The relationship of health activation with risk of future cardiovascular disease among rural family caregivers of patients with chronic illnesses.

BACKGROUND: Family caregivers are at higher risk for developing cardiovascular disease (CVD) than non-caregivers. This risk is worse for those who live in rural compared to urban areas. Health activation, an indicator of engagement in self-care, is predictive of health outcomes and CVD risk in several populations. However, it is not known whether health activation is associated with CVD risk in rural caregivers of patients with chronic illnesses nor is it clear whether sex moderates any association. OBJECTIVES: Our aims were to determine (1) whether health activation independently predicts 10-year CVD risk; and (2) whether sex interacts with health activation in the prediction of 10-year CVD risk among rural family caregivers (N = 247) of patients with chronic illnesses. METHODS: Health activation was measured using the Patient Activation Measure. The predicted 10-year risk of CVD was assessed using the Framingham Risk Score. Data were analyzed using nonlinear regression analysis. RESULTS: Higher levels of health activation were significantly associated with decreased risk of developing CVD (p < 0.028). There was no interaction of sex with health activation on future CVD risk. However, male caregivers had greater risk of developing CVD in the next 10 years than female caregivers (p < 0.001). CONCLUSIONS: We demonstrated the importance of health activation to future CVD risk in rural family caregivers of patients with chronic illnesses. We also demonstrated that despite the higher risk of future CVD among male, the degree of association between health activation and CVD risk did not differ by sex.

Diet Quality Mediates the Relationship Between Chronic Stress and Inflammation in Patients With Metabolic Syndrome.

BACKGROUND: Chronic stress is associated with promotion of inflammation and development of metabolic syndrome, as well as deterioration of diet quality. Inflammation can be modified by changes in dietary intake. OBJECTIVE: The aim of this study was to test the hypothesis that diet quality mediates the relationship of chronic stress with inflammation in patients with metabolic syndrome. METHODS: Participants with metabolic syndrome (n = 73, 62 ± 12 years old, 71% female) completed questionnaires on chronic stress (Perceived Stress Scale-10) and diet quality (Healthy Eating Index-2020). The Perceived Stress Scale-10 was dichotomized. The Healthy Eating Index-2020 score was used as a continuous variable, and higher scores indicate better diet quality. Inflammation was assessed using plasma high-sensitivity C-reactive protein (log-transformed). We used PROCESS in SPSS to test the hypothesis. RESULTS: Patients in the higher stress group had lower Healthy Eating Index-2020 scores (worse diet quality) than those in the lower stress group (57 ± 13 vs 64 ± 10, P = .01). Diet quality mediated the relationship between chronic stress and inflammation (indirect effect, 0.211; 95% bootstrap confidence interval, 0.006-0.496). Higher stress was associated with lower diet quality (effect, -7.152; 95% confidence interval, -13.168 to -1.137) that was associated with increased inflammation (effect, -0.030; 95% confidence interval, -0.052 to -0.007). CONCLUSIONS: Our findings show the important role of diet quality in the relationship of chronic stress with inflammation in patients with metabolic syndrome. Healthcare providers should encourage patients with higher stress to improve diet quality, which can decrease inflammation.

Examining Food Security, Choices and Barriers among Community Supported Agriculture participants during COVID- 19 in Kentucky.

The coronavirus disease (COVID-19) pandemic is challenging food security. Our study's purpose was to examine relationships among food security status, eating patterns and perceived barriers to food choices among shareholders (N= 209) in a Community Supported Agriculture (CSA) program during stay-at-home restrictions due to the pandemic. The food insecure group (n= 33) reported lower consumption of fruits/vegetables, whole grains and greater consumption of fast foods and more barriers to food choices compared to the food secure group (p<.05). A low food insecure proportion (16%) among the CSA participants suggests a potential role of a CSA program to prevent food insecurity.

Psychometric Properties of the Patient Activation Measure in Family Caregivers of Patients With Chronic Illnesses.

