Changes in Glycemic Load Are Positively Associated with Small Changes in Primary Stress Markers of Allostatic Load in Puerto Rican Women.

BACKGROUND: Puerto Ricans experience a high prevalence of type 2 diabetes. Dietary glycemic load (GL) and allostatic load (AL) have been linked with diabetes. AL, the wear and tear on the body from chronic stress, starts with secretion of primary stress markers from activation of the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic nervous system (SNS), and immune system. GL can act as a physiological stressor, contributing to the primary AL response. OBJECTIVE: We examined the relation between GL and a composite score of primary stress markers of AL in Puerto Rican adults. METHODS: Data were from the Boston Puerto Rican Health Study, a cohort study of Puerto Ricans, aged 45-75 y, including 262 men and 697 women with complete data at baseline and 2-y follow-up. GL was calculated from dietary intake obtained with an FFQ. Sex-specific composite primary AL scores included markers of the HPA axis (cortisol and dehydroepiandrosterone sulfate), SNS (epinephrine and norepinephrine), and immune system (C-reactive protein). Linear regression models were stratified by sex and adjusted for covariates. RESULTS: Mean ± SD baseline GL score was 155 ± 28 for men and 135 ± 34 for women. Mean primary stress AL score was 1.25 ± 1.14 for men and 1.25 ± 1.06 for women. GL was not associated with AL score in men. In women, increasing GL from baseline to 2 y was significantly associated with increasing AL, after adjusting for sociodemographics, physical activity, smoking, BMI, menopause, and baseline AL score (ß = 0.03; P = 0.049). Results became marginally significant after further adjustment for chronic diseases (P = 0.06) and intake of fats (P values: saturated fats = 0.08; trans fats = 0.06; unsaturated fats = 0.07), but the magnitude of the association remained unchanged. CONCLUSIONS: Increasing GL over 2 y was positively associated with increasing composite score of primary markers of AL in Puerto Rican women. More studies are needed to confirm our findings.

Provider-Level Variation in Smoking Cessation Assistance Provided in the Cardiology Clinics: Insights From the NCDR PINNACLE Registry.

Background Studies show suboptimal provision of smoking cessation assistance (counseling or pharmacotherapy) for current smokers attempting to quit. We aimed to identify smoking cessation assistance patterns in US cardiology practices. Methods and Results Among 328 749 current smokers seen between January 1, 2013, and March 31, 2016, in 348 NCDR (National Cardiovascular Data Registry) PINNACLE (Practice Innovation and Clinical Excellence)-affiliated cardiology practices, we measured the rates of cessation assistance. We used multivariable hierarchical logistic regression models to determine provider-, practice-, and patient-level predictors of cessation assistance. We measured provider variation in cessation assistance using median rate ratio (the likelihood that the same patient would receive the same assistance at by any given provider; >1.2 suggests significant variation). Smoking cessation assistance was documented in only 34% of encounters. Despite adjustment of provider, practice, and patient characteristics, there was large provider-level variation in cessation assistance (median rate ratio, 6 [95% CI , 5.76-6.32]). Practice location in the South region (odds ratio [OR], 0.48 [0.37-0.63] versus West region) and rural or suburban location (OR, 0.92 [0.88-0.95] for rural; OR, 0.94 [0.91-0.97] for suburban versus urban) were associated with lower rates of cessation assistance. Similarly, older age (OR, 0.88 [0.88-0.89] per 10-year increase), diabetes mellitus (OR, 0.84 [0.82-0.87]), and atrial fibrillation (OR, 0.93 [0.91-0.96]) were associated with lower odds of receiving cessation assistance. Conclusions In a large contemporary US registry, only 1 in 3 smokers presenting for a cardiology visit received smoking cessation assistance. Our findings suggest the presence of a large deficit and largely idiosyncratic provider-level variation in the provision of smoking cessation assistance.

An exploration of the role of religion/spirituality in the promotion of physicians' wellbeing in Emergency Medicine.

