Greater engagement in valued activities is associated with less barriers to quitting smoking among smokers with mobility impairments.

BACKGROUND: Individuals with mobility impairments (MI; use equipment to ambulate) have a high prevalence of both smoking and depression. Behavioral activation (BA) purports that depressed mood is remediated through valued activity engagement and may facilitate smoking cessation in MI populations. OBJECTIVE: We examined cross-sectional associations between activity engagement and variables important for smoking cessation among a high-risk group of smokers (people with MIs) and also describe a smoking cessation intervention based on BA, given the lack of studies on smokers with MIs. METHODS: This study used data from a smoking cessation trial enrolling smokers with MIs (n = 263). We assessed valued activities, activity type, activity restriction due to MI, and replacement of restricted activities. Motivation and confidence to quit smoking, number of cigarettes per day, and mood were also assessed. Analysis was performed with generalized linear (or logistic) regression models adjusted for age and physical functioning using aggregated data at baseline. RESULTS: Greater number and frequency of valued activities was associated with less smoking, depression, negative affect, and stress and higher positive affect and self-efficacy to quit. Activity restriction was associated with greater odds of major depression, and activity replacement with lower odds of major depression, lower stress, and higher positive affect and self-efficacy. Strength of associations varied by activity type. CONCLUSIONS: Consistent with our theoretical model, BA activity constructs were associated with several mediators of smoking outcomes in the expected directions. Smokers engaging in valued activities have more favorable profiles for smoking cessation and mood management.

SisterTalk: final results of a culturally tailored cable television delivered weight control program for Black women.

BACKGROUND: Obesity among Black women continues to exceed that of other women. Most weight loss programs created without reference to specific cultural contexts are less effective for Black than White women. Weight control approaches accessible to Black women and adapted to relevant cultural contexts are important for addressing this problem. This paper reports the final results of SisterTalk, the randomized controlled trial of a cable TV weight control program oriented toward Black women. METHODS: A five group design included a comparison group and a 2 × 2 factorial comparison of a) interactive vs. passive programming and b) telephone social support vs no telephone support, with 12 weekly initial cable TV programs followed by 4 monthly booster videos. At baseline, 3, 8, and 12 months post randomization, telephone and in person surveys were administered on diet, physical activity, and physical measurements of height and weight were taken to calculate body mass index (BMI). Analysis of variance (ANOVA) was used to examine differences over time, and between treatment and comparison groups. Dose variables reflecting use of the TV/video and written materials were also assessed. RESULTS: At 3 months, BMI, weight, and dietary fat were significantly lower and physical activity significantly higher among women exposed to the Cable TV intervention compared to the wait-list comparison group. Significant dietary fat differences were still observed at 8 and 12 month evaluations, but not BMI or physical activity differences. Main effects were not observed for interactive programming or enhanced social support at any time point. Within the intervention group, higher watching of the TV series and higher reading of educational materials were both (separately) associated with significantly lower dietary fat. CONCLUSIONS: Cable TV was an effective delivery channel to assist Black women with weight control, increasing physical activity and decreasing dietary fat during an initial intervention period, but only dietary changes persisted Enhanced social support and the ability to interact with others during the show were not effective complementary intervention components as conducted in this trial. Future research to strengthen the ability of this approach to achieve long term effects may offer even more promising outcomes.

Correlates of weight patterns during middle age characterized by functional principal components analysis.

PURPOSE: Describing weight trajectories using functional methods may further our understanding of how weight impacts health. We characterize weight patterns and describe correlates of these patterns. METHODS: Using a subset of the Framingham Heart Study original cohort limited-access data set (n=1,429), we conducted a functional principal components analysis (PCA) of body mass index from 40 to 55 years of age. Scores from the principal component functions defined weight patterns. Gender-specific logistic regression models provided estimates of association with sociodemographic and lifestyle factors. RESULTS: Overall weight status, weight changes, and cycling emerged as weight patterns during middle age. Overweight/obesity at 25 years was the most consistent correlate of weight patterns (adjusted odds ratios [AORs] for men and women were 14.2 and 3.7 for overall overweight, 99.5 and 28.3 for overall obese, and 1.4 and 3.9 for cycling). Weight status at 25 years was not associated with weight gain in either gender or weight loss in men; for women the AOR was 2.7 for weight loss. CONCLUSIONS: Functional PCA described weight patterns during middle age. The strong associations between weight status at 25 years and overall weight status and cycling during middle age underscore the importance of addressing weight earlier in life.