BACKGROUND: The Patient Activation Measure (PAM) is used clinically and in research to measure an individual's knowledge, skills, and confidence related to their health management engagement. Despite the use of "patient" in the title, the instrument can be used in nonpatient populations. A group at high risk for low activation concerning their own health is family caregivers of patients with chronic illnesses. The psychometric properties of the PAM have not been established in family caregivers. OBJECTIVES: This study aimed to examine the psychometric properties of the PAM 10-item version (PAM-10) in a sample of family caregivers of patients with chronic illnesses. Our focus was on family caregivers' health activation of their own healthcare needs. METHODS: We evaluated the internal consistency reliability of the PAM-10 in a sample of 277 family caregivers. Item-total correlations and interitem correlations were used to assess item homogeneity. Construct validity of the PAM-10 was examined using exploratory factor analysis and testing hypotheses on known relationships. RESULTS: The PAM-10 demonstrated adequate internal consistency. Item-total correlation coefficients and interitem correlation coefficients were acceptable. Construct validity of the instrument was supported. Factor analysis yielded two factors that explained 62.3% of the variance in the model. Lower levels of depressive symptoms were significantly associated with better activation, providing evidence of construct validity. Caregivers with high activation levels were significantly more likely to engage in and adhere to self-care behaviors such as regular exercise, eating a healthy diet, and engaging in stress reduction strategies. DISCUSSION: This study demonstrated that the PAM-10 is a reliable and valid measure for family caregivers of patients with chronic illnesses to measure caregivers' health activation of their own healthcare needs.

Association of psychological distress with reasons for delay in seeking medical care in rural patients with worsening heart failure symptoms.

BACKGROUND: The impact of depressive symptoms and anxiety on rural patients' decisions to seek care for worsening heart failure (HF) symptoms remains unknown. The purposes of this study were (1) to describe rural patients' reasons for delay in seeking care for HF, and (2) to determine whether depressive symptoms or anxiety was associated with patients' reasons for delay in seeking medical care for worsening symptoms. METHODS: A total of 611 rural HF patients were included. Data on reasons for patient delay in seeking medical care (The Reasons for Delay Questionnaire), depressive symptoms (PHQ-9), and anxiety (BSI-ANX) were collected. Statistical analyses included chi-square and multiple regression. RESULTS: A total of 85.4% of patients reported at least 1 reason for delay. Patients with higher levels of depressive symptoms were more likely to cite embarrassment, problems with transportation, and financial concerns as a reason for delay. Patients with anxiety not only cited nonsymptom-related reasons but also reported symptom-related reasons for delay in seeking care (ie, symptoms seemed vague, not sure of symptoms, symptoms didn't seem to be serious enough, and symptoms were different from the last episode). In multiple regression, patients with greater depressive symptoms and anxiety had a greater number of reasons for delay in seeking care (P = .003 and P = .023, respectively). CONCLUSIONS: Our findings suggest that enhancement of patients' symptom appraisal abilities and improvement in psychological distress may result in a reduction in delay in seeking medical care for worsening symptoms in rural patients with HF.

Changes in physical activity during the initial stages of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic response limited access to many traditional forms of physical activity (PA). Purpose:To assess changes in objectively measured PAofUniversity staff during the initial stageofthe COVID-19 pandemic. METHODS: We implemented a repeated measures natural experiment design. PA data (walking distance, steps∙d#x2D;1, and Moderate#x2D;to#x2D;Vigorous PA (MVPA) time) from commercial grade triaxial accelerometers were collected from employees (N#x3D;625) of a large, public university in the southeast United States during the months of Jan#x2D;May in calendar years 2019 and 2020. RESULTS: Walking distance (6#x2D;9#x25;, p#x3C;0.001) and steps∙d#x2D;1(7#x2D;11#x25;, p#x3C;0.001) were lower during April and May 2020 compared to 2019. However, MVPA time was not significantly different among calendar years for the months of March#x2D;May. Steps∙d#x2D;1significantly decreased after WHO's worldwide pandemic declaration (10,348#xB1;171 v. 9551#xB1;156 steps∙d#x2D;1, p#x3C;0.001) and campus closure (10,100#xB1;160 v. 9,186#xB1;167 steps∙d#x2D;1, p#x3C;0.001). Conversely, steps∙d#x2D;1significantly increased after implementation of the state's "Healthy at Home" order (9,693#xB1;177 vs. 10,156#xB1;185 steps∙d#x2D;1, p#x3C;0.001). CONCLUSION: A decrease in daily steps, but not MVPA, suggests increased sedentary behavior, not reduced participation in exercise, during the early stages of the COVID#x2D;19 pandemic. Specific pandemic response policies may positively or negatively affect PA and sedentary behavior.