BACKGROUND: Burnout is highly prevalent among Emergency Medicine (EM) physicians and has significant impact on quality of care and workforce retention. The objective of this study was to determine whether higher religion/spirituality (R/S) is associated with a lower prevalence of burnout among EM physicians (primary outcome). A history of malpractice lawsuits and maladaptive behaviors were the secondary outcomes. METHODS: This was a cross-sectional, survey-based study conducted among a random sample of physicians from the Massachusetts College of Emergency Physicians mailing list. Burnout was measured using a validated 2-item version of the Maslach Burnout Inventory. Maladaptive behaviors (smoking, drinking, and substance use) and medical malpractice were self-reported. R/S measures included organized religiosity, religious affiliation, private R/S practice, self-rated spirituality, religious rest, and religious commitment. Logistic regression was used to model study outcomes as a function of R/S predictors. RESULTS: Of 422 EM physicians who received the invitation to participate, 138 completed the survey (32.7%). The prevalence of burnout was 27%. No significant associations were observed between burnout and R/S indicators. Maladaptive behaviors (adjusted OR = 0.42, CI: 0.19 to 0.96; p = 0.039) and history of medical malpractice (adjusted OR = 0.32; CI: 0.11 to 0.93; p = 0.037) were less likely among physicians reporting to be more involved in organized religious activity and to observe a day of rest for religious reasons, respectively. CONCLUSION: This study provides preliminary evidence for a possible protective association of certain dimensions of R/S on maladaptive behaviors and medical malpractice among EM physicians.

All-cause, cardiovascular, and cancer mortality rates in postmenopausal white, black, Hispanic, and Asian women with and without diabetes in the United States: the Women's Health Initiative, 1993-2009.

Using data from the Women's Health Initiative (1993-2009; n = 158,833 participants, of whom 84.1% were white, 9.2% were black, 4.1% were Hispanic, and 2.6% were Asian), we compared all-cause, cardiovascular, and cancer mortality rates in white, black, Hispanic, and Asian postmenopausal women with and without diabetes. Cox proportional hazard models were used for the comparison from which hazard ratios and 95% confidence intervals were computed. Within each racial/ethnic subgroup, women with diabetes had an approximately 2-3 times higher risk of all-cause, cardiovascular, and cancer mortality than did those without diabetes. However, the hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups. Population attributable risk percentages (PARPs) take into account both the prevalence of diabetes and hazard ratios. For all-cause mortality, whites had the lowest PARP (11.1, 95% confidence interval (CI): 10.1, 12.1), followed by Asians (12.9, 95% CI: 4.7, 20.9), blacks (19.4, 95% CI: 15.0, 23.7), and Hispanics (23.2, 95% CI: 14.8, 31.2). To our knowledge, the present study is the first to show that hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups when stratified by diabetes status. Because of the "amplifying" effect of diabetes prevalence, efforts to reduce racial/ethnic disparities in the rate of death from diabetes should focus on prevention of diabetes.

Determinants of racial/ethnic disparities in incidence of diabetes in postmenopausal women in the U.S.: The Women's Health Initiative 1993-2009.

OBJECTIVE: To examine determinants of racial/ethnic differences in diabetes incidence among postmenopausal women participating in the Women's Health Initiative. RESEARCH DESIGN AND METHODS: Data on race/ethnicity, baseline diabetes prevalence, and incident diabetes were obtained from 158,833 women recruited from 1993-1998 and followed through August 2009. The relationship between race/ethnicity, other potential risk factors, and the risk of incident diabetes was estimated using Cox proportional hazards models from which hazard ratios (HRs) and 95% CIs were computed. RESULTS: Participants were aged 63 years on average at baseline. The racial/ethnic distribution was 84.1% non-Hispanic white, 9.2% non-Hispanic black, 4.1% Hispanic, and 2.6% Asian. After an average of 10.4 years of follow-up, compared with whites and adjusting for potential confounders, the HRs for incident diabetes were 1.55 for blacks (95% CI 1.47-1.63), 1.67 for Hispanics (1.54-1.81), and 1.86 for Asians (1.68-2.06). Whites, blacks, and Hispanics with all factors (i.e., weight, physical activity, dietary quality, and smoking) in the low-risk category had 60, 69, and 63% lower risk for incident diabetes. Although contributions of different risk factors varied slightly by race/ethnicity, most findings were similar across groups, and women who had both a healthy weight and were in the highest tertile of physical activity had less than one-third the risk of diabetes compared with obese and inactive women. CONCLUSIONS: Despite large racial/ethnic differences in diabetes incidence, most variability could be attributed to lifestyle factors. Our findings show that the majority of diabetes cases are preventable, and risk reduction strategies can be effectively applied to all racial/ethnic groups.

