Factors promoting completion of advance directives in the hospital.

BACKGROUND: The 1991 Patient Self-Determination Act required health care providers to give patients information about advance directives. OBJECTIVES: To investigate whether the requirement to distribute information to hospital patients increased completion of the health care proxy. To also explore factors that might influence use of advance directives, including demographic variables and methods of informing patients about the directives. PATIENTS AND METHODS: We interviewed 419 randomly selected patients who were admitted for a planned admission to two tertiary care, teaching hospitals. Patients at one hospital received proxy information before the day of admission, at a pretesting visit, or by mail. The other hospital distributed the proxy information only on the day of admission. RESULTS: Before receiving hospital materials, 17% of all patients had completed proxies. After receiving hospital proxy forms, an additional 40% completed proxies at the hospital that distributed forms before the day of admission. Only 4% of the patients completed proxies at the hospital that distributed information only on the day of admission. The most frequently cited barrier to completion of a proxy was not seeing the form. Few patients said they did not want to think about the subject. CONCLUSIONS: Completion rates for advance directives may be markedly improved by altering the time for distributing information to patients admitted to the hospital for a planned admission. Patients were more likely to complete a proxy in the hospital that distributed the form in advance of the day of admission, a result that was unexplained by other variables in the study. Although many patients would prefer to receive information about advance directives during an office visit with a physician, hospitalization can provide a valuable opportunity for many patients to complete directives.

Socioeconomic status and obesity: a review of the literature.

A review of 144 published studies of the relationship between socioeconomic status (SES) and obesity reveals a strong inverse relationship among women in developed societies. The relationship is inconsistent for men and children in developed societies. In developing societies, however, a strong direct relationship exists between SES and obesity among men, women, and children. A review of social attitudes toward obesity and thinness reveals values congruent with the distribution of obesity by SES in different societies. Several variables may mediate the influence of attitudes toward obesity and thinness among women in developed societies that result in the inverse relationship between SES and obesity. They include dietary restraint, physical activity, social mobility, and inheritance.

Health concerns of high school students and teachers' beliefs about student health concerns.

Information about health concerns of adolescents can assist in assessment and treatment of their particular medical problems. Because teachers are important figures in the lives of young people, their beliefs about student health concerns are often solicited. A survey to assess adolescent health concerns and teachers' beliefs about student health concerns was conducted in two urban high schools on a sample of 831 students and 146 teachers. An assessment of 22 health concerns among the students revealed that a moderate level of concern existed on virtually every issue (the mean percentage "very concerned" was 55%), with black students and girls reporting more concern about many topics. In contrast, teachers significantly underestimated the level of concern of the students by an average of 13%, consistently having inaccurate beliefs about the types and level of student concerns. Students are concerned about health issues and are in need of health education and counseling in these areas. Teachers are not always aware of the level and types of student health concerns and may not be good sources of information about adolescent health.

Ten-year changes in the obesity, abdominal adiposity, and serum lipoprotein cholesterol measures of Western Samoan men.

Previously reported associations between abdominal adiposity and coronary heart disease (CHD) may be mediated through serum lipids. In the present longitudinal study, 43 Western Samoan men who participated in a 1982 study were recontacted for a second determination of anthropometric and serum lipoprotein cholesterol levels. The men showed dramatic increases in weight (mean change +/- SD: 10.5 +/- 8.8 kg), abdominal circumference (10.0 +/- 7.6 cm), total cholesterol (49.5 +/- 26.4 mg/dl), and non-HDL cholesterol (53.1 +/- 26.6 mg/dl). A new indicator was used to estimate changes in abdominal adiposity: the residual from the regression of change in the abdominal circumference on change in body weight (the AR). The AR was significantly correlated with changes in total (r = 0.38) and non-HDL cholesterol (r = 0.39). Changes in HDL cholesterol were correlated with changes in weight only (r = -0.37). These bivariate relations remained significant in multiple linear regression analyses. These longitudinal results are the first to suggest changes in abdominal adiposity are related to changes in total and non-HDL cholesterol levels.

A practical method of estimating stature of bedridden female nursing home patients.

Accurate measurement of stature is important for the determination of several nutritional indices as well as body surface area (BSA) for the normalization of creatinine clearances. Direct standing measurement of stature of bedridden elderly nursing home patients is impossible, and stature as recorded in the chart may not be valid. An accurate stature obtained by summing five segmental measurements was compared to the stature recorded in the patient's chart and calculated estimates of stature from measurement of a long bone (humerus, tibia, knee height). Estimation of stature from measurement of knee height was highly correlated (r = 0.93) to the segmental measurement of stature while estimates from other long-bone measurements were less highly correlated (r = 0.71 to 0.81). Recorded chart stature was poorly correlated (r = 0.37). Measurement of knee height provides a simple, quick, and accurate means of estimating stature for bedridden females in nursing homes.