Potential directions for farm stress research: A systematic review of educational interventions to reduce psychosocial stress among farm and rural populations.

BACKGROUND: Despite prevalence of high psychosocial stress and suicide among farm and rural populations, few studies exist that measure effectiveness of stress reduction interventions. PURPOSE: To (1) compare studies with educational interventions on psychosocial stress as measured by reliable and valid instruments in farm and rural populations and (2) identify educational strategies utilized among effective interventions. METHODS: This systematic review was conducted across 4 electronic databases and Google Scholar to identify research that reported outcomes of stress reduction educational interventions among farm and rural populations. Original research articles published in English between January 1980 and October 2020 were included. Literature was excluded that: (1) used cognitive behavioral therapy, (2) reported outcomes of post-traumatic distress disorders, and (3) examined clinical guidelines or policy change. Extracted data included study characteristics, outcomes, and delivery methodology. FINDINGS: Title and abstract screening resulted in 256 manuscripts assessed for inclusion criteria. The final selection of 22 studies were categorized into 2 educational intervention delivery methods: home/community setting or virtual. Fourteen out of 22 studies reported significant stress reduction. Virtual interventions had the most promising impact on psychosocial stress with significant reduction reported in 4 of 6 studies; however, mixed results were found among all delivery methods. CONCLUSIONS: Educational interventions may reduce psychosocial stress among farm and rural populations, though important questions remain. We recommend future research should focus on barriers to participation, development of measurement tools, and consistent outcome measurement.

Age- and sex-matched comparison of diet quality in patients with heart failure to similarly aged healthy older adults.

The aims of this study were to (1) compare diet quality between patients with heart failure (HF) and age- and sex-matched community-dwelling healthy older adults and (2) determine whether having HF was associated with a lower Healthy Eating Index-2015 (HEI-2015) score and risk of micronutrient deficiency. The HEI-2015 and macro- and micronutrient intakes of patients with HF were compared with healthy older adults (N 102; 55-92 years old; 53 % female). A paired t-test or Wilcoxon singed-rank test, McNemar's test, and conditional logistic regression were used to assess the association between diet quality and HF status. Median values for HEI-2015 and the number of micronutrient deficiency were used to dichotomise into groups in the conditional logistic regression. There was no significant between-group difference in the HEI-2015 total score (P 0⋅059), whereas the whole grain component was lower in patients with HF than in healthy older adults (3⋅1 ± 3⋅5 v. 4⋅5 ± 3⋅1, P 0⋅037; respectively). Total caloric intake was lower in patients with HF than in healthy older adults (1683 ± 595 v. 2104 ± 670 kcal; P < 0⋅001). Patients with HF had a higher average number of micronutrient deficiencies than healthy older adults (4[2, 6] v. 1[0, 4], respectively, P < 0⋅001). Patients with HF had four times higher odds of being in a high micronutrient deficiency group than healthy older adults, controlling for socio-demographics and body mass index (adjusted odds ratio [95 % confidence interval]: 4⋅04[1⋅06, 15⋅41]). Our findings demonstrate that diet quality measured by nutritional intake identifies patients with HF with lower caloric intake and higher micronutrient deficiencies compared with age- and sex-matched healthy older adults.

Older and younger patients' perceptions, evaluations, and responses to worsening heart failure symptoms.

BACKGROUND: Whether recognition and prompt response to worsening symptoms are worse in older compared with younger patients with heart failure (HF) is unclear. OBJECTIVES: The aims of this study were to compare older and younger patients (1) perceptions, evaluations, and responses to worsening HF symptoms, and (2) responses once worsening symptoms were perceived. METHODS: A mixed-methods study was conducted and to compare data between older (≥ 65) and younger (< 65) in 185 patients hospitalized with HF. RESULTS: There were few differences attributed to age. In response to higher perceived symptom distress, patients in both groups did nothing and hoped their symptoms would go away (p = 0.004), ignored symptoms and continued doing what they were doing (p = 0.002), or laid down to relax (p < 0.001). CONCLUSIONS: The majority of patients, regardless of age, did not recognize, interpret, and respond appropriately to HF symptoms. Interventions should be tested that target better symptom appraisal and promote appropriate symptom responses in patients with HF across all ages.