Depression severity, diet quality, and physical activity in women with obesity and depression.

Major depressive disorder (MDD) is prevalent in clinical weight-loss settings and predicts poor weight-loss outcomes. It is unknown whether the severity of depressive symptoms among those with MDD is associated with diet quality or physical activity levels. This knowledge is important for improving weight-loss treatment for these patients. It was hypothesized that more severe depression is associated with poorer diet quality and lower physical activity levels among individuals with obesity and MDD. Participants were 161 women with current MDD and obesity enrolled in the baseline phase of a weight-loss trial between 2007 and 2010. Depression severity was measured with the Beck Depression Inventory II. The Alternate Healthy Eating Index was applied to data from three 24-hour diet recalls to capture overall diet quality. Daily metabolic equivalents expended per day were calculated from three 24-hour physical activity recalls. Greater depression severity was associated with poorer overall diet quality (estimate=-0.26, standard error 0.11; P=0.02), but not with physical activity (estimate=0.07, standard error 0.05; P=0.18), in linear regression models controlling for income, education, depression-related appetite change, binge eating disorder, and other potential confounds. Associations with diet quality were primarily driven by greater intake of sugar (r=0.20; P<0.01), saturated fat (r=0.21; P<0.01), and sodium (r=0.22; P<0.01). More severe depression was associated with poorer overall diet quality, but not physical activity, among treatment-seeking women with MDD and obesity. Future studies should identify mechanisms linking depression to diet quality and determine whether diet quality improves with depression treatment.

Spontaneous coronary artery dissection during cabergoline therapy.

Although spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, it should be considered during the evaluation of patients who have chest pain. Coronary vasospasm can lead to spontaneous dissection. The dopamine agonist cabergoline is known to cause digital vasospasm. Herein, we report a case of spontaneous right coronary artery dissection in a 43-year-old woman who was taking cabergoline as therapy for prolactinoma. To our knowledge, this is the first report of an apparent relationship between cabergoline therapy and spontaneous coronary artery dissection. The possible association of cabergoline with coronary artery spasm and dissection should be considered in patients who present with chest pain while taking this medication.

Prospective analysis of association between use of statins and melanoma risk in the Women's Health Initiative.

BACKGROUND: Melanoma is the most lethal form of skin cancer, with an estimated 68,130 new cases and 8700 deaths in the United States in 2010. The increasing incidence and high death rate associated with metastatic disease support the need to focus on prevention. The authors used data from the Women's Health Initiative (WHI) to assess whether 3-hydroxy-3 methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of melanoma. METHODS: The study population consisted of 119,726 postmenopausal white women, in which 1099 cases of malignant melanoma were identified over an average (± standard deviation) of 11.6 ± 3.2 years. All diagnoses were confirmed by medical record review and pathology reports. Information on statin use was collected at baseline and during follow-up. Self-administered and interview-administered questionnaires were used to collect information on other risk factors. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Analyses investigated the association of any statin use, type, potency, lipophilic status, and duration of use with melanoma. RESULTS: Statins were used by 8824 women (7.4%) at baseline. The annualized rate of melanoma was 0.09% among statin users and 0.09% among nonusers The multivariable adjusted HR for statin users compared with nonusers was 1.14 (95% CI, 0.91-1.43). There were no significant differences in risk based on statin type, potency, category, duration, or in time-dependent models. CONCLUSIONS: There was no significant association between statin use and melanoma risk among postmenopausal women in the WHI.