Incident diabetes in relation to weight patterns during middle age.

The authors examined the association between weight patterns during middle age and incident type 2 diabetes mellitus using a subset (n = 1,476) of the Framingham Heart Study original cohort limited-access data set (1948-2003). Participants diagnosed with diabetes before age 50 years were excluded. A functional principal components analysis of body mass index from age 40 years to age 50 years was used to define weight patterns in terms of overall weight status (normal weight, overweight, or obese), weight change (weight loss, stable weight, or weight gain), and weight cycling. Overall overweight and obesity were associated with higher rates of diabetes (for overall overweight, crude hazard ratio (HR) = 3.2, 95% confidence interval (CI): 2.3, 4.6; for overall obesity, crude HR = 8.8, 95% CI: 6.0, 12.8). Weight cycling was also associated with higher rates of diabetes (crude HR = 1.6, 95% CI: 1.2, 2.1). Neither weight loss nor weight gain was associated with incident diabetes. After adjustment for overall weight status, weight cycling was no longer associated with higher rates of diabetes. This study underscores the importance of obesity in diabetes risk and the importance of preventing the development of overweight and obesity earlier in life.

Dietary behaviors and portion sizes of black women who enrolled in SisterTalk and variation by demographic characteristics.

OBJECTIVE: To describe the dietary behaviors of black women who enrolled in the SisterTalk weight control study. DESIGN: Baseline data collected via telephone survey and in-person screening. SETTING: Boston, Massachusetts and surrounding areas. PARTICIPANTS: 461 black women completed the baseline assessments. MAIN OUTCOME MEASURES: Measured height and weight; self-reported demographics, risk factors, and dietary variables including fat-related eating behaviors, food portion size, and fruit, vegetable, and beverage intake. ANALYSIS: Analysis of variance (ANOVA) models with food habits questionnaire (FHQ) scores as the dependent variable and demographic categories as the independent variables; ANOVA models with individual FHQ item scores as the dependent variable and ethnic identification as the independent variable. RESULTS: More than 60% reported eating < 5 servings of fruits and vegetables/day. Self-reported portion sizes were large for most food items. Older age, being born outside the United States, living without children, and being retired were significantly associated with a higher prevalence of fat-lowering behaviors. The frequency of specific fat-lowering behaviors and portion size also differed by ethnic identification. CONCLUSIONS AND IMPLICATIONS: The findings support the need for culturally appropriate interventions to improve the dietary intake of black Americans. Further studies should examine the dietary habits, food preparation methods, and portion sizes of diverse groups of black women.

Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers.

This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive any telephone calls, with an effectiveness to cost ratio of 1:US dollars 84. Our results suggest that telephone-based motivational smoking cessation counseling may be a feasible and cost-effective method for low-income pregnant smokers enrolled in prenatal care.

Assessing fat-related dietary behaviors among black women: reliability and validity of a new Food Habits Questionnaire.