Hostility predicts mortality but not recurrent acute coronary syndrome.

BACKGROUND: Hostility is associated with greater risk for cardiac disease, cardiac events and dysrhythmias. Investigators have reported equivocal findings regarding the association of hostility with acute coronary syndrome (ACS) recurrence and mortality. Given mixed results on the relationship between hostility and cardiovascular outcomes, further research is critical. AIMS: The aim of our study was to determine whether hostility was a predictor of ACS recurrence and mortality. METHODS: We performed a secondary analysis of data (N = 2321) from a large randomized clinical trial of an intervention designed to reduce pre-hospital delay among patients who were experiencing ACS. Hostility was measured at baseline with the Multiple Adjective Affect Checklist (MAACL) and patients were followed for 24 months for evaluation of ACS recurrence and all-cause mortality. We used Cox proportional hazards modeling to determine whether hostility was predictive of time to ACS recurrence or all-cause mortality. RESULTS: The majority of patients were married (73%), Caucasian (97%), men (68%), and had a mean age of 67 ± 11 years. Fifty-seven percent of participants scored as hostile based on the established MAACL cut point (mean score = 7.56 ± 3.8). Hostility was an independent predictor of all-cause mortality (p = < 0.039), but was not a predictor of ACS recurrence (p = 0.792). CONCLUSION: Hostility is common in patients with ACS and its relationship to clinical outcomes is important to the design of future interventions to improve long-term ACS mortality.

Delay in seeking medical care for worsening heart failure symptoms: predictors and association with cardiac events.

AIMS: The association of delay in seeking medical care to subsequent cardiac events remains unknown in patients with worsening heart failure (HF) symptoms. The aims of this study were to (i) identify factors predicting care-seeking delay and (ii) examine the impact of care-seeking delay on subsequent cardiac rehospitalization or death. METHODS AND RESULTS: We studied 153 patients hospitalized with an exacerbation of HF. Potential predictors of delay including demographic, clinical, psychosocial, cognitive, and behavioural variables were collected. Patients were followed for 3 months after discharge to determine time to the first cardiac rehospitalization or death. The median delay time was 134 h (25th and 75th percentiles 49 and 364 h). Non-linear regression showed that New York Heart Association functional class III/IV (P = 0.001), worse depressive symptoms (P = 0.004), better HF knowledge (P = 0.003), and lower perceived somatic awareness (P = 0.033) were predictors of delay time from patient perception of worsening HF to subsequent hospital admission. Cox regression revealed that patients who delayed longer (more than 134 h) had a 1.93-fold higher risk of experiencing cardiac events (P = 0.044) compared to non-delayers. CONCLUSIONS: Care-seeking delay in patients with worsening HF symptoms was significantly associated with an increased risk of rehospitalization and mortality after discharge. Intervention strategies addressing functional status, psychological state, cognitive and behavioural factors are essential to reduce delay and thereby improve outcomes.

Perceived Control Predicts Symptom Status in Patients With Heart Failure.

BACKGROUND: Symptom status is an important indicator of disease progression in patients with heart failure (HF). Perceived control is a target of most self-care interventions and is associated with better outcomes in HF; however, little is known about the relationship between perceived control and symptom status in patients with HF. OBJECTIVE: The aims of this study were to (1) determine the relationship of perceived control to HF symptom status and (2) examine the associations of perceived control to self-care and of self-care to symptom status. METHODS: A total of 115 patients with HF were included. Data on symptom status (Memorial Symptom Assessment Scale-HF), perceived control (Control Attitudes Scale-Revised), and self-care (Self-Care of Heart Failure Index) were collected. Other covariates included were age, gender, New York Heart Association class, comorbidity burden, and depressive symptoms. Multiple regression analyses were performed to analyze the data. RESULTS: Lower perceived control predicted worse symptom status after controlling for covariates (P = .009). Other covariates predictive of worse symptom status were younger age, New York Heart Association class III/IV, and higher levels of depressive symptoms. Higher levels of perceived control were associated with better self-care (P = .044). Better self-care was associated with better symptom status (P = .038). CONCLUSIONS: Lower levels of perceived control were independently associated with worse symptom status in patients with HF. Intervention strategies targeting perceived control should be tested to determine whether they could improve symptom status.

