The course of depressive symptoms in the first 12 months post-stroke and its association with unmet needs.

AIM: To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs. METHODS: A prospective cohort study among stroke patients admitted to inpatient rehabilitation. Depressive symptoms were assessed 3, 6, and 12 months post-stroke using the Hospital Anxiety and Depression Scale, and categorized into three trajectories: no (all times <8), non-consistent (one or two times ≥8), or persistent (all times ≥8) depressive symptoms. Unmet needs were assessed using the Longer-Term Unmet Needs questionnaire. Multivariable logistic regression analyses were used to investigate the association between depressive symptoms and unmet needs. RESULTS: One hundred and fifty-one patients were included, of whom 95 (62.9%), 38 (25.2%), and 18 (11.9%) had no, non-consistent, or persistent depressive symptoms, respectively. Depressive symptoms three months post-stroke persisted in 43.9% and recurred in 19.5% of patients during the first 12 months post-stroke. Depressive symptoms were significantly associated with the occurrence and number of unmet needs (odds ratio 6.49; p = 0.003 and odds ratio 1.28; p = 0.005, respectively). CONCLUSIONS: Depressive symptoms three months post-stroke were likely to persist or recur during the first 12 months post-stroke. Depressive symptoms are associated with unmet needs. These results suggest that routine monitoring of depressive symptoms and unmet needs should be considered post-stroke.Implications for rehabilitationPatients with depressive symptoms three months post-stroke have a high risk of developing persistent or recurrent depressive symptoms during the first 12 months post-stroke.Unmet needs are associated with both non-consistent and persistent depressive symptoms post-stroke.These results suggest that health professionals should routinely screen for depressive symptoms and health care needs around three months post-stroke.In patients with depressive symptoms at three months post-stroke early treatment of depressive symptoms and addressing unmet needs should be considered and depressive symptoms should be routinely monitored during the first 12 months post-stroke.

Societal burden of stroke rehabilitation: Costs and health outcomes after admission to stroke rehabilitation.

OBJECTIVE: To estimate societal costs and changes in health-related quality of life in stroke patients, up to one year after start of medical specialist rehabilitation. DESIGN: Observational. PATIENTS: Consecutive patients who received medical specialist rehabilitation in the Stroke Cohort Outcomes of REhabilitation (SCORE) study. METHODS: Participants completed questionnaires on health-related quality of life (EuroQol EQ-5D-3L), absenteeism, out-of-pocket costs and healthcare use at start and end of rehabilitation and 6 and 12 months after start. Clinical characteristics and rehabilitation costs were extracted from the medical and financial records, respectively. RESULTS: From 2014 to 2016 a total of 313 stroke patients completed the study. Mean age was 59 (standard deviation (SD) 12) years, 185 (59%) were male, and 244 (78%) inpatients. Mean costs for inpatient and outpatient rehabilitation were US$70,601 and US$27,473, respectively. For inpatients, utility (an expression of quality of life) increased significantly between baseline and 6 months (EQ-5D-3L 0.66-0.73, p = 0.01; visual analogue scale 0.77-0.82, p < 0.001) and between baseline and 12 months (visual analogue scale 0.77-0.81, p < 0.001). CONCLUSION: One-year societal costs from after the start of rehabilitation in stroke patients were considerable. Future research should also include costs prior to rehabilitation. For inpatients, health-related quality of life, expressed in terms of utility, improved significantly over time.

Health Care Use and Its Associated Factors 5-8 Years after Stroke.