Prospective analysis of association between use of statins or other lipid-lowering agents and colorectal cancer risk.

PURPOSE: To determine whether 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) are associated with a decreased risk of colorectal cancer. METHODS: The population included 159,219 postmenopausal women enrolled in the Women's Health Initiative in which 2000 pathologically confirmed cases of colorectal cancer were identified during an average of 10.7 (S.D. 2.9) years. Information on statins was collected at baseline and years 1, 3, 6, and 9. Self- and interviewer-administered questionnaires were used to collect information on other risk factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by the use of Cox proportional hazards regression to evaluate the relationship between statin use and risk. Statistical tests were two-sided. RESULTS: Statins were used by 12,030 (7.6%) women at baseline. The annualized colorectal cancer rate was 0.13% among users and 0.12% among nonusers. The multivariable adjusted HR for users versus nonusers was 0.99 (95% confidence interval [CI], 0.83-1.20, p = .95), and 0.79 (95% CI, 0.56-1.11) for users of ≥3 years. In the multivariable adjusted time-dependent model, the HR for lovastatin was 0.62 (95% CI, 0.39-0.99). There was no effect of tumor location, stage or grade. CONCLUSIONS: There was a reduction in colorectal cancer risk associated with lovastatin and a nonsignificant association with longer duration of use.

Constipation and risk of cardiovascular disease among postmenopausal women.

BACKGROUND: Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events. METHODS: We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women's Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years). RESULTS: The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events. CONCLUSION: In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.

Religion and healthy lifestyle behaviors among postmenopausal women: the women's health initiative.

Worship attendance has been associated with longer survival in prospective cohort studies. A possible explanation is that religious involvement may promote healthier lifestyle choices. Therefore, we examined whether attendance is associated with healthy behaviors, i.e. use of preventive medicine services, non-smoking, moderate drinking, exercising regularly, and with healthy dietary habits. The population included 71,689 post-menopausal women enrolled in the Women's Health Initiative observational study free of chronic diseases at baseline. Attendance and lifestyle behaviors information was collected at baseline using self-administered questionnaires. Healthy behaviors were modeled as a function of attendance using logistic regression. After adjustment for confounders, worship attendance (less than weekly, weekly, and more than weekly vs. never) was positively associated with use of preventive services [OR for mammograms: 1.34 (1.19, 1.51), 1.41 (1.26, 1.57), 1.33 (1.17, 1.52); breast self exams: 1.14 (1.02, 1.27), 1.33 (1.21, 1.48), 1.25 (1.1, 1.43); PAP smears: 1.22 (1.01, 1.47-weekly vs. none)]; non-smoking: [1.41 (1.35, 1.48), 1.76 (1.69, 1.84), 2.27 (2.15, 2.39)]; moderate drinking [1.35 (1.27, 1.45), 1.60 (1.52, 1.7), 2.19 (2.0, 2.4)]; and fiber intake [1.08 (1.03, 1.14), 1.16 (1.11, 1.22), 1.31 (1.23, 1.39), respectively], but not with regular exercise or with lower saturated fat and caloric intake. These findings suggest that worship attendance is associated with certain, but not all, healthy behaviors. Further research is needed to get a deeper understanding of the relationship between religious involvement and healthy lifestyle behaviors and of the inconsistent patterns in this association.

The dynamics of chronic gout treatment: medication gaps and return to therapy.