Inflammatory properties of diet mediate the effect of depressive symptoms on Framingham risk score in men and women: Results from the National Health and Nutrition Examination Survey (2007-2014).

Depression is common in patients with cardiovascular disease (CVD) and associated with inflammation. Inflammation contributes to the development of CVD and can be modulated by diet. However, the role of inflammatory properties of diet in the relationship between depressive symptoms and CVD risk is not well understood. We hypothesized that the inflammatory properties of diet mediate the relationship between depressive symptoms and CVD risk in men and women. Cross-sectional data collected by the National Health and Nutrition Examination Survey (2007-2014) were used for the study. Depressive symptoms scores, inflammatory properties of diet, and CVD risk were measured by the Patient Health Questionnaire-9 (PHQ-9), the Dietary Inflammatory Index (DII), and the Framingham risk score (FRS), respectively. Generalized linear models were used for the mediation analysis. There were significant differences in the proportions of men and women in the depressed group (PHQ-9 ≥ 10; 5.24 ±â€¯0.65% vs 9.36 ±â€¯0.87%, P < .001) and high CVD risk group (FRS >20%; 16.47 ±â€¯0.79% vs 6.03 ±â€¯0.32%, P < .001). The DII partially mediated the relationship between depressive symptoms and CVD risk in men (indirect effect: 0.06, P = .010) but fully mediated the relationship between depressive symptoms and CVD risk in women (indirect effect: 0.10, P < .001). These findings confirmed our hypothesis that inflammatory properties of diet at least partially mediate the relationship between depressive symptoms and CVD risk in men and women. Our findings suggest that interventions designed to reduce depressive symptoms should contain strategies to reduce pro-inflammatory and increase anti-inflammatory properties of diet to decrease CVD risk.

Factors Influencing Cardiovascular Risk Factors and Health Perception Among Kentuckians Living in Appalachia.

BACKGROUND: Cardiovascular disease (CVD) and risk factors for CVD are prevalent among Appalachians from Kentucky. Appalachian men and women have high rates of engagement in unhealthy behaviors and poor physical health measures that increase their risk for CVD. OBJECTIVE: In this study, the relationship among gender, CVD risk factors, and health perception in Appalachians from Kentucky was explored. METHODS: This cross-sectional secondary analysis is from a randomized controlled trial on CVD health in rural Kentucky. To assess gender differences in smoking history, χ was used. Independent t tests compared the mean between participants 50 years or younger and those older than 50 years with differences in body mass index (BMI), waist circumference, systolic and diastolic blood pressure, hemoglobin A1C, total cholesterol, and physical activity. A multivariate linear regression analysis assessed variables predicting the outcome of health perception. RESULTS: Most participants had a mean BMI of 33 kg/m and 94.3% of men used smokeless tobacco compared to 5.7% of the women. Differences existed between gender and current, ever, or never smoked (P < .001). Women had higher total cholesterol levels but men had higher waist circumference. Participants older than 50 years had higher engagement in physical activity than did those 50 years or younger. Higher BMI and hemoglobin A1C level were significant predictors of worse health perception (P ≤ .05). For every unit increase in the physical activity scale, there was a 0.2-unit improvement in health perception (P ≤ .001). CONCLUSION: Appalachians from Kentucky have many CVD risk factors. Minimal engagement in preventative measures against CVD can worsen patient outcomes.

Predictors of Adherence to Self-Care in Rural Patients With Heart Failure.

