Daytime Sleepiness Is Associated with Lower Cognitive Scores: The Look AHEAD Study.

Background: Daytime sleepiness is common in older adults and may result from poor nighttime sleep due to sleep disordered breathing, fragmented sleep, or other sleep disorders. Daytime sleepiness may be associated with cognition in older adults. Objectives: We investigated the association between self-reported daytime sleepiness and cognitive function in the Look AHEAD clinical trial. Design: Observational follow-up of a randomized clinical trial of an intensive lifestyle intervention. Setting: Clinic. Participants: Participants (n=1,778) aged 45-76 years at baseline with type 2 diabetes and overweight or obesity. Interventions: Participants were randomized to an intensive lifestyle intervention for weight loss or a control condition of diabetes support and education. Measurements: Participants provided self-reported levels of daytime sleepiness at baseline and years 12-13. Cognitive function was assessed with a neurocognitive battery at years 12-13 and 18-20. Results: Participants who reported having frequent daytime sleepiness (often or always) performed significantly worse than others on the cognitive composite (-0.35; p-value=0.014) after controlling for covariates. When stratified by intervention arm, participants assigned to the intensive lifestyle intervention who reported often/always having daytime sleepiness performed worse on Digit Symbol Coding (-0.63; p-value=0.05) and Trail Making Part-B (-0.56; p-value=0.02) after controlling for covariates. Statistical interactions revealed associations between daytime sleepiness and the following covariates: race and ethnicity, APOE ε4 carrier status, baseline history of cardiovascular disease, and depression. Conclusions: Daytime sleepiness over ~13 years predicted poorer cognitive performance in older individuals who, by virtue of having diabetes and overweight/obesity, are at high risk for sleep disorders and cognitive impairment.

Lifestyle interventions influence relative errors in self-reported diet intake of sodium and potassium.

PURPOSE: To characterize the distribution of errors in self-reported sodium and potassium dietary intakes relative to more objective urine measures among participants receiving lifestyle interventions. METHODS: We analyzed longitudinal data from 900 individuals with hypertension who had been enrolled in a randomized controlled clinical trial to establish whether usual care or three lifestyle interventions (weight loss, sodium reduction, and combined weight loss and sodium reduction) could effectively substitute for phamacotherapy. Repeated standardized 24-hour diet recalls and 24-hour urine collections were collected over up to three years of follow-up to estimate sodium and potassium intakes. By contrasting self-reported and urine-based sodium and potassium data collected before and during interventions, we examined the relative impact of intervention assignment on estimated intakes, repeatability, and multivariate measurement error. RESULTS: Relative to urine-based measures, mean self-reported sodium intakes were biased about 10% lower among participants assigned to combined weight loss and sodium reduction, but were unaffected by the other interventions. The repeatability of self-report measures increased slightly with time, particularly among participants assigned to sodium interventions. Errors in self-reported sodium and potassium intakes were correlated before the start of the intervention, but became uncorrelated among individuals assigned to sodium restriction interventions. CONCLUSIONS: Lifestyle interventions may influence not only diet intake, but also the measurement of diet intake.

Using a hand-held computer to collect data in an orthopedic outpatient clinic: a randomized trial of two survey methods.

OBJECTIVES: In a randomized study, the authors examine how data can be collected at the point of care. Specifically, examining to what extent handheld computer data collection systems introduce bias or increase respondent difficulty. METHODS: Volunteers were randomized to 1 of 2 survey methods: the hand-held computer or a paper and pencil form of similar content. Differences between group scale scores were compared using the Wilcoxon (rank sum) test. RESULTS: The hand-held computer system produced comparable scores to paper and pencil surveys. However, there was evidence of lower internal consistency reliability with the handheld computer. CONCLUSIONS: This study demonstrated the comparability of the hand-held computer methodology to the paper and pencil methodology in obtaining survey information in an ambulatory clinic. The hand-held computer method of survey data collection offers an alternative to paper methods when point-of-care administration is acceptable. Preliminary evidence shows that this method produces comparable results to paper forms.

Predictors and mediators of successful long-term withdrawal from antihypertensive medications. TONE Cooperative Research Group. Trial of Nonpharmacologic Interventions in the Elderly.