OBJECTIVE: To identify gaps in therapy with urate-lowering drugs for the treatment of gout as well as factors associated with resuming therapy. METHODS: From 2 integrated delivery systems, we identified patients 18 years or older with a diagnosis of gout who initiated use of a urate-lowering drug from January 1, 2000 through June 30, 2006 and who had a gap in therapy. A gap was defined as a period of over 60 days after the completion of 1 prescription in which no refill for a urate-lowering drug was obtained. Survival curves were used to assess return to therapy of urate-lowering drugs. Cox proportional hazards analysis estimated the association between covariates and return to therapy. RESULTS: There were 4166 new users of urate-lowering drugs (97% received allopurinol), of whom 2929 (70%) had a gap in therapy. Among those with a gap, in 75% it occurred in the first year of therapy. Fifty percent of patients with a gap returned to therapy within 8 months, and by 4 years it was 75%. Age 45-74 years (<45 referent) and greater duration of urate-lowering drug use before the gap was associated with resuming treatment within 1 year. In contrast, receipt of nonsteroidal anti-inflammatory drugs or glucocorticoids in the year before the gap was associated with a reduced likelihood of resuming therapy. CONCLUSIONS: The majority of gout patients with gaps in urate-lowering drug use returned to treatment. More investigation is needed to better understand why patients may go for months without refilling prescriptions, given the clinical consequences of nonadherence.

A new dietary inflammatory index predicts interval changes in serum high-sensitivity C-reactive protein.

Inflammation is associated with a number of chronic conditions, such as cancer and cardiovascular disease. Reducing inflammation may help prevent or treat these conditions. Diet has consistently been shown to modulate inflammation. To facilitate research into the inflammatory effect of diet on health in humans, we sought to develop and validate an Inflammatory Index designed to assess the inflammatory potential of individuals' diets. An Inflammatory Index was developed based on the results of an extensive literature search. Using data from a longitudinal observational study that carefully measured diet and the inflammatory marker, serum high-sensitivity (hs) C-reactive protein (CRP), in approximately 600 adults for 1 y, we conducted analyses to test the effect of Inflammatory Index score on hs-CRP as a continuous and dichotomous (3 mg/L) indicator of inflammatory response, while controlling for important potential confounders. Results based on continuous measures of hs-CRP suggested that an increasing Inflammatory Index score (representing movement toward an antiinflammatory diet) was associated with a decrease in hs-CRP. Analyses using hs-CRP as a dichotomous variable showed that an antiinflammatory diet was associated with a decrease in the odds of an elevated hs-CRP (P = 0.049). The results are consistent with the ability of the Inflammatory Index to predict hs-CRP and provide additional evidence that diet plays a role in the regulation of inflammation, even after careful control of a wide variety of potential confounders.

Adherence with urate-lowering therapies for the treatment of gout.

INTRODUCTION: Adherence to urate-lowering drugs (ULDs) has not been well evaluated among those with gout. Our aim was to assess the level and determinants of non-adherence with ULDs prescribed for gout. METHODS: We identified persons using two integrated delivery systems aged 18 years or older with a diagnosis of gout who initiated use of allopurinol, probenecid or sulfinpyrazone from 1 January 2000 to 30 June 2006. Non-adherence was measured using the medication possession ratio (MPR) over the first year of therapy and defined as an MPR < 0.8. Descriptive statistics were calculated and logistic regression was used to estimate the strength of the association between patient characteristics and non-adherence. RESULTS: A total of 4,166 gout patients initiated ULDs; 97% received allopurinol. Median MPR for any ULD use was 0.68 (interquartile range (IQR) 0.64). Over half of the patients (56%) were non-adherent (MPR < 0.8). In adjusted analyses, predictors of poor adherence included younger age (odds ratio (OR) 2.43, 95% confidence interval (CI) 1.86 to 3.18 for ages <45 and OR 1.44, 95% CI 1.08 to 1.93 for ages 45 to 49), fewer comorbid conditions (OR 1.46, 95% CI 1.20 to 1.77), no provider visits for gout prior to urate-lowering drug initiation (OR 1.28, 95% CI 1.05 to 1.55), and use of non-steroidal anti-inflammatory drugs in the year prior to urate-lowering drug initiation (OR 1.15, 95% CI 1.00 to 1.31). CONCLUSIONS: Non-adherence amongst gout patients initiating ULDs is exceedingly common, particularly in younger patients with less comorbidity and no provider visits for gout prior to ULD initiation. Providers should be aware of the magnitude of non-adherence with ULDs.