BACKGROUND: The common reality of not following a recommended course of treatment is a major cause of poor health outcomes in patients with heart failure (HF). The purpose of this study was to identify predictors of adherence to HF self-care recommendations in rural HF patients who received an intervention to promote symptom management and self-care. METHODS: Data from 349 rural HF patients (42% female, 90% Caucasian) randomized to the intervention arms of the study were used. Adherence was measured using the European Heart Failure Self-Care Scale questionnaire, a brief measure that asks patients to report their adherence to a variety of recommended HF symptom management behaviors (ie, daily weight monitoring, when to call the physician, medications, diet, and exercise). The following predictors were tested: age, gender, marital status, education level, depression score (measured using PHQ-9), anxiety score (measured with the Brief Symptom Inventory), and level of perceived control (measured using Control Attitudes Scale-R). Multivariate linear regression was used to test the model. RESULTS: The model to predict adherence was significant (P < .0001). Of the covariates tested in the regression model, being a male (P = .009), having less anxiety (P = .018), not being depressed (P = .017), and having higher perceived control (P = .003) were predictors of improved self-care score at 3 months. CONCLUSION: Adherence is a multifaceted and a challenging behavior based on the assumption that the patient agrees with self-care recommendations. These data suggest interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.

Missed opportunities! End of life decision making and discussions in implantable cardioverter defibrillator recipients.

BACKGROUND: Recent guidelines highlight the need for clinician-patient discussions regarding end-of-life (EOL) choices prior to implantable cardioverter defibrillator (ICD) implantation. Health literacy could affect the quality and quantity of such discussions. OBJECTIVE: Our objective was to determine the association of health literacy with experiences, attitudes, and knowledge of the ICD at EOL. METHODS: In this cross-sectional study, we used validated instruments to measure health literacy and patient experiences, attitudes, and knowledge of the ICD at EOL. RESULTS: Of the 240 ICD recipients, 76% of participants reported never having discussed the implications of a future withdrawal of defibrillation therapy with their healthcare provider. Increased odds of choosing to maintain defibrillation therapy were associated with female gender and lower ICD knowledge. CONCLUSIONS: From patients' perspectives, EOL discussions with providers were minimal. Most patients hold misperceptions about ICD function that could interfere with optimal EOL care, particularly for those with inadequate health literacy.

Perceived control and quality of life among recipients of implantable cardioverter defibrillator.

BACKGROUND: Perceived control is strongly associated with health-related quality of life (HRQOL) among patients with chronic conditions, and it is possible to increase perceived control with appropriate intervention. Little is known about the relationship between perceived control and HRQOL in implantable cardioverter defibrillator (ICD) recipients. OBJECTIVES: To determine the relationship of perceived control with quality of life in ICD recipients and to determine predictors of perceived control in this population. METHODS: A total of 263 ICD recipients (63% male, age 61 ± 14 years) completed the Control Attitude Scale-Revised to measure perceived control and completed self-reported measures on potential correlates of perceived control (i.e., depressive symptoms, anxiety, social support, and ICD concerns). The EuroQol-5D was used to measure HRQOL. Regression analysis was used to determine predictors of perceived control and its relationship to HRQOL, controlling for covariates. RESULTS: Lower perceived control (ß = 0.30, p < .01), and higher levels of depression (ß = -0.30, p < .01) and anxiety (ß = -0.18, p < .05) predicted lower levels of HRQOL. Higher anxiety (ß = -0.17, p < .05), higher depression (ß = -0.23, p < .05), lower social support (ß = 0.26, p < .01), and higher ICD-related concerns (ß = -0.16, p < .05) independently predicted lower perceived control. CONCLUSIONS: Interventions targeting patients' ICD concerns and psychosocial factors before, and continuing after, ICD insertion are needed to improve ICD recipients' perceived control and, in turn, their HRQOL.

A cohort study examining the factors influencing changes in physical activity levels following an acute coronary syndrome event.