OBJECTIVES: To describe health care use and its associated factors in the chronic phase after stroke. METHODS: Patients completed a questionnaire on health care use, 5-8 years after hospital admission for stroke. It comprised the number of visits to physicians or other health care professionals over the past 6 months (Physician-visits; Low ≤1 or High ≥2) and other health care professionals (Low = 0 or High ≥ 1). In addition the Longer-term Unmet Needs after Stroke (LUNS), Frenchay Activity Index (FAI) and Physical and Mental Component Summary Scales of the Short Form 12 (PCS and MCS) were administered. Their associations with health care use (high, low) were determined by means of logistic regression analysis, adjusted for sex and age. RESULTS: Seventy-eight of 145 patients (54%) returned the questionnaires; mean time-since-stroke was 80.3 months (SD10.2), age-at-stroke 61.7 years (SD13.8), and 46 (59%) were male. Physician contacts concerned mainly the general practitioner (58; 79.5%). Forty-one (52.6%) and 37 (47.4%) of the patients had a high use of physician and other health professionals visits, respectively. Worse PCS scores were associated with both high use of physician and other health professionals visits (OR .931; 95%CI .877-.987 and OR .941; 95%CI .891-.993, respectively), whereas the FAI, MCS, or LUNS were not related to health care use. CONCLUSIONS: Health care use after stroke is substantial and is related to physical aspects of health status, not to mental aspects, activities or unmet needs, suggesting a mismatch between patients' needs and care delivered.

Patients' outcome expectations and their fulfilment in multidisciplinary stroke rehabilitation.

BACKGROUND: Patients' expectations of the outcomes of rehabilitation may influence the outcomes and satisfaction with treatment. OBJECTIVES: For stroke patients in multidisciplinary rehabilitation, we aimed to explore patients' outcome expectations and their fulfilment as well as determinants. METHODS: The Stroke Cohort Outcomes of REhabilitation (SCORE) study included consecutive stroke patients admitted to an inpatient rehabilitation facility after hospitalisation. Outcome expectations were assessed at the start of rehabilitation (admission) by using the three-item Expectancy scale (sum score range 3-27) of the Credibility/Expectancy Questionnaire (CEQ). After rehabilitation, patients answered the same questions formulated in the past tense to assess fulfilment of expectations. Baseline patient characteristics were recorded and health-related quality of life (EQ-5D) was measured at baseline and after rehabilitation. The number of patients with expectations unfulfilled or fulfilled or exceeded was computed by subtracting the admission and discharge CEQ Expectancy scores. Multivariable regression analysis was used to determine the factors associated with outcome expectations and their fulfilment, estimating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We included 165 patients (96 males [58.2%], mean (SD) age 60.2 years [12.7]) who completed the CEQ Expectancy instrument at admission (median score 21.6, interquartile range [IQR] 17.0-24.0); 79 completed it both at admission (median score 20.6, IQR 16.6-24.4) and follow-up (median score 20.0, IQR 16.4-22.8). For 40 (50.6%) patients, expectations of therapy were fulfilled or exceeded. No patient characteristic at admission was associated with baseline CEQ Expectancy score. Odds of expectation fulfilment were associated with low expectations at admission (OR 0.70, 95% CI 0.60-0.83) and improved EQ-5D score (OR 1.35, 95% CI 1.04-0.75). CONCLUSIONS: In half of the stroke patients in multidisciplinary rehabilitation, expectations were fulfilled or exceeded, most likely in patients with low expectations at admission and with improved health-related quality of life. More research into the role of health professionals regarding the measurement, shaping and management of outcome expectations is needed.

Cognitive-motor interference during goal-directed upper-limb movements.

Research and clinical practice have focused on effects of a cognitive dual-task on highly automated motor tasks such as walking or maintaining balance. Despite potential importance for daily life performance, there are only a few small studies on dual-task effects on upper-limb motor control. We therefore developed a protocol for assessing cognitive-motor interference (CMI) during upper-limb motor control and used it to evaluate dual-task effects in 57 healthy individuals and two highly prevalent neurological disorders associated with deficits of cognitive and motor processing (57 patients with Parkinson's disease [PD], 57 stroke patients). Performance was evaluated in cognitive and motor domains under single- and dual-task conditions. Patterns of CMI were explored to evaluate overall attentional capacity and attention allocation. As expected, patients with neurological deficits showed different patterns of CMI compared to healthy individuals, depending on diagnosis (PD or stroke) and severity of cognitive and/or motor symptoms. Healthy individuals experienced CMI especially under challenging conditions of the motor task. CMI was greater in PD patients, presumably due to insufficient attentional capacity in relation to increased cognitive involvement in motor control. Although no general increase of CMI was observed in stroke patients, correlation analyses suggested that especially patients with severe motor dysfunction experienced CMI. Clinical ratings of cognitive and motor function were weakly associated with CMI, suggesting that CMI reflects a different construct than these unidimensional clinical tests. It remains to be investigated whether CMI is an indicator of difficulties with day-to-day activities.