OBJECTIVE: To describe the development of the SisterTalk Food Habits Questionnaire (STFHQ). DESIGN: Formative research was conducted to adapt previous tools for the study's target population. A pilot tool (168 questions) was tested. The new 94-question tool was then used for evaluation of the SisterTalk project. Lastly, a 4-week reliability calibration study of the revised STFHQ was conducted in comparison with a food frequency questionnaire (FFQ). ANALYSIS: Reliability was assessed using test-retest correlations. Validity was assessed by correlations between STFHQ scores with FFQ calculated calories, total fat (g) and percentage of calories from fat. Three scoring methods (ie, introductory, product, and detail) were calculated along with inclusion or exclusion of dining out questions and alternate methods of scoring for food items not consumed. RESULTS: Reliability (correlation) was 0.87. Inclusion of dining out questions and imputation of zero for food items never consumed were more highly associated with fat intake than other scoring methods. The introductory score was most highly correlated with fat (g), whereas the product and detail scoring methods correlated highest with percentage of calories from fat. Responsiveness to the SisterTalk intervention was highest with the detail score. CONCLUSIONS AND IMPLICATIONS: The STFHQ is a reliable and valid tool that may be useful for evaluating dietary change for black women.

Melanoma early detection with thorough skin self-examination: the "Check It Out" randomized trial.

BACKGROUND: Monthly thorough skin self-examination (TSSE) is an important practice for early melanoma detection that is performed by a small minority of the population. DESIGN: A randomized trial was conducted to determine whether a multicomponent intervention can increase TSSE performance and to describe the effects on performance of skin surgeries compared with a similar control intervention focused on diet. SETTING/PARTICIPANTS: One thousand three hundred fifty-six patients attending a routine primary care visit in southeastern New England participated in this trial. INTERVENTIONS: Participants received instructional materials, including cues and aids, a video, and a brief counseling session and (at 3 weeks) a brief follow-up phone call (from a health educator) and tailored feedback letters. MEASURES: Performance of TSSE assessed by telephone interview and having a surgical procedure performed on the skin were confirmed by examining medical records. RESULTS: TSSE was performed by substantially more participants at 2, 6, and 12 months in the intervention group than in the control group (55% vs 35%, p<0.0001 at 12 months). We also noted that a substantially higher proportion in the intervention group had skin surgery in the first 6 months (8.0% vs 3.6%, p=0.0005), but there was no difference at 6 to 12 months (3.9% vs 3.3%, p=0.5). CONCLUSIONS: The TSSE intervention was effective in increasing performance of TSSE, in that it resulted in increased surgery on the skin, and that increase in skin procedures only persisted for 6 months. Intervention to increase TSSE may result in long-term benefit in early detection of melanoma while causing only a short-term excess of skin surgeries.

Cost-effectiveness of minimal contact education strategies for cholesterol change.

OBJECTIVES: To compare the effectiveness and cost effectiveness of minimal contact nutrition interventions that varied in intensity on lowering total blood cholesterol (BC) levels. DESIGN: A randomized trial in which public, work, religious, and medical sites were randomly assigned to one of six minimal-contact nutrition interventions for lowering total BC. SETTING: 36 public, work, religious, and medical sites in southern New England (total sites = 144). PARTICIPANTS: The number of eligible participants at baseline was 10,144, which included 1425 Hispanics, who were over-recruited for this study. INTERVENTION: One of six brief interventions was provided to participants: 1) feedback tip sheet only; 2) tip sheet plus Rate Your Plate (RYP); 3) tip sheet, RYP, plus Let's Eat Kit (LEK); 4) all written materials plus CD audio intervention (AUD); 5) all written materials plus counseling from a trained lay person (LAY-C); and 6) all written materials plus counseling by a nutritionist (NUT-C). The educational materials were adapted to be culturally and linguistically appropriate for a Hispanic audience, and the counselors for the Hispanic participants were bilingual. MEASURES: Total blood cholesterol levels were measured using fingerstick methods at baseline, 3 months, and 12 months after the intervention. RESULTS: Blood cholesterol (BC) was significantly reduced from baseline to 12-month follow-up among most experimental groups. Only LAY-C and NUT-C conditions demonstrated significant BC reductions at three months. The BC change in the NUT-C group was statistically different from the feedback only condition at three months only. At three-month followup, BC was reduced 1.6% for the total sample, 2.8% for participants with borderline-high BC levels, and 3.4% for participants with high BC. Generally, the two conditions receiving counseling resulted in the largest percentage changes in BC levels. When examining BC change data by ethnicity, Hispanic participants in the audio condition achieved the largest overall 12-month change (4%). Generally, total costs increased as the intensity of the experimental condition increased. When comparing 3-month and 12-month cost effectiveness, LAY-C and NUT-C were approximately the same, whereas LEK and AUD conditions tended to become more expensive than the other interventions. CONCLUSIONS: Brief nutrition counseling is an effective component of BC reduction programs. Culturally tailoring programs can result in substantial reductions in BC among Hispanic participants. Overall, even the most expensive intervention was fairly inexpensive compared to other, more intensive clinical interventions.