BACKGROUND: Low physical activity has long been identified as a risk factor for coronary heart disease. AIMS: The aim of this study was to determine the factors that influence changes in the physical activity of patients following an acute coronary syndrome event. METHODS: The prospective, inferential cohort design recruited patients admitted to hospital following an acute coronary syndrome event across five research sites. Physical activity was assessed using the short form international physical activity questionnaire. RESULTS: Data were collected at baseline and 3 months on 380 patients. The sample profile was: 21% women; body mass index 28 ± 4.6; unstable angina 36%; ST-segment elevation myocardial infarction 25%; non-ST-segment elevation myocardial infarction 39% and a mean age of 63 ± 11.8. There was a significant improvement in physical activity at 3 months ( n=380, t=-3.704, P≤0.001). All regression models, baseline, 3 months and change in physical activity were significant ( p≤0.001). Low physical activity was associated with: at baseline not having health insurance, older age and depression; at 3 months not having health insurance, not in employment and low baseline physical activity; and improvement in physical activity was associated with low physical activity at baseline and not being in employment. CONCLUSIONS: While physical activity improved significantly, 45% did not reach guideline recommendation levels at 3 months post-event. Physical activity change was little influenced by sociodemographic, clinical, psychological and behavioural factors, suggesting the need to look elsewhere such as behavioural change and improved processes across the care divide to improve physical activity in this at-risk population.

A cluster and inferential analysis of myocardial infarction symptom presentation by age.

BACKGROUND: Pre-hospital delay time in myocardial infarction is usually longer in older than in younger patients, with symptom presentation known to be a contributing factor. AIM: The aim of this article is to examine symptom presentation differences, by age, in patients with myocardial infarction. METHODS: This is a cross-sectional study using secondary analysis of a multi-site randomised controlled trial on pre-hospital delay time. Data were analysed using logistic regression and factor analysis. RESULTS: Post-myocardial infarction patients were recruited prior to discharge ( n=1211), 54% were ≥65 years and 80% male. The average number of symptoms was three, with the ≥65 years age group reporting significantly less symptoms. Logistic regression controlling for gender, diabetes and diagnosis with 11 symptoms (χ2=52.09, p<0.001) was significant. Those ≥65 years had less chest symptoms, sweating, stomach upset and left arm pain, in addition to longer pre-hospital delay time. This group also had less symptom clustering and fewer symptoms within atypical clusters. Non-chest clusters occurred in 22% and 18% of the older and younger group respectively. Of note, two clusters 'atypical' (upset stomach/sweating) and 'typical arm' (right and left arm pain symptoms), accounted for 14% and 5% of myocardial infarction presentations in the ≥65 years group, within which 25% and 24% had no chest symptoms. CONCLUSIONS: The results of this study indicate that myocardial infarction symptom presentation in older patients is likely to be less recognisable and more complex. Increased awareness of the presentation profile of older patients could expedite their triage, diagnosis and, consequently, their prognosis.

Body Mass Index Category Moderates the Relationship Between Depressive Symptoms and Diet Quality in Overweight and Obese Rural-Dwelling Adults.

PURPOSE: This study was conducted to (1) compare diet quality among depressed and nondepressed overweight and obese rural-dwelling adults and (2) determine whether body mass index (BMI) category moderates the relationship between depressive symptoms and overall diet quality. METHODS: Rural adults in Kentucky (n = 907) completed the 9-item Patient Health Questionnaire (PHQ-9) that assessed depressive symptoms and a food frequency questionnaire that generated 2005 Healthy Eating Index (HEI) scores. Participants were grouped into overweight (BMI 25-29.9 kg/m2 ) and obese (≥30 kg/m2 ), and nondepressed (PHQ-9 < 10) and depressed (PHQ-9 ≥ 10) groups. Bootstrapped ANCOVAs were used to compare diet quality among the 4 groups. Ordinary least-squares regression using PROCESS was used to determine whether BMI category (overweight vs obese) moderated the association between depressive symptoms and overall diet quality. RESULTS: Overall diet quality was poorer in the obese depressed group than in the obese nondepressed group. Intake of fruit and dark green/orange vegetables and legumes was lower in the obese depressed group than in the overweight nondepressed group. Depressive symptoms predicted poor overall diet quality (B = -0.287, P < .001) and the relationship was moderated by BMI category (coefficient of BMI category* depressive symptom interaction term = 0.355, P < .049). A significant inverse relationship between depressive symptoms and overall diet quality was observed in the overweight group but not in the obese group. CONCLUSION: Components of diet quality vary according to BMI category and depressive symptom status. The relationship between depressive symptoms and diet quality is influenced by BMI category.