BACKGROUND: National guidelines recommend consideration of step down or withdrawal of medication in patients with well-controlled hypertension, but knowledge of factors that predict or mediate success in achieving this goal is limited. OBJECTIVE: To identify patient characteristics associated with success in controlling blood pressure (BP) after withdrawal of antihypertensive medication. DESIGN: The Trial of Nonpharmacologic Interventions in the Elderly tested whether lifestyle interventions designed to promote weight loss or a reduced intake of sodium, alone or in combination, provided satisfactory BP control among elderly patients (aged 60-80 years) with hypertension after withdrawal from antihypertensive drug therapy. Participants were observed for 15 to 36 months after attempted drug withdrawal. MAIN OUTCOME MEASURES: Trial end points were defined by (1) a sustained BP of 150/90 mm Hg or higher, (2) a clinical cardiovascular event, or (3) a decision by participants or their personal physicians to resume BP medication. RESULTS: Proportional hazards regression analyses indicated that the hazard (+/- SE) of experiencing an end point among persons assigned to active interventions was 75% +/- 9% (weight loss), 68% +/- 7% (sodium reduction), and 55% +/- 7% (combined weight loss/sodium reduction) that of the hazard for those assigned to usual care. Lower baseline systolic BP (P < .001), fewer years since diagnosis of hypertension (P < .001), fewer years of antihypertensive treatment (P < .001), and no history of cardiovascular disease (P = .01) were important predictors of maintaining successful nonpharmacological BP control throughout follow-up, based on logistic regression analysis. Age, ethnicity, baseline level of physical activity baseline weight, medication class, smoking status, and alcohol intake were not statistically significant predictors. During follow-up, the extent of weight loss (P = .001) and urinary sodium excretion (P = .04) were associated with a reduction in the risk of trial end points in a graded fashion. CONCLUSIONS: Withdrawal from antihypertensive medication is most likely to be successful in patients with well-controlled hypertension who have been recently (within 5 years) diagnosed or treated, and who adhere to life-style interventions involving weight loss and sodium reduction. More than 80% of these patients may have success in medication withdrawal for longer than 1 year.

Antihypertensive medication use among recruits for the Trial of Nonpharmacologic Interventions in the Elderly (TONE).

OBJECTIVES: To examine the distribution and correlates of the classes of antihypertensive medications taken by persons aged 60 to 80. DESIGN: Cross-sectional screening. SETTING: Four academic medical centers in the southern and eastern United States. PARTICIPANTS: Volunteers (N = 2601) entering a clinical trial testing the value of nonpharmacologic approaches to control blood pressure who were either taking one or two (single or combined) medications for the treatment of hypertension and expressed willingness to be withdrawn from these medications according to a standardized protocol. MEASUREMENTS: Medication use, blood pressure, and data from self-administered questionnaires collected during standardized clinic visits. RESULTS: Calcium channel blockers (23.9%) were the most frequent single agent antihypertensive medications used by cohort members, followed by diuretics (17.9%) and angiotension-converting enzyme (ACE) inhibitors (17.5%). The most common combination agents were composed of diuretics with either calcium channel blockers (5.4%), ACE inhibitors (4.0%), or beta-blockers (3.7%). Women were twice as likely to be taking diuretics, and less likely to be taking ACE inhibitors and beta-blockers, than men. Blacks were more likely to be taking diuretics and calcium channel blockers, and less likely to be taking beta-blockers and ACE inhibitors, than others. These relationships could not be attributed to differences in geographical area, other demographic factors, age, or medical history. CONCLUSIONS: These usage patterns appear to mirror those in the population of the United States as a whole, which has trended toward greater usage of calcium channel blockers and ACE inhibitors with declining use of diuretics. The distribution of antihypertensive medications among older hypertensives is markedly different between women and men and between black Americans and others.

The Forsyth County Cervical Cancer Prevention Project--I. Cervical cancer screening for black women.

The Forsyth County Cervical Cancer Prevention Project was a 5 year National Cancer Institute-funded community-based public health education program implemented to address the problem of excess mortality from cervical cancer among black women in Forsyth County, North Carolina. The intervention was a community-based public health education program that included mass media, direct education workshops, and provision of education on cervical cancer and screening to health care providers. The intervention was implemented from November 1988 to September 1991. Evaluation of the community intervention used a quasi-experimental design, with Forsyth County, North Carolina, receiving the program and Durham County, North Carolina, serving as the control. Comparison of pre- and post-intervention telephone survey data revealed that, overall, awareness of cervical cancer and the Pap smear increased. Knowledge, attitudes and behaviors showed little change, considering those interviewed in aggregate. Among women defined as high-risk (elderly, low socioeconomic status, public health clinic patients and/or those who do not receive regular care), a significant trend toward greater participation in screening was detected for the 6 month period following the intervention. These results suggest that awareness of cervical cancer can be increased by public health education, but that the additional attention coming to patients through the actions of health care providers and health care delivery systems may supply the additional input needed to produce behavior change.

The Forsyth County Cervical Cancer Prevention Project--II. Compliance with screening follow-up of abnormal cervical smears.

The Forsyth County Cervical Cancer Prevention Project was a community-wide cancer education program to address the problem of cervical cancer incidence and mortality among minority women in Forsyth County, North Carolina. This paper reports program results with regard to increasing compliance with follow-up for abnormal cervical smears. An analysis of trends prior to and after implementation of the educational program was conducted in one private and two public health primary care clinics to provide an assessment of impact of the project in improving compliance with follow-up among black women. A similar analysis also was conducted for white women. The results of medical record reviews of follow-up procedures for 878 abnormal cervical smears suggested a modest program effect among black women. The percentage of black women who returned for follow-up and treatment of an abnormal cervical smear significantly increased during the time the program was in effect. The trend analysis further indicated that the decline did not begin prior to the intervention period and was maintained throughout the duration of the intervention. No significant change in the percentage who returned for follow-up was found for white women.

Factors influencing the return rate in a direct mail campaign to inform minority women about prevention of cervical cancer.

