Activating lay health influencers to promote tobacco cessation.

OBJECTIVE: To evaluate the effect of tobacco cessation brief-intervention (BI) training for lay "health influencers," on knowledge, self-efficacy and the proportion of participants reporting BI delivery post-training. METHODS: Randomized, community-based study comparing In-person or Web-based training, with mailed materials. RESULTS: In-person and Web-training groups had significant post-training cessation knowledge and self-efficacy gains. All groups increased the proportion of individuals reporting BIs at follow-up, with no significant between-group differences. Irrespective of participants' prior intervention experience, 80%-86% reported BIs within the past 90 days; 71%-79% reported >1 in the past 30. CONCLUSIONS: Web and In-person training significantly increase health influencer cessation knowledge and self-efficacy. With minimal prompting and materials, even persons without BI experience can be activated to encourage tobacco cessation.

Description of a clinical stream of back-pain patients based on electronic medical records.

Back pain consists of a spectrum of conditions, with no common etiology and therefore no dominant method of treatment. The purpose of this study is to describe the complexity of a collection of 8000 back pain patients who appeared in an integrative medicine clinic, as a prelude to conducing comparative effectiveness research on CAM alternatives to conventional therapy. Approximately 23% of all clinic patients were diagnosed at some time with back pain. Nearly half had treatment periods of less than one month, while more than 25% were treated for back pain for more than two years. Women were represented more than twice as often as men. The initial diagnosis categories that occurred most frequently were lumbar symptoms, cervical symptoms, and a general category, with smaller numbers having lumbar anatomic, thoracic symptom, brachial neuritis, or sciatica diagnoses. There were few strong relationships between initial diagnosis pattern and length of back pain treatment period. While 77% of back pain patients presented with diagnoses in only a single category, there were many composite categories each of which was sparsely represented. Between 50% and 75% of patients used some CAM service, depending on their initial diagnosis pattern. Patients with complex initial diagnosis patterns strongly tended to chose CAM, and among CAM-users those with complex diagnoses tended toward chiropractic, as opposed to acupuncture or bodywork. The CAM usage patterns of men and women were highly similar. Again among CAM users, 82% used only a single type of CAM service, and multiple service uses tend to be combined at random. Between two-thirds and three-quarters of multiple CAM service users had very simple temporal patterns of use, dominated by use of one type of CAM at a time.

Intervention in overweight children improves body mass index (BMI) and physical activity.

BACKGROUND: Childhood obesity is a growing epidemic in family medicine with few clinical treatment options. We implemented and evaluated a group office-visit intervention by family physicians for overweight children and their parents, emphasizing nutrition and physical activity within a resiliency psychosocial model. METHODS: The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months in the study. Participants included 35 children who met eligibility criteria of being in third through fifth grades and having a body mass index (BMI) above the 85th percentile. The 3-month, 12-session intervention, "Choices," included topics on nutrition, physical activity, and resiliency. The sessions were developed for delivery by a family physician and a nutritionist who received training in positive psychology and resilience skills. Main outcome measures were BMI z scores for age and sex and z scores for weight by age and sex, as well as qualitative interviews to understand individual and family processes. RESULTS: The intervention resulted in a significant effect on one primary outcome, BMI z score (-0.138 per 9 months [P = .017]) and a trend toward significance on the weight for age z score (-0.87 per 9 months [P = .09]). The net shift of activity from the low metabolic equivalents (METs) to the high METs had an intervention effect of 2.84 METs (P = .037). Families reported lasting changes in behaviors and attitudes. DISCUSSION: The innovative approach used in this study demonstrated modest efficacy in reducing BMI z score, changing physical activity levels, and possibly shifting family dynamics.

A community-based intervention to prevent obesity beginning at birth among American Indian children: study design and rationale for the PTOTS study.