Association between dietary fiber and markers of systemic inflammation in the Women's Health Initiative Observational Study.

OBJECTIVE: Systemic inflammation may play an important role in the development of atherosclerosis, type 2 diabetes, and some cancers. Few studies have comprehensively assessed the direct relations between dietary fiber and inflammatory cytokines, especially in minority populations. Using baseline data from 1958 postmenopausal women enrolled in the Women's Health Initiative Observational Study, we examined cross-sectional associations between dietary fiber intake and markers of systemic inflammation (including serum high-sensitivity C-reactive protein [hs-CRP], interleukin-6 [IL-6], and tumor necrosis factor-alpha receptor-2 [TNF-alpha-R2]) in addition to differences in these associations by ethnicity. METHODS: Multiple linear regression models were used to assess the relation between fiber intake and makers of systemic inflammation. RESULTS: After adjustment for covariates, intakes of dietary fiber were inversely associated with IL-6 (P values for trend were 0.01 for total fiber, 0.004 for soluble fiber, and 0.001 for insoluble fiber) and TNF-alpha-R2 (P values for trend were 0.002 for total, 0.02 for soluble, and <0.001 for insoluble fibers). Although the samples were small in minority Americans, results were generally consistent with those found among European Americans. We did not observe any significant association between intake of dietary fiber and hs-CRP. CONCLUSION: These findings lend support to the hypothesis that a high-fiber diet is associated with lower plasma levels of IL-6 and TNF-alpha-R2. Contrary to previous reports, however, there was no association between fiber and hs-CRP among postmenopausal women. Future studies on the influence of diet on inflammation should include IL-6 and TNF-alpha-R2 and enroll participants from ethnic minorities.

Dietary quality 1 year after diagnosis of coronary heart disease.

OBJECTIVE: The purpose of this ancillary study is to determine the quality of diets in patients with documented coronary heart disease (CHD). DESIGN: Dietary data were originally collected using a 24-hour dietary recall in 555 patients with CHD, 1 year after a diagnostic coronary angiography. Data used for this investigation were collected between March 2001 and November 2003. SUBJECTS/SETTING: Patients were participants in a clinical trial to improve adherence to lipid-lowering medications. The Alternate Healthy Eating Index, an instrument designed to evaluate the degree to which a diet has the potential to prevent cardiovascular disease, measured dietary quality. MAIN OUTCOME MEASURES: Linear regression models were used to assess the association of dietary quality with patients' sociodemographic and clinical characteristics. RESULTS: Mean age of participants was 61 years, with an average body mass index of 30 (calculated as kg/m(2)). Sixty percent were men. Average daily caloric intake was 1,775 kcal, with 50% of calories derived from carbohydrates, 18% from protein, and 32% from total fat. Average Alternate Healthy Eating Index score was 30.8 out of a possible maximum score of 80. Only 12.4% of subjects met the recommended consumption of vegetables, 7.8% for fruit, 8% for cereal fiber, and 5.2% for trans-fat intake. Lower dietary quality was associated with lower total caloric intake, as well as with smoking, obesity, and lower educational level. CONCLUSIONS: A high proportion of patients reported poor dietary quality 1 year after experiencing a coronary event. Our data support continued efforts to enhance healthful dietary changes over time for secondary prevention of CHD. Dietary change should be emphasized with CHD patients who are less educated, smokers, or obese.

Gender differences in predictors of body weight and body weight change in healthy adults.