The Longer-term Unmet Needs after Stroke Questionnaire: Cross-Cultural Adaptation, Reliability, and Concurrent Validity in a Dutch Population.

BACKGROUND: Unmet needs are common after stroke. We aimed to translate the 22-item Longer-term Unmet Needs after Stroke (LUNS) Questionnaire and validate it in a Dutch stroke population. METHODS: The LUNS was translated and cross-culturally adapted according to international guidelines. After field testing, the Dutch version was administered twice to a hospital-based cohort 5-8 years after stroke. Participants were also asked to complete the Frenchay Activity Index (FAI) and Short Form (SF)-12. To explore acceptability, the response and completion rates as well as number of missing items were computed. For concurrent validity, the differences in health status (FAI, SF-12) between groups who did and did not report an unmet need were calculated per item. To determine the 14-day test-retest reliability, the percentage of agreement between the first and the second administration was calculated for each item. RESULTS: Seventy-eight of 145 patients (53.8%) returned the initial Dutch LUNS (average age 68.3 [standard deviation 14.0] years, 59.0% male); 66 of these patients (84.6%) fully completed it. Of all items, 3.3% were missing. Among completers, the median number of unmet needs was 3.5 (2.0-5.0; 1.0-14.0). For 15 of 22 items, there was a significant association with the FAI or SF-12 Mental or Physical Component Summary scales. The percentage of agreement ranged from 69.8% to 98.1% per item. CONCLUSIONS: Among the 53.8% who completed the survey, the LUNS was concluded to be feasible, reliable, and valid; two-thirds of its items were related to activities and quality of life. Its usefulness and acceptability when administered in routine practice require further study.

Return to work of cancer patients after a multidisciplinary intervention including occupational counselling and physical exercise in cancer patients: a prospective study in the Netherlands.

OBJECTIVES: To support return to work (RTW) among cancer patients, a multidisciplinary rehabilitation programme was developed which combined occupational counselling with a supervised physical exercise programme during chemotherapy. The aim was to investigate RTW rates of cancer patients and to evaluate changes in work-related quality of life and physical outcomes. DESIGN: Longitudinal prospective intervention study using a one-group design. SETTING: Two hospitals in the Netherlands. PARTICIPANTS: Of the eligible patients, 56% participated; 93 patients with a primary diagnosis of cancer receiving chemotherapy and on sick leave were included. Patients completed questionnaires on RTW, the importance of work, work ability (WAI), RTW self-efficacy, fatigue (MFI), and quality of life (EORTC QLQ C-30) at baseline and 6, 12 and 18 months follow-up. Before and after the exercise programme 1-repetition maximum (1RM) muscle strength and cardiorespiratory fitness (VO2 peak) were assessed. RESULTS: Six months after the start of a multidisciplinary rehabilitation programme that combined occupational counselling with a supervised physical exercise programme, 59% of the cancer patients returned to work, 86% at 12 months and 83% at 18 months. In addition, significant improvements (p<0.05) in the importance of work, work ability, RTW self-efficacy, and quality of life were observed, whereas fatigue levels were significantly reduced. After completing the exercise programme, 1RM muscle strength was significantly increased but there was no improvement in VO2 peak level. CONCLUSIONS: RTW rates of cancer patients were high after completion of the multidisciplinary rehabilitation programme. A multidisciplinary rehabilitation programme which combines occupational counselling with a supervised physical exercise programme is likely to result in RTW, reduced fatigue and increased importance of work, work ability, and quality of life.