Eating and physical activity behaviors associated with adult obesity have early antecedents, yet few studies have focused on obesity prevention interventions targeting very young children. Efforts to prevent obesity beginning at birth seem particularly important in populations at risk for early-onset obesity. National estimates indicate that American Indian (AI) children have higher rates of overweight and obesity than children of other races/ethnicities. The Prevention of Toddler Obesity and Teeth Health Study (PTOTS) is a community-partnered randomized controlled trial designed to prevent obesity beginning at birth in AI children. PTOTS was developed to test the effectiveness of a multi-component intervention designed to: promote breastfeeding, reduce sugar-sweetened beverage consumption, appropriately time the introduction of healthy solid foods, and counsel parents to reduce sedentary lifestyles in their children. A birth cohort of 577 children from five AI tribes is randomized by tribe to either the intervention (three tribes) or the comparison condition (two tribes). The strengths and weaknesses of PTOTS include a focus on a critical growth phase, placement in the community, and intervention at many levels, using a variety of approaches.

Pilot study of inflammatory responses following a negative imaginal focus in persons with chronic pain: analysis by sex/gender.

BACKGROUND: Recent evidence suggests that differential stress and immune responses may play a role in the sex/gender disparity for pain. Pain pathology and psychological stress are both associated with elevated levels of proinflammatory cytokines. OBJECTIVE: This pilot study tested a negative imaginal focus to assess whether it would elicit a proinflammatory cytokine response and whether responses would vary by sex/gender. METHODS: Adults with chronic musculoskeletal pain were recruited from an outpatient, multidisciplinary pain clinic in Portland, Oregon, between 2007 and 2008. All participants underwent a psychologist-guided 10-minute focus on the negative aspects of their pain condition and the imagined worsening of their pain; no control group was used. Serum collected at baseline and postfocus (1, 2, and 2.5 hours) was assayed for interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). Cortisol was assayed at each time point and at 15 minutes postfocus. RESULTS: Thirty-six outpatients (aged 26-62 years; 23 women, 13 men) participated in the study. Compared with men, women displayed greater negative emotional expression during the experiment, and this in turn mediated their IL-6 inflammatory responses. Relative to men, the IL-6 response trajectory was delayed for women. The IL-6 and TNF-a findings suggest women's maximal cytokine responses were not captured by the final time point. CONCLUSIONS: This pilot study provides preliminary evidence that women with chronic pain may experience increased and delayed inflammatory responses following negative emotional expression induced by thinking negatively about their pain condition. The findings have implications for pain catastrophizing research. This early-phase research suggests that the timing and duration of the cytokine response are critical factors to consider in future pain research.

Cross-cultural comparison of visitors to CAM practitioners in the United States and Norway.

OBJECTIVES: The United States and Norway are among the countries that have the highest total expenditure on health per capita and also high utilization of complementary and alternative medicine (CAM). However, these countries have fundamentally different health care systems. The aim was therefore to compare characteristics of adults who have seen a CAM practitioner during the last year in the United States and Norway. METHODS: Data from the National Health Interview Survey in the United States from 2002 and the Level of Living survey in Norway from 2002 were used. Both surveys were nationally representative household surveys of the noninstitutionalized civilian population. The data consist of 6612 individuals from Norway and 31,044 individuals from the United States. RESULTS: In the United States, 7.4% of the population had seen a CAM practitioner during the last 12 months compared to 8.7% in Norway (p < 0.001 for difference). In both the United States and Norway, seeing a CAM practitioner was most strongly associated with seeing other health care practitioners and having experienced better or worse self-reported health in the last year. Being male and a daily smoker reduced the odds of seeing a CAM practitioner in both countries. In the United States, but not Norway, having higher education was strongly associated with seeing a CAM practitioner. Higher education was the variable with the biggest difference between the two countries. CONCLUSIONS: This study indicates that in a country that provides health care services for all based on need regardless of personal income (Norway), the utilization of CAM practitioners is higher and less associated with use of other health care providers than a country with low government expenditure on health (the United States).