Nutrient intake and obesity in a multidisciplinary assessment of osteoarthritis.

The nutritional composition of diets and prevalence of obesity in 77 osteoarthritis patients were assessed biweekly for 12 weeks as part of a multidisciplinary approach to the management of osteoarthritis. Height was measured at the first visit, and weight was measured at each of the seven biweekly follow-up visits. A body mass index was calculated, based on height and weight, to determine obesity. Nutrient information was obtained by use of a 24-hour dietary recall and a food frequency questionnaire. Seventy-nine percent of the patients were obese. Obesity was positively related to pain from osteoarthritis and was more prevalent among these osteoarthritis patients than it is among the general geriatric population. Dietary intakes of vitamin D, folacin, vitamin B6, zinc, and pantothenic acid were below 80% of the recommended dietary allowance. Osteoarthritis patients may benefit from weight loss if they are obese and from eating more foods that supply the nutrients in which they are deficient. In addition to providing nutritional recommendations to avoid dietary deficiencies, a registered dietitian can assist in the multidisciplinary treatment of osteoarthritis by providing weight-control counseling and follow-up.

Psychological evaluation of well-being in the multidisciplinary assessment of osteoarthritis.

Relationships among psychological well-being, pain, and disability were investigated in 77 osteoarthritis patients who were followed up for 12 weeks by a multidisciplinary assessment and management team. The General Well-Being Schedule and six subscales were used to measure overall psychological well-being in this group of elderly patients (mean age, 69 years). Individuals with high levels of pain and disability at the initial and final visits had less psychological well-being, less control over emotions and behaviors, more concern about their health, and more depressive symptoms. Patients who were more disabled reported lower energy levels and more anxiety. Overall, the subset of osteoarthritis patients aged 65 to 74 years was similar in psychological well-being to the same age group in the general population.

Psychosocial aspects of the multidisciplinary assessment of osteoarthritis.

The social network, family functioning, and health-protective behaviors of 77 osteoarthritis patients treated for 12 weeks by a multidisciplinary team were assessed. Measures included assessments of social network using components of the OARS, family satisfaction using the APGAR, family cohesion and adaptability using the FACES II, alcohol abuse using the CAGE, and indicators of health-protective behaviors. Participants were generally socially active, socially integrated, and satisfied with family relationships. Reported health-protective behaviors were low, indicating the need for assistance in improving preventive health practices. Few of the patients appeared to be at risk for alcoholism. Improvements in pain and activities of daily living were not correlated with changes in social functioning. Social functioning appeared to be relatively stable and not altered by short-term improvements in osteoarthritis. Social workers can play an important role in facilitating individual and family adjustment to the limitations imposed by osteoarthritis and in the rehabilitation process for osteoarthritis patients.

Patterns of interrelations among health-promotion behaviors.

We examined the interrelationships among 36 health behaviors for men and 38 for women in a telephone survey of a national sample of 3,025 adults. Wide variations existed in the frequency of respondents engaging in healthy practices, ranging from 9% to 96%. Men practiced an average of 17, and women 19, healthy behaviors. Correlations between health behaviors were weak, with an absolute value averaging r = .07, ranging from r = .00 to r = .71. Factor analysis revealed 10 underlying dimensions among the behaviors, which we interpreted for men as: (1) health care use, (2) exercise and recreation activity, (3) alcohol use, (4) smoking, (5) physical activity, (6) dental care, (7) nutrition, (8) sleep, (9) beverage use, and (10) breakfast. Women had the same 10 factors as men, except for a women's health screening factor instead of a beverage use factor. These findings suggest that engaging in one health behavior is not necessarily associated with practicing others, and that public health and individual counseling efforts to encourage healthy behaviors should be multifaceted and behavior-specific.

Health promotion beliefs and practices of fourth-year medical students.

Little is known about medical student beliefs about health promotion issues or about their prevention practices with patients. We administered a questionnaire about health promotion beliefs and practices to fourth-year medical students in a required course, "Preventive Medicine in Clinical Practice," at the University of Maryland School of Medicine. During a three-year period we surveyed 343 students. A majority of students believed that most of 23 health behaviors were of some importance to health promotion, and their responses were similar to those of practicing physicians in prior studies. Most students reported that they assessed preventive practices in their patients but did not feel well prepared to counsel patients about health issues. Students reported they were currently unsuccessful in modifying patient health behaviors and expressed limited optimism about future success in helping patients change health promotion behaviors with further training and support. There were no differences between students entering primary care specialties and other students. Information about medical student health promotion and disease prevention beliefs and practices can be applied in curriculum development.

Health promotion: physicians' beliefs, attitudes, and practices.