Practice variation in the structure of stroke rehabilitation in four rehabilitation centres in the Netherlands.

OBJECTIVE: To describe practice variation in the structure of stroke rehabilitation in 4 specialized multidisciplinary rehabilitation centres in the Netherlands. DESIGN AND METHODS: A multidisciplinary expert group formulated a set of 23 elements concerning the structure of inpatient and outpatient stroke rehabilitation, categorized into 4 domains: admission-related (n = 7), treatment-related (n = 10), client involvement-related (n = 2), and facilities-related (n = 4). In a cross-sectional study in 4 rehabilitation centres data on the presence and content of these elements were abstracted from treatment programmes and protocols. In a structured expert meeting consensus was reached on the presence of practice variation per element. RESULTS: Practice variation was observed in 22 of the 23 structure elements. The element "strategies for patient involvement" appeared similar in all rehabilitation centres, whereas differences were found in the elements regarding admission, exclusion and discharge criteria, patient subgroups, care pathways, team meetings, clinical assessments, maximum time to admission, aftercare and return to work modules, health professionals, treatment facilities, and care-giver involvement. CONCLUSION: Practice variation was found in a wide range of aspects of the structure of stroke rehabilitation.

Return-to-work intervention for cancer survivors: budget impact and allocation of costs and returns in the Netherlands and six major EU-countries.

BACKGROUND: Return-to-work (RTW)-interventions support cancer survivors in resuming work, but come at additional healthcare costs. The objective of this study was to assess the budget impact of a RTW-intervention, consisting of counselling sessions with an occupational physician and an exercise-programme. The secondary objective was to explore how the costs of RTW-interventions and its financial revenues are allocated among the involved stakeholders in several EU-countries. METHODS: The budget impact (BI) of a RTW-intervention versus usual care was analysed yearly for 2015-2020 from a Dutch societal- and from the perspective of a large cancer centre. The allocation of the expected costs and financial benefits for each of the stakeholders involved was compared between the Netherlands, Belgium, England, France, Germany, Italy, and Sweden. RESULTS: The average intervention costs in this case were €1,519/patient. The BI for the Netherlands was €-14.7 m in 2015, rising to €-71.1 m in 2020, thus the intervention is cost-saving as the productivity benefits outweigh the intervention costs. For cancer centres the BI amounts to €293 k in 2015, increasing to €1.1 m in 2020. Across European countries, we observed differences regarding the extent to which stakeholders either invest or receive a share of the benefits from offering a RTW-intervention. CONCLUSION: The RTW-intervention is cost-saving from a societal perspective. Yet, the total intervention costs are considerable and, in many European countries, mainly covered by care providers that are not sufficiently reimbursed.

Benefits of combining inspiratory muscle with 'whole muscle' training in children with cystic fibrosis: a randomised controlled trial.

BACKGROUND: The purpose of this study (randomised controlled trial) was to assess the effects of an 8-week combined 'whole muscle' (resistance+aerobic) and inspiratory muscle training (IMT) on lung volume, inspiratory muscle strength (PImax) and cardiorespiratory fitness (VO2 peak) (primary outcomes), and dynamic muscle strength, body composition and quality of life in paediatric outpatients with CF (cystic fibrosis, secondary outcomes). We also determined the effects of a detraining period. METHODS: Participants were randomly allocated with a block on gender to a control (standard therapy) or intervention group (initial n=10 (6 boys) in each group; age 10±1 and 11±1 years). The latter group performed a combined programme (IMT (2 sessions/day) and aerobic+strength exercises (3 days/week, in-hospital)) that was followed by a 4-week detraining period. All participants were evaluated at baseline, post-training and detraining. RESULTS: Adherence to the training programme averaged 97.5%±1.7%. There was a significant interaction (group×time) effect for PImax, VO2peak and five-repetition maximum strength (leg-press, bench-press, seated-row) (all (p<0.001), and also for %fat (p<0.023) and %fat-free mass (p=0.001), with training exerting a significant beneficial effect only in the intervention group, which was maintained after detraining for PImax and leg-press. CONCLUSION: The relatively short-term (8-week) training programme used here induced significant benefits in important health phenotypes of paediatric patients with CF. IMT is an easily applicable intervention that could be included, together with supervised exercise training in the standard care of these patients.