Influence of stressors on breast cancer incidence in the Women's Health Initiative.

OBJECTIVE: To examine associations among life events stress, social support, and breast cancer incidence in a cohort of postmenopausal women. DESIGN AND MAIN OUTCOME MEASURE: Women's Health Initiative observational study participants, breast cancer free at entry, who provided assessment of stressful life events, social support, and breast cancer risk factors, were prospectively followed for breast cancer incidence (n = 84,334). RESULTS: During an average of 7.6 years of follow-up, 2,481 invasive breast cancers were diagnosed. In age-adjusted proportional hazards models, 1 stressful life event was associated with increased risk, but risk decreased with each additional stressful life event. After adjustment for confounders the decreasing risk was not significant. Stressful life events and social support appeared to interact in relation to breast cancer risk such that women who had greater number of stressful life events and low social support had a decreased risk of breast cancer. CONCLUSIONS: This study found no independent association between stressful life events and breast cancer risk. The results are compatible with a more complex model of psychosocial factors interacting in relation to breast cancer risk.

Using a website to build community and enhance outcomes in a group, multi-component intervention promoting healthy diet and exercise in adolescents.

OBJECTIVE: This article describes website use and behavioral outcomes in a multi-component lifestyle intervention promoting healthy diet and exercise. METHODS: A 2-year randomized clinical trial to improve bone density in 228 adolescent girls, the intervention included a website designed to enhance intervention adherence, retention of participants, and behavioral outcomes. Measures included diet and exercise recalls, surveys, and web-usage data. RESULTS: Website use was associated with increases in calcium intake (ss = 69.72, p =.01, ES = 0.15) and high-impact activity (ss = 10.93, p =.04, ES =.13). Use of web pages related to behavioral feedback and communications was not significantly associated with behavioral outcomes. The most visited website pages had content related to incentive points, caption contests, and fun facts. CONCLUSIONS: Web elements of a multi-component intervention may promote retention and engagement in target behaviors. Such websites may be most acceptable to adolescent participants if they blend fun and behavioral elements, rather than exclusively focusing on behavioral changes.

Hip bone density predicts breast cancer risk independently of Gail score: results from the Women's Health Initiative.

BACKGROUND: The Gail model has been commonly used to estimate a woman's risk of breast cancer within a certain time period. High bone mineral density (BMD) is also a significant risk factor for breast cancer, but it appears to play no role in the Gail model. The objective of the current study was to investigate whether hip BMD predicts postmenopausal breast cancer risk independently of the Gail score. METHODS: In this prospective study, 9941 postmenopausal women who had a baseline hip BMD and Gail score from the Women's Health Initiative were included in the analysis. Their average age was 63.0 +/- 7.4 years at baseline. RESULTS: After an average of 8.43 years of follow-up, 327 incident breast cancer cases were reported and adjudicated. In a multivariate Cox proportional hazards model, the hazards ratios (95% confidence interval [95% CI]) for incident breast cancer were 1.35 (95% CI, 1.05-1.73) for high Gail score (>or=1.67%) and 1.25 (95% CI, 1.11-1.40) for each unit of increase in the total hip BMD T-score. Restricting the analysis to women with both BMD and a Gail score above the median, a sharp increase in incident breast cancer for women with the highest BMD and Gail scores was found (P < .05). CONCLUSIONS: The contribution of BMD to the prediction of incident postmenopausal breast cancer across the entire population was found to be independent of the Gail score. However, among women with both high BMD and a high Gail score, there appears to be an interaction between these 2 factors. These findings suggest that BMD and Gail score may be used together to better quantify the risk of breast cancer.

Pilot study of dietary influences on mammographic density in pre- and postmenopausal Hispanic and non-Hispanic white women.

