low-fat diet over 6 months. The difference in weight loss was not explained by differences in energy intake because women on the two diets reported similar daily energy consumption. We hypothesized that chronic ingestion of a low-carbohydrate diet increases energy expenditure relative to a low-fat diet and that this accounts for the differential weight loss. To study this question, 50 healthy, moderately obese (body mass index, 33.2 +/- 0.28 kg/m(2)) women were randomized to 4 months of an ad libitum low-carbohydrate diet or an energy-restricted, low-fat diet. Resting energy expenditure (REE) was measured by indirect calorimetry at baseline, 2 months, and 4 months. Physical activity was estimated by pedometers. The thermic effect of food (TEF) in response to low-fat and low-carbohydrate breakfasts was assessed over 5 h in a subset of subjects. Forty women completed the trial. The low-carbohydrate group lost more weight (9.79 +/- 0.71 vs. 6.14 +/- 0.91 kg; P < 0.05) and more body fat (6.20 +/- 0.67 vs. 3.23 +/- 0.67 kg; P < 0.05) than the low-fat group. There were no differences in energy intake between the diet groups as reported on 3-d food records at the conclusion of the study (1422 +/- 73 vs. 1530 +/- 102 kcal; 5954 +/- 306 vs. 6406 +/- 427 kJ). Mean REE in the two groups was comparable at baseline, decreased with weight loss, and did not differ at 2 or 4 months. The low-fat meal caused a greater 5-h increase in TEF than did the low-carbohydrate meal (53 +/- 9 vs. 31 +/- 5 kcal; 222 +/- 38 vs. 130 +/- 21 kJ; P = 0.017). Estimates of physical activity were stable in the dieters during the study and did not differ between groups. These results confirm that short-term weight loss is greater in obese women on a low-carbohydrate diet than in those on a low-fat diet even when reported food intake is similar. The differential weight loss is not explained by differences in REE, TEF, or physical activity and likely reflects underreporting of food consumption by the low-fat dieters.

Psychosocial outcomes of a pilot multidisciplinary program for weight management.

OBJECTIVE: To investigate psychosocial effects of a 6-month pilot multidisciplinary weight-management program for young females. METHODS: Participants (n=57), ages 8-15, completed the Revised Children's Manifest Anxiety Scale (RCMAS) and Self-Perception Profile for Children (SPPC) at baseline, 6 months, and 12 months. RESULTS: Positive changes were noted in the scores of both surveys. Significant decreases occurred in the RCMAS mean Total Anxiety and Worry/Oversensitivity scores; significant increases were found in the SPPC mean Social Acceptance and Athletic Competence scores. CONCLUSIONS: Enrollment in multifaceted weight-management programs that include stress management and social support may reduce anxiety level and enhance self-perception.

A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women.

Untested alternative weight loss diets, such as very low carbohydrate diets, have unsubstantiated efficacy and the potential to adversely affect cardiovascular risk factors. Therefore, we designed a randomized, controlled trial to determine the effects of a very low carbohydrate diet on body composition and cardiovascular risk factors. Subjects were randomized to 6 months of either an ad libitum very low carbohydrate diet or a calorie-restricted diet with 30% of the calories as fat. Anthropometric and metabolic measures were assessed at baseline, 3 months, and 6 months. Fifty-three healthy, obese female volunteers (mean body mass index, 33.6 +/- 0.3 kg/m(2)) were randomized; 42 (79%) completed the trial. Women on both diets reduced calorie consumption by comparable amounts at 3 and 6 months. The very low carbohydrate diet group lost more weight (8.5 +/- 1.0 vs. 3.9 +/- 1.0 kg; P < 0.001) and more body fat (4.8 +/- 0.67 vs. 2.0 +/- 0.75 kg; P < 0.01) than the low fat diet group. Mean levels of blood pressure, lipids, fasting glucose, and insulin were within normal ranges in both groups at baseline. Although all of these parameters improved over the course of the study, there were no differences observed between the two diet groups at 3 or 6 months. beta- Hydroxybutyrate increased significantly in the very low carbohydrate group at 3 months (P = 0.001). Based on these data, a very low carbohydrate diet is more effective than a low fat diet for short-term weight loss and, over 6 months, is not associated with deleterious effects on important cardiovascular risk factors in healthy women.

Effect of weight change on bone mass in female adolescents.

The purpose of this study was to examine changes in bone mineral density/bone mineral content (BMD/BMC) in obese female adolescents (Tanner stages 2 to 4) pursuing a weight reduction program. This was a prospective pilot clinical investigation involving 92 obese females screened to meet inclusion criteria and required to participate in a 6-month weight loss intervention. Baseline, 6 months, and 12 months measurements were taken for total body/lumbar spine BMD/BMC and percentage body fat. Survey instrumentation included the following: calcium food frequency/24-hour dietary recall, physical activity, and psychological assessments for anxiety/self-esteem. Changes in bone measurements were compared with changes in body weight measurements using multiple linear regression. Other potentially confounding variables analyzed included bone area, calcium intake, baseline Tanner stage, activity level, and height. Total body/lumbar spine BMD/BMC changes were found to be most significantly correlated with weight changes in the subject population. Although mean weight increased, the rate of increase per a given height velocity slowed to an appropriate height for weight ratio. Individuals who lost weight did not lose BMD/BMC; however, the rate of growth declined when compared with all study subjects whose bone growth rate was consistent with normal weight female adolescents. In this study, weight changes were strongly related to bone measurement changes in an obese adolescent female population. Dietitians counseling obese young girls are encouraged to emphasize the importance of a healthy weight loss program with optimal calcium intake and inclusive of weight-bearing exercises.

Exercise and eating disorders in college-aged women: profiling excessive exercisers.

This study examined associations among excessive exercise, eating disorders, and selected psychological characteristics in college women (N = 586). Participants were recruited from university classes and administered the Obligatory Exercise Questionnaire, Eating Disorders Inventory-2, Bulimia Test-Revised, and other psychosocial measures. Results indicated that obligatory exercise is best viewed as multidimensional. These dimensions were used, through cluster analysis, to generate a typology of exercisers. One identified group clearly manifested eating disorder traits and behaviors, as well as signs of psychological disturbance. Another group who exercised with equal intensity but less emotional fixation showed the fewest signs of eating disorders and psychological distress.