Aerobic fitness is associated with lower risk of hospitalization in children with cystic fibrosis.

BACKGROUND: Children with cystic fibrosis (CF) often have to be hospitalized because of acute exacerbation of their respiratory symptoms. Given the fact that improved peak oxygen uptake (VO2peak ) is positively associated with lung function and overall health in children with CF, this study examined the association between VO2peak and the need for hospitalization in a cohort of pediatric CF patients. METHODS: In a 3-year study, 77 CF children with mild-to-moderately severe CF (forced expiratory volume in 1 sec [FEV1 ] ≥ 50%) underwent a maximal exercise test to determine VO2peak . Anthropometric, lung function and muscle strength measurements were also conducted and dates of hospitalization were recorded for the study period. Associations were then determined between the variables recorded and hospitalization by univariate and multivariate Cox proportional hazards regression analyses. RESULTS: VO2peak was 38.6 ± 6.7 ml kg(-1) min(-1) for boys and 31.9 ± 6.9 ml kg(-1) min(-1) for girls. In multivariate analyses, VO2peak was the only variable significantly associated with time to hospitalization (hazard ratio 0.91, P = 0.03). CONCLUSION: A significant association was detected between greater aerobic fitness, and lower risk of hospitalization. Because hospitalization due to respiratory exacerbation is a powerful prognostic factor, our findings provide further support for the importance of aerobic fitness evaluation in the management of children with mild-to-moderately severe CF.

Physical exercise and return to work: cancer survivors' experiences.

PURPOSE: In this qualitative study, we aimed to explore cancer survivors' experiences with (1) return to work (RtW) and work performance, (2) a physical exercise program after treatment, and (3) the perceived link between physical exercise and work. METHODS: Semi-structured individual interviews were held with ten cancer survivors of working age who had been treated with chemotherapy and had afterwards completed a group-based supervised physical exercise program. The interviews were audio-taped and transcribed verbatim. MaxQDA was used for coding and analysis. A second assessor was involved in coding two of the interviews. RESULTS: Eight participants returned to work. Most said that they had suffered cognitive deficits that impaired their work performance. According to half of the participants, the support in RtW from their occupational physician had been insufficient. Overall, the majority of participants enjoyed the exercise program. The main perceived effects were "improved fitness" and "renewed energy." Most participants thought that physical exercise had likely contributed to their ability to return to work, primarily by increasing energy levels. Some believed that physical exercise had enhanced their work performance by improving their ability to cope with demanding work. Some respondents found that a supportive work environment stimulated their continuation of physical exercise. CONCLUSIONS: Cancer survivors experienced a positive influence of physical exercise on RtW and work performance and a positive influence of RtW on physical exercise. By stimulating and facilitating physical exercise during and after RtW, the time to lasting RtW may be shortened, work performance may be optimized, and sustained participation in physical exercise may be achieved. IMPLICATIONS FOR CANCER SURVIVORS: Stimulating and facilitating physical exercise before and during the process of RtW may enhance fitness and energy levels and may lower fatigue and cognitive symptoms during work. An integrated rehabilitation strategy combining physical exercise and adequate support in RtW may shorten the time to lasting RtW, improve work performance, and lead to sustained participation in physical exercise. Ultimately, this strategy may improve cancer survivors' quality of life.

A multidisciplinary intervention to facilitate return to work in cancer patients: intervention protocol and design of a feasibility study.