OBJECTIVE: The extent to which modifiable dietary factors may account for some of the variability demonstrated in mammographic density across ethnic groups is unknown. The purpose of this study was to provide pilot data describing the relationship between dietary variables and mammographic density in pre- and postmenopausal Hispanic and non-Hispanic white (NHW) women (N=238) ranging in age from 41 to 50 years (premenopausal only) or 56 to 70 years (postmenopausal only). DESIGN: Using a cross-sectional design, computer-assisted density assessments were performed on mammograms of both breasts and averaged for analysis. The Arizona Food Frequency Questionnaire was used to estimate dietary intake. RESULTS: Study participants were well educated and overweight, with mean mammographic densities ranging from 20.25% for postmenopausal Hispanic women to 46.94% for premenopausal NHW women. Hispanic women reported higher energy intake than NHW women, but energy-adjusted intake of other nutrients was generally comparable. There was preliminary evidence of ethnic variability in diet-mammographic density associations. Among premenopausal Hispanic women, density was inversely associated with dairy, calcium, and vitamin D intakes (P

Youth: a health plan-based lifestyle intervention increases bone mineral density in adolescent girls.

OBJECTIVE: To test the efficacy of a health plan-based lifestyle intervention to increase bone mineral density in adolescent girls. DESIGN: Two-year randomized, controlled trial. SETTING: Large health maintenance organization. PARTICIPANTS: Girls 14 to 16 years old with body mass index below the national median. Intervention Behavioral intervention (bimonthly group meetings, quarterly coaching telephone calls, and weekly self-monitoring) designed to improve diet and increase physical activity. MAIN OUTCOME MEASURES: Total bone mineral density was measured by dual-energy x-ray absorptiometry. Behavioral outcomes included intake of calcium, vitamin D, soda, and fruits and vegetables; high-impact and strength-training physical activity; measures of strength and fitness; and biomarkers (osteocalcin and naltrexone). RESULTS: Compared with control subjects, girls in the intervention group had significantly higher bone mineral density in the spine and trochanter regions during the first study year, which was maintained during the second study year. The naltrexone biomarker demonstrated a greater relative decrease in the intervention group compared with the control group, with nonsignificant changes in osteocalcin consistent with more bone building in the intervention group. Participants in the intervention group reported significantly greater consumption of calcium in both study years, vitamin D in the first year, and fruits and vegetables in both years. We found no effect on soda consumption or target exercise rates. CONCLUSIONS: A comprehensive health care-based lifestyle intervention can effectively improve dietary intake and increase bone mineral gains in adolescent girls. To our knowledge, this study is the first to significantly improve bone mass in adolescent girls in a non-school-based intervention. Trial Registration ClinicalTrials.gov Identifier: NCT00067600.

Mammography screening rates decline: a person-time approach to evaluation.

OBJECTIVES: Early detection through mammography can reduce breast cancer mortality. This cohort study evaluated trends in mammography screening, demonstrating a person-time approach. METHODS: Included were women HMO members aged 50-69 from 1999 to 2002 who had not had breast cancer, dysplasia, fibrocystic disease, or implant. The amount of person-time covered by mammography as a percent of the time eligible for mammography screening (the prevention index (PI)) was calculated using electronic data. The denominator was the time during which the guidelines recommended that each participant should have been covered by a mammogram (every 24 months), excluding times when breast mass, abnormal mammogram, galactorrhea, or other breast disorders were under evaluation. The numerator was the time during which she was covered by a mammogram. RESULTS: The number of women who contributed person-time increased from 43,283 to 49,512 and the number of screening mammograms declined from 23,586 to 22,719. The overall PI for screening mammography declined from 67.0 (67% of eligible person-time was appropriately covered by a mammogram) to 62.5, and the proportion of women with no coverage during a given year increased 16%. CONCLUSIONS: This study shows a declining pattern of mammography screening using a person-time approach, a decline greater than that shown by methods that include diagnostic mammograms. The study highlights opportunities for use of the PI and quality improvement initiatives to improve breast cancer outcomes.

Linksets of tumor chromosome breakpoints related to survival in ovarian adenocarcinoma.