There is a paucity of research describing the health-promotion beliefs, attitudes, and practices of physicians. Self-reported data from a survey of 1,040 primary care physicians showed that a majority of physicians (97 percent) believed they should modify patients' behaviors to minimize risk factors and rated a variety of health behaviors as important in promoting health. While most physicians gathered information about risk factors and believed they were prepared to counsel patients, only a small percentage (3-18 percent) reported being very successful in helping patients achieve behavioral change. However, given appropriate support, physicians reported that they could be up to six times more successful in influencing behavioral change. This study indicated that physicians have strong beliefs and interests in health promotion, are interested in continuing education about health promotion topics, and desire a variety of new skills to help patients modify their health behaviors.

Investigating whether medical students' intolerance of ambiguity is associated with their specialty selections.

At one medical school in 1982, 175 entering medical students indicated their medical specialty preferences, completed Budner's Intolerance of Ambiguity scale, and supplied demographic information. Most (91%) completed medical school, and their specialty choices at graduation from the National Resident Matching Program were recorded. Initial specialty preference was a poor predictor of later specialty choice (R2 = .11). The students' intolerance of ambiguity was not significantly associated with either their initial medical specialty preferences or their specialty choices at graduations. This finding supports previous studies showing that specialty preferences changed dramatically during medical school, but does not reveal any support for a relationship between students' initial intolerance of ambiguity and their specialty selections.

Dietary practices of ballet, jazz, and modern dancers.

Ballet dancers have been shown to have nutrition problems and poor dietary practices. We asked dance instructors and dance directors to distribute a questionnaire to dancers involved in three dance types. Of the 106 dancers who completed the questionnaire, 71% participated in ballet, 60% in jazz, and 74% in modern dance; 31% participated in all three types of dance. The body mass index was similar for all types of dancers. More than half (60%) of the dancers used vitamin and mineral supplements, and 18% of the females reported irregular menstruation. Wide ranges existed in intake of foods from each of four food groups, caffeine, and alcohol. Printed media (magazines and books) were the primary sources of nutrition information. Dietitians may encounter many types of dancers and should be aware that dancers involved in ballet and other types of dance may have dietary practices that could improve with nutrition education and counseling.

Acculturation and dietary practices among Korean Americans.

OBJECTIVE: Examine variation in dietary practices and nutritional intakes of Korean Americans at different acculturation levels. DESIGN: Cross-sectional mail survey. SUBJECTS/SETTING: US national sample of 348 Korean Americans (46% of the Korean American sample to whom questionnaires were delivered). STATISTICAL ANALYSIS PERFORMED: Analysis of variance, Pearson correlation, Spearman rank correlation, chi 2 test, and multiple regression analysis. RESULTS: Korean Americans who were more acculturated consumed more American food and less Korean food. American foods such as oranges, low-fat milk, bagels, tomatoes, and bread were consumed regularly by Korean Americans; Korean foods such as rice, kimchi, garlic, green onions, and Korean soup were also consumed regularly. American foods were adopted the most at breakfast and the least at dinner. Bicultural people regularly incorporated more different types of foods into their diet. Despite significant differences in dietary practices, dietary quality did not vary by acculturation status. APPLICATION/CONCLUSIONS: Acculturation was influential in the dietary patterns of Korean Americans. Specific information about Korean diet related to acculturation status can be used by dietitians who work with Korean Americans. Dietitians can benefit from gathering and applying specific information about Korean diets and diets of other ethnic groups; they also need to recognize the changing nature of dietary patterns as acculturation occurs.

Dietary habits, weight history, and vitamin supplement use in elderly osteoarthritis patients.

Osteoarthritis is a chronic disabling disease in the elderly, but few studies have examined nutritional parameters of osteoarthritis patients. For 82 ambulatory elderly osteoarthritis patients, a registered dietitian assessed the following: consumption of 72 food items, using a food-frequency questionnaire; weight history, by measuring current weight and asking the weight at age 20, maximum adult weight, and minimum adult weight; dietary habits; and vitamin supplement consumption. Joint pain and activities of daily living (ADL) were assessed by a physician. On the basis of the Four Food Group guidelines, dietary intakes were suboptimal in the dairy and grain groups, which are important sources of calcium, vitamin D, thiamin, iron, and riboflavin. Eighty percent of the sample were obese (BMI greater than or equal to 27). The average weight change since early adulthood was a gain of 59 lb. Current joint pain and ADL restrictions were not related to obesity or weight gain. Vitamin/mineral supplements were consumed by 37% of the sample.

Health protective behaviors in first year medical students.