INTRODUCTION: Returning to work can be problematic for cancer survivors due to suboptimal workplace support, a heavy workload, decreased physical functioning and fatigue. The timely and permanent return to work (RtW) of cancer patients favourably influences quality of life and economic independence. Multidisciplinary interventions aimed at timely and enduring RtW are lacking. The objectives of this article are (1) to describe the protocol of an intervention aimed at RtW of cancer patients, comprising of counselling by an oncological occupational physician and supervised physical exercise in a clinical setting during treatment and (2) to present the design of the study aimed at evaluating the feasibility of this intervention. METHODS AND ANALYSIS: The intervention comprises three counselling sessions with an oncological occupational physician and a 12-week moderate-to-high intensity physical exercise programme, starting at the onset of chemotherapy. The intervention is aimed at cancer patients treated with curative intent, aged 18-60 years, employed and on sick leave. It will take place in two large medical centres in the Netherlands. The feasibility of the intervention will be evaluated as follows: the number of sessions, topics discussed and exercises executed will be registered by care providers; patients' and care providers' opinions will be assessed by questionnaires and interviews, respectively; and the proportion of invited patients that participated will be calculated. ETHICS AND DISSEMINATION: The study results will be used for optimising the intervention content and may serve as a foundation for future implementation. The Medical Ethics Committees of the Academic Medical Center and the participating medical centres approved the study protocol.

Health-related quality of life of Spanish children with cystic fibrosis.

PURPOSE: To investigate (1) the contributions of sex, age, nutritional status- and physical-fitness-related variables on health-related quality of life (HRQOL) in Spanish children with cystic fibrosis, and (2) the agreement on HRQOL between children and their parents. METHODS: In 28 children aged 6-17 years, body mass index percentile, percentage body fat, physical activity, pulmonary function, cardiorespiratory fitness, functional mobility, and dynamic muscle strength were determined using objective measures. HRQOL was measured using the revised version of the cystic fibrosis questionnaire. Simple and multiple linear regression analyses were performed to determine the variables associated with HRQOL. To assess the agreement on HRQOL between children and parents, intra-class correlation coefficients (ICCs) were calculated. RESULTS: Girls reported worse emotional functioning, a higher treatment burden, and more respiratory problems than boys. Greater functional mobility appeared associated with a less favourable body image and more eating disturbances. Agreement on HRQOL between children and parents was good to excellent, except for the domain of treatment burden. CONCLUSIONS: Sex and age were stronger predictors of HRQOL than nutritional status- or physical-fitness-related variables. Children reported a lower treatment burden than their parents perceived them to have.

Intrahospital weight and aerobic training in children with cystic fibrosis: a randomized controlled trial.

PURPOSE: The purpose of our study was to assess the effects of an 8-wk intrahospital combined circuit weight and aerobic training program performed by children with cystic fibrosis (of low-moderate severity and stable clinical condition) on the following outcomes: cardiorespiratory fitness (VO2peak) and muscle strength (five-repetition maximum (5RM) bench press, 5RM leg press, and 5RM seated row) (primary outcomes) and pulmonary function (forced vital capacity, forced expiratory volume in 1 s), weight, body composition, functional mobility (Timed Up and Down Stairs and 3-m Timed Up and Go tests), and quality of life (secondary outcomes). We also determined the effects of a detraining period (4 wk) on the aforementioned outcomes. METHODS: We performed a randomized controlled trial design. Eleven participants in each group (controls: 7 boys, age = 11 ± 3 yr, body mass index = 17.2 ± 0.8 kg · m(-2) (mean ± SEM); intervention: 6 boys, age = 10 ± 2 yr, body mass index = 18.4 ± 1.0 kg · m(-2)) started the study. RESULTS: Adherence to training averaged 95.1% ± 7.4%. We observed a significant group × time interaction effect (P = 0.036) for VO2peak. In the intervention group, VO2peak significantly increased with training by 3.9 mL · kg(-1) · min(-1) (95% confidence interval = 1.8-6.1 mL · kg(-1) · min(-1), P = 0.002), whereas it decreased during the detraining period (-3.4 mL · kg(-1) · min(-1), 95% confidence interval = -5.7 to -1.7 mL · kg(-1) · min(-1), P = 0.001). In contrast, no significant changes were observed during the study period within the control group. Although significant improvements were also observed after training for all 5RM strength tests (P < 0.001 for the interaction effect), the training improvements were not significantly decreased after the detraining period in the intervention group (all P > 0.1 for after training vs detraining). We found no significant training benefits in any of the secondary outcomes. CONCLUSIONS: A short-term combined circuit weight and aerobic training program performed in a hospital setting induces significant benefits in the cardiorespiratory fitness and muscle strength of children with cystic fibrosis.