BACKGROUND: Overweight and obesity are important predictors of a wide variety of health problems. Analysis of naturally occurring changes in body weight can provide valuable insights in improving our understanding of the influence of demographic, lifestyle, and psychosocial factors on weight gain in middle-age adults. OBJECTIVE: To identify gender-specific predictors of body weight using cross-sectional and longitudinal analyses. METHODS AND PROCEDURES: Anthropometric, lifestyle and psychosocial factors were measured at baseline and then quarterly for 1 year in 572 healthy adult volunteers from Central Massachusetts who were recruited between 1994 and 1998. Linear mixed models were used to analyze the relationship between body weight and potential predictors, including demographic (e.g., age, educational level), lifestyle (e.g., diet, physical activity, smoking), and psychosocial (e.g., anxiety, depression) factors. RESULTS: Over the 1-year study period, on average, men gained 0.3 kg and women lost 0.2 kg. Predictors of lower body weight at baseline in both men and women included current cigarette smoking, greater leisure-time physical activity, and lower depression and anxiety scores. Lower body weights were associated with a lower percentage of caloric intake from protein and greater occupational physical activity levels only among men; and with higher education level only among women. Longitudinal predictors of 1-year weight gain among women included increased total caloric intake and decreased leisure-time physical activity, and among men, greater anxiety scores. DISCUSSION: Demographic, lifestyle and psychosocial factors are independently related to naturally occurring changes in body weight and have marked differential gender effects. These effects should be taken into consideration when designing interventions for weight-loss and maintenance at the individual and population levels.

A randomized clinical trial comparing low-glycemic index versus ADA dietary education among individuals with type 2 diabetes.

OBJECTIVE: We compared the effects of a low glycemic index (GI) diet with the American Diabetes Association (ADA) diet on glycosylated hemoglobin (HbA1c) among individuals with type 2 diabetes. METHODS: Forty individuals with poorly controlled type 2 diabetes were randomized to a low-GI or an ADA diet. The intervention, consisting of eight educational sessions (monthly for the first 6 mo and then at months 8 and 10), focused on a low-GI or an ADA diet. Data on demographics, diet, physical activity, psychosocial factors, and diabetes medication use were assessed at baseline and 6 and 12 mo. Generalized linear mixed models were used to compare the two groups on HbA1c, diabetic medication use, blood lipids, weight, diet, and physical activity. RESULTS: Participants (53% female, mean age 53.5 y) were predominantly white with a mean body mass index of 35.8 kg/m(2). Although both interventions achieved similar reductions in mean HbA1c at 6 mo and 12 mo, the low-GI diet group was less likely to add or increase dosage of diabetic medications (odds ratio 0.26, P = 0.01). Improvements in high-density lipoprotein cholesterol, triacylglycerols, and weight loss were similar between groups. CONCLUSION: Compared with the ADA diet, the low-GI diet achieved equivalent control of HbA1c using less diabetic medication. Despite its limited size, this trial suggests that a low-GI diet is a viable alternative to the ADA diet. Findings should be evaluated in a larger randomized controlled trial.

Methodology for adding glycemic index and glycemic load values to 24-hour dietary recall database.

OBJECTIVES: We describe a method of adding the glycemic index (GI) and glycemic load (GL) values to the nutrient database of the 24-hour dietary recall interview (24HR), a widely used dietary assessment. We also calculated daily GI and GL values from the 24HR. METHODS: Subjects were 641 healthy adults from central Massachusetts who completed 9067 24HRs. The 24HR-derived food data were matched to the International Table of Glycemic Index and Glycemic Load Values. The GI values for specific foods not in the table were estimated against similar foods according to physical and chemical factors that determine GI. Mixed foods were disaggregated into individual ingredients. RESULTS: Of 1261 carbohydrate-containing foods in the database, GI values of 602 foods were obtained from a direct match (47.7%), accounting for 22.36% of dietary carbohydrate. GI values from 656 foods (52.1%) were estimated, contributing to 77.64% of dietary carbohydrate. The GI values from three unknown foods (0.2%) could not be assigned. The average daily GI was 84 (SD 5.1, white bread as referent) and the average GL was 196 (SD 63). CONCLUSION: Using this methodology for adding GI and GL values to nutrient databases, it is possible to assess associations between GI and/or GL and body weight and chronic disease outcomes (diabetes, cancer, heart disease). This method can be used in clinical and survey research settings where 24HRs are a practical means for assessing diet. The implications for using this methodology compel a broader evaluation of diet with disease outcomes.