Individual health behaviors are an important aspect of preventive care. A survey of 164 entering medical students examined their health protective behaviors, including the three things they most frequently did to protect their health and thirty specific health behaviors studied in a previous analysis of the general population. The first semester results show similarities between the students and the general population. Diet and sleep were among the most important health protective behaviors in students and the population, but exercise and relaxation/stress control were more prevalent in students than in the public. Medical students were much more likely to be nonsmokers and wear seat belts than the public, but less likely to get regular checkups or see doctors when they felt healthy. Students also reported fewer personal safety and accident prevention behaviors. A resurvey at the beginning of the second semester showed a very high consistency with original behaviors. Among the students there were few health behavior differences by sex and martial status. These findings suggest students in medical school practice common but not extensive health protective behaviors which do not decline severely upon entry to medical school.

Intolerance of ambiguity in students entering medical school.

Intolerance of ambiguity is the perception of ambiguous situations as a threat. Medical students with differing levels of intolerance of ambiguity may select medical specialties based upon the amount of ambiguity existing in the practice of each specialty. A cross-sectional survey at one state university administered Budner's Intolerance of Ambiguity Scale to all entering first-year medical students for four consecutive years (N = 609) to investigate patterns of intolerance of ambiguity in relationship with demographic variables and initial medical specialty preference. The medical students in this study were more intolerant of ambiguity than those first studied by Budner in 1962. Students entering in 1985 were slightly more intolerant of ambiguity than students in 1988. Students age 23 and older were less intolerant of ambiguity than students 18-22 years old. Men and students with natural/physical science undergraduate majors were more intolerant of ambiguity than their counterparts. However, medical specialty preference was not related to intolerance of ambiguity. Intolerance of ambiguity may be a personality trait or a learned characteristic, and needs further investigation.

Marital status, fatness and obesity.

Marital status is related to morbidity and mortality, with married people healthier and at lower risk of death than those who are unmarried (especially among men). However, the relationship between marital status and obesity is not well established. Role theory suggests through a marital causation model that people in the marital role are more likely to be obese, and through a marital selection model that people in the marital role are less likely to be obese because of stigmatization. The martial causation model was examined using data from the National Survey of Personal Health Practices and Consequences, a cross-sectional national telephone survey of 3025 adults age 20-64 in the United States. Sequential regression analyses revealed that married men were significantly fatter and more likely to be obese than never married or previously married men, even when demographic, social, and physical variables were controlled. By contrast, marital status was not significantly associated with fatness or obesity among women when other variables were controlled. The marital role appears to influence fatness and obesity among men, but not women.

Acculturation and health in Korean Americans.

Despite increasing research on the relationships between acculturation and health, it is unclear whether (1) ethnic group variation occurs in acculturation-health relationships, (2) acculturation components vary differently in relationship to health, (3) biculturalism has beneficial effects on health and (4) multidimensional health relationships occur with acculturation. This study examined the Korean American ethnic group, considering how acculturation was related with five dimensions of health: smoking, physical activity, fat intake, body weight, and reported health. Pretested questionnaires were mailed to a national sample with Korean American surnames, and 55% of the deliverable sample responded, producing 356 usable questionnaires. Acculturation was measured using a two-culture matrix model and Gordon's theoretical work, and showed three distinct groups (acculturated, bicultural and traditional) and four components (American structural, American cultural, Korean structural and Korean cultural). Bicultural men were least likely to smoke, while acculturated and bicultural women were more likely to smoke than traditional women. Korean structural and cultural components were related to men's smoking. Higher acculturation was related to light physical activity, but not to vigorous physical activity. Fat intake did not differ by acculturation status. Higher acculturation was associated with higher body weight and better self-reported health only in men. Higher American cultural component scores were associated with better self-reported health in men. Among Korean Americans, acculturation components varied in their relationships with health, beneficial effects of being bicultural on health were not found, and acculturation-health relationships were multidimensional. Overall, ethnic group variation in health occurred, with Korean Americans similar to some ethnic groups but different than others. Future health research and practice can benefit by acknowledging the complexity of acculturation and its multidimensional effects on health.

A conceptual model of the food and nutrition system.

The food system is a widely used concept, but few systematic frameworks model the full scope and structure of the food and nutrition system. Bibliographic searches, a modified Delphi technique, focus groups and interviews with experts on the topic were conducted to identify existing models of agriculture, food, nutrition, health and environmental systems. These models were examined, classified and synthesized into an integrated conceptual model of the food and nutrition system. Few existing models broadly described the system and most focused on one disciplinary perspective or one segment of the system. Four major types of models were identified: food chains, food cycles, food webs and food contexts. The integrated model developed here included three subsystems (producer, consumer, nutrition) and nine stages (production, processing, distribution, acquisition, preparation, consumption, digestion, transport, metabolism). The integrated model considers the processes and transformations that occur within the system and relationships between the system and other systems in the biophysical and social environments. The integrated conceptual model of the food and nutrition system presents food and nutrition activities as part of a larger context and identifies linkages among the many disciplines that deal with the food and nutrition system.