Reliability of assessment and circumstances of performance of thorough skin self-examination for the early detection of melanoma in the Check-It-Out Project.

BACKGROUND: Thorough skin self-examination (TSSE) has substantial potential to reduce melanoma mortality by early detection. METHODS: We interviewed 2,126 patients before a scheduled routine visit with a primary care physician, at which participation in a randomized trial was offered as part of the Check-It-Out Project. We asked about skin examination behavior and related issues. RESULTS: By our a priori definition of TSSE, 18% of participants performed this activity, but other definitions led to widely varying estimates of 12% to 38%. Using a partner to assist in the examination was strongly associated with TSSE. That partner was generally the spouse, and wives were more likely to assist their husbands in these examinations than the reverse. The availability of a wall mirror was a particularly important predictor of TSSE performance. Visual impairment also affected performance. CONCLUSIONS: Estimates of TSSE performance vary substantially with the questions used to elicit this information. Partners, particularly spouses, appear to play a critical role in the conduct of TSSE, and wives appear more often and more effectively engaged in this process. Appropriate circumstances, such as availability of a wall mirror, are also important factors. These findings can be used to design interventions to increase TSSE performance with the ultimate aim of reducing melanoma mortality.

The development of SisterTalk: a cable TV-delivered weight control program for black women.

Overweight and obesity have reached epidemic proportions in the United States, with black women disproportionately affected. SisterTalk is a weight control program designed specifically for delivery to black women via cable TV. The theoretical and conceptual frameworks and formative research that guided the development and cultural tailoring of SisterTalk are described. Social Action Theory was applied in the development of SisterTalk along with a detailed behavioral analysis of the way that black women view weight and weight loss within the context of their cultural and social realities. The entire intervention development process was framed using this information, rather than by changing only superficial aspects of program delivery. Community networking and both qualitative and quantitative interview techniques from the fields of social marketing and cultural anthropology were used to involve black women from Boston in the design and implementation of a program that would be practical, appealing, and culturally sensitive. Also discussed are strategies for evaluating the program, and lessons learned that might have broader applicability are highlighted. The development of the SisterTalk program could provide a useful starting point for development of successful weight control programs for black women in other parts of the United States as well as for other ethnic and racial groups.

Baseline fat-related dietary behaviors of white, Hispanic, and black participants in a cholesterol screening and education project in New England.