Biological processes are often accompanied by occurrences of multiple events, such as activation of certain cell types, change in prevalence of cell subpopulations (such as T cells), changes in concentration of proteins or peptides, or breaks in chromosomes. Some co-occurrences of these events are by chance, but others may have meaningful relations to the underlying biological process. The methodology of linksets is designed to detect the presence of potentially meaningful co-occurrences. Due to the complex ways in which linksets can determine the observed occurrences of multiple events, some moderately powerful computational methods are necessary for statistical estimation. Here, linkset models are fitted to data on chromosome breakpoints in ovarian adenocarcinomas, in order to answer the question motivating the project that collected them--whether there are nonrandom co-occurrences of breakpoints in particular chromosome regions, and whether these might be of prognostic significance. The results identify breakpoints in 1p1 as associated with early mortality when they occur in linksets of breakpoints in 1p3 and any one of 11q1, 11q2, or 6q2. Conversely, breakpoints in 6p2, 1q3, and 7p1 occur in linksets associated with late mortality. This is, to our knowledge, the first demonstration of a new method for analyzing patterns of event occurrence in biological data.

Informing cancer prevention strategies for African Americans: the relationship of African American acculturation to fruit, vegetable, and fat intake.

Acculturation has been associated with health-related behaviors in African Americans. We sought to determine if there is a relationship between acculturation and dietary intake in African Americans. African Americans in the PREMIER trial completed the African American Acculturation Scale (AAAS) and 2 nonconsecutive 24-h dietary recalls (n = 238). Analysis of variance (ANOVA) and canonical correlation were used to assess relationships between acculturation and dietary intakes. Canonical correlation (p = 0.05) showed that traditional African Americans had lower intakes of fruits/vegetables and milk/dairy with higher intakes of fats, meat, and nuts. This pattern was supported by differences in the ANOVA. African American acculturation is related to dietary intake. These findings have implications for the design of cancer-related public health messages targeted to African Americans.

Physical activity, cardiorespiratory fitness, and their relationship to cardiovascular risk factors in African Americans and non-African Americans with above-optimal blood pressure.

This report describes cross-sectional associations among physical activity, cardiorespiratory fitness, dietary habits, and cardiovascular disease (CVD) risk factors in a large sample (n = 810) of African Americans (n = 279) and non-African Americans (n = 531) with above-optimal blood pressure. Participants in PREMIER, a clinical trial for blood pressure control through lifestyle approaches, underwent baseline assessments to determine physical activity level, cardiorespiratory fitness category, dietary intake, and CVD risk factors. Mean levels of body mass index (BMI), total cholesterol, LDL cholesterol, HDL cholesterol, daily percent calories from fat and saturated fat, daily servings of fruits and vegetables, and daily fiber intake were examined across three physical activity levels and two fitness categories. Hypertension status was also assessed. Data were stratified by sex and ethnicity. For all participants, those in the low fitness category had higher BMI levels. Total cholesterol was lower in African American women in the high fitness category. Mean values of more than five daily servings of fruits and vegetables were reported by non-African American women and African American men in the high activity category. Higher intake of dietary fiber was found for non-African American women at the high activity level, with a similar trend observed for African American women. Future work examining these associations prospectively should include sufficient minority representation to enhance generalizability to all population groups and determine the beneficial effects from increased physical activity and improved cardiorespiratory fitness.

Bayes without priors.

BACKGROUND AND OBJECTIVES: Classical statistical inference has attained a dominant position in the expression and interpretation of empirical results in biomedicine. Although there have been critics of the methods of hypothesis testing, significance testing (P-values), and confidence intervals, these methods are used to the exclusion of all others. METHODS: An alternative metaphor and inferential computation based on credibility is offered here. RESULTS: It is illustrated in three datasets involving incidence rates, and its advantages over both classical frequentist inference and Bayesian inference, are detailed. CONCLUSION: The message is that for those who are unsatisfied with classical methods but cannot make the transition to Bayesianism, there is an alternative path.

Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment.

BACKGROUND: Many older patients with fractures are not managed in accordance with evidence-based clinical guidelines for osteoporosis. Guidelines recommend that these patients receive treatment for clinically apparent osteoporosis or have bone mineral density measurements followed by treatment when appropriate. This cohort study was conducted to further characterize the gap between guidelines and actual practice with regard to bone mineral density measurement and treatment of older women after a fracture. Our purpose was to aid in the design of more effective future interventions. METHODS: We identified female members of a not-for-profit group-model health maintenance organization who were fifty years of age or older and who had a diagnosis of a new fracture as defined in the study. We used administrative databases and the clinical electronic medical records to obtain data on demographics, diagnoses, drugs dispensed by the pharmacy, and the measurement of bone mineral density. RESULTS: The study population included 3812 women with an average age of 71.3 years. Fewer than 12% of the women had a diagnosis of osteoporosis prior to the index fracture; 10.7% had an increased risk for secondary osteoporosis and 38.8%, for falls because of a diagnosis or medication. It was found that 46.4% of the study population had been managed as specified by clinical guidelines. The patients who had been managed as specified by the guidelines were younger and less likely to have the risk factor of a weight of <127 lb (58 kg), a hip fracture, or a wrist fracture. They were also more likely to be taking steroids on a chronic basis and to have had a vertebral fracture. The percentage of women who had measurement of bone mineral density increased during the study period, from 1.3% in 1998 to 10.2% in 2001. Of the patients receiving treatment for osteoporosis, 73.6% adhered to the treatment regimen. CONCLUSIONS: Adherence to guidelines for evaluation and treatment for osteoporosis after a patient sustained a fracture did not improve between 1998 and 2001 despite the promulgation of evidence-based guidelines. Methods to enhance education and facilitate processes of care will be necessary to reduce this gap. It may be fruitful to target high-risk subgroups for tailored interventions for prevention of refracture.

The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults.

Dietary strategies to prevent and treat osteoporosis focus on increased intake of calcium and vitamin D. Modification of whole dietary patterns and sodium reduction may also be effective. We examined the effects of two dietary patterns and three sodium levels on bone and calcium metabolism in a randomized feeding study. A total of 186 adults, aged 23-76 y, participated. After a 2-wk run-in period, participants were assigned randomly to diets containing three levels of sodium (50, 100 and 150 mmol/d) to be consumed for 30 d in random order. Serum osteocalcin (OC), C-terminal telopeptide of type I collagen (CTX), fasting serum parathyroid hormone (PTH), urinary sodium, potassium, calcium and cAMP were measured at baseline and at the end of each sodium period. The Dietary Approaches to Stop Hypertension (DASH) diet reduced serum OC by 8-11% and CTX by 16-18% (both P < 0.001). Urinary calcium excretion did not differ between subjects that consumed the DASH and control diets. Reducing sodium from the high to the low level significantly decreased serum OC 0.6 microg/L in subjects that consumed the DASH diet, fasting serum PTH 2.66 ng/L in control subjects and urinary calcium 0.5 mmol/24 h in both groups. There were no consistent effects of the diets or sodium levels on urinary cAMP. In conclusion, the DASH diet significantly reduced bone turnover, which if sustained may improve bone mineral status. A reduced sodium intake reduced calcium excretion in both diet groups and serum OC in the DASH group. The DASH diet and reduced sodium intake may have complementary, beneficial effects on bone health.

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

PURPOSE: To describe PREMIER, a randomized trial to determine the effects of multi-component lifestyle interventions on blood pressure (BP). METHODS: Participants 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. CONCLUSION: Results from the PREMIER trial will provide scientific rationale for implementing multi-component behavioral lifestyle intervention programs to control BP and prevent CVD.

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

BACKGROUND: It 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. METHODS: Questionnaires 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. RESULTS: Overall, 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. CONCLUSIONS: Smoking 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.