Short and long term effects of a lifestyle intervention for construction workers at risk for cardiovascular disease: a randomized controlled trial.

BACKGROUND: The prevalence of overweight and elevated cardiovascular disease (CVD) risk among workers in the construction industry is relatively high. Improving lifestyle lowers CVD risk and may have work-related benefits. The purpose of the study was to evaluate the effects on physical activity (PA), diet, and smoking of a lifestyle intervention consisting of individual counseling among male workers in the construction industry with an elevated risk of cardiovascular disease (CVD). METHODS: In a randomized controlled trial including 816 male blue- and white-collar workers in the construction industry with an elevated risk of CVD, usual care was compared to a 6-month lifestyle intervention. The intervention consisted of individual counseling using motivational interviewing techniques, and was delivered by an occupational physician or occupational nurse. In three face to face and four telephone contacts, the participant's risk profile, personal determinants, and barriers for behavior change were discussed, and personal goals were set. Participants chose to aim at either diet and PA, or smoking. Data were collected at baseline and after six and 12 months, by means of a questionnaire. To analyse the data, linear and logistic regression analyses were performed. RESULTS: The intervention had a statistically significant beneficial effect on snack intake (ß-1.9, 95%CI -3.7; -0.02) and fruit intake (ß 1.7, 95%CI 0.6; 2.9) at 6 months. The effect on snack intake was sustained until 12 months; 6 months after the intervention had ended (ß -1.9, 95%CI -3.6; -0.2). The intervention effects on leisure time PA and metabolic equivalent-minutes were not statistically significant. The beneficial effect on smoking was statistically significant at 6 (OR smoking 0.3, 95%CI 0.1;0.7), but not at 12 months (OR 0.8, 95%CI 0.4; 1.6). CONCLUSIONS: Beneficial effects on smoking, fruit, and snack intake can be achieved by an individual-based lifestyle intervention among male construction workers with an elevated risk of CVD. Future research should be done on strategies to improve leisure time PA and on determinants of maintenance of changed behavior. Considering the rising prevalence of unhealthy lifestyle and CVD, especially in the aging population, implementation of this intervention in the occupational health care setting is recommended. TRIAL REGISTRATION: Current Controlled Trials ISRCTN60545588

Beverage consumption and anthropometric outcomes among schoolchildren in Guatemala.

This analysis explores the clustering of beverage patterns in a single day in private vs. public school children in urban Guatemala. This study is based on measurements taken from 356 third- and fourth-grade pupils from the highland city of Quetzaltenango. Height, weight and body mass index were assessed, and one day's intake of all foods and beverages using a pictorial workbook and dietician assisted recall. Mean differences in beverage consumption were compared for private vs. public school children and by anthropometric outcomes (stunting, overweight and obesity). Plain water was consumed by 30.9% of the children on the day intakes were measured, with higher proportions of water drinkers among private school children. Children having reported water intake on that day consumed 154 fewer kcal (-7.7%) compared with the energy intake of children not having reported water intake (P = 0.02). Significantly more children of high socio-economic status (SES) consumed dairy, fruit juice, commercial fruit juice, fruit drink and soda whereas low SES children consumed thin gruels and infusions. A key result from this study is the finding of a lower energy intake shown by children reporting water intake.

An individually based lifestyle intervention for workers at risk for cardiovascular disease: a process evaluation.