The Forsyth County Cervical Cancer Prevention Project was a 5-year community-based health education program funded by the National Cancer Institute. The program was developed to reduce cervical cancer mortality among black women in Forsyth County, and it was targeted to those ages 18 and older. The program tried to educate the target population through a combination of mass media and direct education. This paper reports on an experiment conducted to investigate sources of influence on the effectiveness of direct mail, a technique used to augment mass media health education. Direct mail has shown promise as a method for reaching target populations that are difficult to reach with other mass media approaches. Using commercially prepared mailing lists sorted by zip code and other characteristics of the resident, health-related materials can be targeted to persons at their homes. A randomized experiment involving 1,000 households was carried out to estimate the influence of type of postage and address (name versus "resident or occupant") on the response rate to direct mail. Results indicated that there was no significant advantage from use of first class over bulk rate postage, but the return was significantly greater when the envelope bore a name rather than "resident or occupant."

The use of illustrations and narrative text style to improve readability of a health education brochure.

Research suggests that much of the available health education literature requires a level of reading ability that makes it inaccessible to a large proportion of the population in greatest need of health information. The present study tested the value of illustrations and a narrative text style as means of improving the readability of a brochure designed to provide information on cervical cancer and condyloma. Two versions of the brochure were designed, one that had only text presented as simple sentences in bullet-type format (SMOG reading level score of 7.7), and a second version that had somewhat more difficult text formatted in a narrative style (SMOG grade level score of 8.4) together with drawings designed to complement the text. A randomized study design was used to test for comprehension, perceived ease of understanding, and overall rating of the two brochures. Women selected from one private and three public health primary-care clinics were randomly assigned to read one of the two brochures. The brochure with illustrations and narrative text was given a significantly higher overall rating than the one with bullet-type text and no illustrations, while no difference was found in perceived ease of reading. Among poor readers, comprehension was significantly greater for women who read the brochure with illustrations and narrative text, with no difference in comprehension of the two brochures for better readers. The results suggest that the use of aids such as illustrations and text style can make health education literature more accessible to high-risk populations, while remaining interesting enough to appeal to individuals at all levels of reading ability.

Implementation of mass media community health education: the Forsyth County Cervical Cancer Prevention Project.

The Forsyth County Cervical Cancer Prevention Project (FCP) is a community-based health education project funded by the National Cancer Institute. The target population includes around 25 000 black women age 18 and older who reside in Forsyth County, North Carolina. The overall goal of the program is to prevent mortality from cervical cancer by promoting Pap smears and return for follow-up care when needed. Based on the principles of social marketing, a plan to reach the target population with mass media educational messages through electronic and print channels was developed. Guided by marketing objectives, the target population was divided into relatively discrete segments. The segments included church attenders, patients in waiting rooms of public and selected health providers, female students at local colleges, shoppers, viewers of radio and television, newspaper readers, and business owners and managers. Introduction of the program was based on strategies developed for reaching the target population in each segment with television, radio and print mass media messages. Qualitative assessment of the mass media developed by the program indicated that all forms of communication helped to increase awareness of the program.

Errors in reporting cervical screening among public health clinic patients.

This study examines women's knowledge of whether or not they had a cervical smear as part of their examination in a public health clinic for sexually transmitted diseases. Usable interviews were completed with a cluster sample of 318 women. Approximately 56% of the women were not able to correctly report if they had a cervical smear; and 90% of the erroneous responses consisted of reporting a cervical smear when none actually was done. Young women and single women were more likely to report incorrectly. Overall, the results suggest considerable error in overreporting cervical screening in this population.

The role of focus groups in health education for cervical cancer among minority women.

Focus groups were used in the development of community-based public health education designed to reduce mortality from cervical cancer among black women in Forsyth County, North Carolina. The educational goals of this National Cancer Institute (NCI) funded project were to increase the proportion of black women, age 18 and older, who obtain Pap smears on a regular basis and return for followup care when necessary. A series of four focus groups were conducted to help develop the conceptual basis for designing educational messages and materials. The groups were led by a black, female professional focus group moderator, and explored a variety of health-related topics ranging from general, ordinary concerns of daily living to knowledge and attitudes about cancer screening. The group discussions suggested that health is regarded as very important to the target population, particularly when related to family functioning. Regarding the Pap smear, most women knew about the test, but had little awareness of its role in the early detection of cervical cancer. Fear and fatalism were clearly the dominant, top-of-mind reactions to cancer, and there was little differentiation among sites or types of cancer. Despite the overall pessimism, the groups agreed that early diagnosis and treatment provide the best hope for good outcomes with cancer.

Readability of the public education literature on cancer prevention and detection.

This paper presents an analysis of the readability level of the educational literature on cancer prevention and early detection. Cancer education brochures and pamphlets were obtained from the American Cancer Society, the National Cancer Institute, private companies, public nonprofit agencies, and state health departments. A total of 183 brochures and pamphlets were examined and reading level (SMOG) scores were computed for 159 of them. The average reading level of the printed cancer education materials was found to be between 10th and 11th grade, with little overall variation by publishing agency, topic, cancer site, focus, or target population. In general, the results suggest that much of the cancer education literature may be of limited value in providing information to the low-income, low-education population.