OBJECTIVE: To examine baseline fat-related dietary behaviors of white, Hispanic, and black participants in Minimal Contact Education for Cholesterol Change, a National Institutes for Health-funded cholesterol screening and education project conducted in New England. SUBJECTS: A sample of 9,803 participants who joined the study at baseline (n=7,817 white; n=1,425 Hispanic; and n=561 black). METHODS: Participants completed baseline questionnaires that included demographic and psychosocial items as well as the Food Habits Questionnaire, a dietary assessment tool measuring fat-related dietary behaviors. They also had their blood cholesterol level and height and weight measured. STATISTICAL ANALYSES: Analysis of variance (ANOVA) was used to compare racial/ethnic groups on continuous demographic variables, and the chi(2) test of association was used to compare groups on demographic categorical variables. Multivariate analysis of variance (MANOVA) was used to compare mean differences between racial/ethnic groups on six behavioral subscales (Fat Factors) differentiating domains of behavior related to fat intake and to compare 27 individual fat-related dietary behaviors. RESULTS: After adjusting for sex, age, marital status, education, employment status, and percent time lived in the United States, white participants had the lowest Food Habits Questionnaire summary score (2.44) (indicating a lower fat diet), followed by Hispanic (2.61) and black (2.68) participants. The three ethnic groups also differed on the prevalence of Fat Factors and specific fat-related dietary behaviors. White participants were more likely to use lower-fat alternatives, to avoid frying, to replace meat, and to modify meat to make it lower in fat. However, they were least likely to eat fruits and vegetables for snacks and desserts. Hispanic participants were more likely to engage in fat-avoidance behaviors and to eat fruits and vegetables for snacks and desserts. Black participants were less likely to eat meatless meals and modify meats to make them lower in fat. Black and Hispanic participants were more likely than white participants to fry foods. Hispanics were less likely to read food labels for nutrition information. The most and least prevalent fat-related behaviors also differed by each ethnic group, showing that different behaviors were more and less easily implemented by each ethnic group. CONCLUSIONS/APPLICATIONS: The results of this study suggest that there is a need for improvement in dietary behaviors related to fat intake, especially for blacks and Hispanics, and that the specific dietary behavior issues differ widely by ethnicity. These results can be used by nutrition educators and researchers to help them decide what messages to emphasize in dietary counseling, nutrition education programs, and materials. The results can also be used to help design better dietary assessment tools and more effective interventions for culturally diverse populations.

Comparison of baseline fat-related eating behaviors of Puerto Rican, Dominican, Colombian, and Guatemalan participants who joined a cholesterol education project.

OBJECTIVE: The objective is to compare baseline fat-related eating behaviors among Hispanic subgroups who joined a cholesterol education research project in New England. DESIGN: Participants attended baseline screenings as part of the study. They had their height, weight, and blood cholesterol measured and completed baseline surveys with demographic, risk factor, dietary, and psychosocial questions. PARTICIPANTS: A total of 370 Puerto Rican, 210 Colombian, 357 Dominican, and 102 Guatemalan subjects participated in the baseline. MAIN OUTCOME MEASURES: Dietary behavior was measured using the Food Habits Questionnaire (FHQ), which was originally developed to assess food choices and preparation patterns related to adopting a low-fat diet. Measures include FHQ fat summary scores (a reflection of total fat intake), fat behavior subscales, and individual fat-related behaviors. ANALYSIS: Analysis of variance was used to compare FHQ fat summary scores and multivariate analysis of variance was used to compare fat behavior scores and individual food item scores for the 4 Hispanic subgroups. Age and gender were covariates in the models. RESULTS: Puerto Rican participants had a significantly higher mean FHQ fat summary score than Dominicans and Guatemalans and a higher prevalence of many fat-related eating behaviors. Although there were some differences by subgroup, the 4 most prevalent fat-related behaviors were similar: cooking with fat/oil, eating higher-fat sweets, eating higher-fat snacks, and eating dinners with meat. CONCLUSIONS AND IMPLICATIONS: Future educational programs and materials for diverse Hispanic audiences in the northeastern United States should include the above issues; however, educational materials and programs ought to be tailored to individuals whenever possible. Efforts may need to focus on Puerto Ricans, who had a higher prevalence of many fat-related behaviors in this study.

The accuracy of self-reported smoking status assessed by cotinine test strips.

We evaluated a new cotinine test strip to assess smoking status. Urine cotinine was measured using cotinine test strips and also by gas chromatographic techniques (GC) (as the reference criterion). Smoking status was assessed with a self-administered questionnaire. The cotinine test strip identified smokers with a very high level of agreement (97.3% using 100 ng/ml and 97.1% using 250 ng/ml for the cutoff point) and non-smokers with a fair-to-moderate level of agreement (74.5% using 100 ng/ml and 86.4% using 250 ng/ml for the cutoff point). These data suggest that the cotinine test strip appears to provide a reasonably accurate measure of smoking status. Since this was the first study to evaluate the cotinine test strip using the test strip prototype, larger clinical trials are needed to evaluate the validity of the cotinine test strip compared to GC measurements to confirm smoking status.