PURPOSE: Evaluate counselors' adherence to an intervention protocol, counselors' competence, and the associations between three process indicators and body weight at follow-up in a 6-month individually based lifestyle intervention for construction workers. DESIGN: Process evaluation with qualitative and quantitative data. SETTING: Occupational health service. SUBJECTS: A total of 408 male construction workers with an elevated risk of cardiovascular disease received the intervention, and 27 occupational health professionals delivered the intervention. INTERVENTION: Seven counseling sessions, the first during which four prescribed items had to be discussed. Motivational interviewing (MI) was used as a counseling technique. MEASURES AND ANALYSIS: The number of sessions and the items discussed were registered by the counselors. Adherence to MI was determined by expert scoring of transcripts of random segments of 19 counseling sessions. Counselors' competence was rated by participants and counselors separately. Associations between three process indicators and body weight at follow-up were determined by linear and logistic regression analyses. RESULTS: Two-thirds of all participants attended five or more sessions, and 38.5% attended all seven sessions. In 90.2% of all cases, the counselor discussed all obligatory items in the first session. MI adherence was reached in one audiotaped fragment. Most (86.3%) of all participants agreed with the counselor being competent. Neither counselors' competence nor number of sessions or items discussed was significantly associated with body weight loss. CONCLUSIONS: Performing five sessions and discussing four prescribed items was feasible for the counselors, whereas performing MI was not. Still, participants were positive about the counselors' competence and willing to attend the intervention sessions. Investigators are encouraged to report the evaluation of their intervention process to improve future lifestyle interventions in research or in practice.

Cost-effectiveness and cost-benefit of a lifestyle intervention for workers in the construction industry at risk for cardiovascular disease.

OBJECTIVE: To investigate the cost-effectiveness and cost-benefit of a lifestyle intervention for construction workers with an elevated risk of cardiovascular disease. METHODS: In this randomized controlled trial, usual care was compared to a 6-month individual-based lifestyle intervention. At 6 and 12 months, weight, absenteeism, health care use, and lifestyle-related expenses were determined. Missing data were imputed. A cost-effectiveness analysis was performed from a societal perspective. Uncertainty around the incremental cost-effectiveness ratio (ICER) was estimated by bootstrapped cost-effect pairs. A cost-benefit analysis was performed from an employer's perspective, subtracting the incremental costs from the incremental benefits. RESULTS: The ICER was € 145/kg weight loss. The difference between intervention and control group in net employer costs was € 254 (95% CI: -1070 to 1536). CONCLUSION: Implementation of this important and effective intervention depends on the societal and employer's willingness to pay.

Sustained body weight reduction by an individual-based lifestyle intervention for workers in the construction industry at risk for cardiovascular disease: results of a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a lifestyle intervention for male workers in the construction industry at risk of cardiovascular disease (CVD). METHODS: In a randomized controlled trial performed in the Netherlands between 2007 and 2009, usual care was compared to 6 months of individual counseling using motivational interviewing techniques, delivered face to face and by telephone. Participants aimed at improving energy balance-related behavior or smoking cessation. Linear regression analyses were performed to determine the effects. RESULTS: Body weight had significantly decreased at 6 (ß=-1.9, 95% CI -2.6; -1.2) and 12 months (ß=-1.8, 95%CI -2.8; -1.1). The intervention effects were also significant for diastolic blood pressure at 6 months (ß=-1.7, 95% CI -3.3; -0.1). Among participants who had aimed at energy balance, the intervention had a significant favorable effect on body weight at 6 (ß=-2.1, 95% CI -2.9; -1.3) and 12 months (ß=-2.2, 95% CI -3.1; -1.3) and at HDL cholesterol (ß=0.05, 95% CI 0.01; 0.10) and HbA1c (ß=-0.06, 95%CI -0.12; -0.001) at 12 months, although there was no intervention effect on these variables over time. CONCLUSION: Individual-based counseling resulted in significant beneficial long-term effects on body weight. This is an important finding for occupational health, considering the rising prevalence of obesity and CVD.