Hierarchies of evidence applied to lifestyle Medicine (HEALM): introduction of a strength-of-evidence approach based on a methodological systematic review.

BACKGROUND: Current methods for assessing strength of evidence prioritize the contributions of randomized controlled trials (RCTs). The objective of this study was to characterize strength of evidence (SOE) tools in recent use, identify their application to lifestyle interventions for improved longevity, vitality, or successful aging, and to assess implications of the findings. METHODS: The search strategy was created in PubMed and modified as needed for four additional databases: Embase, AnthropologyPlus, PsycINFO, and Ageline, supplemented by manual searching. Systematic reviews and meta-analyses of intervention trials or observational studies relevant to lifestyle intervention were included if they used a specified SOE tool. Data was collected for each SOE tool. Conditions necessary for assigning the highest SOE grading and treatment of prospective cohort studies within each SOE rating framework were summarized. The expert panel convened to discuss the implications of findings for assessing evidence in the domain of lifestyle medicine. RESULTS AND CONCLUSIONS: A total of 15 unique tools were identified. Ten were tools developed and used by governmental agencies or other equivalent professional bodies and were applicable in a variety of settings. Of these 10, four require consistent results from RCTs of high quality to award the highest rating of evidence. Most SOE tools include prospective cohort studies only to note their secondary contribution to overall SOE as compared to RCTs. We developed a new construct, Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), to illustrate the feasibility of a tool based on the specific contributions of diverse research methods to understanding lifetime effects of health behaviors. Assessment of evidence relevant to lifestyle medicine requires a potential adaptation of SOE approaches when outcomes and/or exposures obviate exclusive or preferential reliance on RCTs. This systematic review was registered with the International Prospective Register of Systematic Reviews, PROSPERO [CRD42018082148].

Prospects and possible pitfalls of a preventive Polypill: confessions of a health promotion convert.

A proposal by Wald and Law (2003) for a single pill containing a statin, three half-dose antihypertensives, aspirin, and folic acid, met with a storm of controversy and seemed to have been relegated as much to the fanciful as to the accolades it might have deserved. The benefits such a Polypill could confer on people age 55+y were to reduce both cardiovascular and stroke events by 80% or more. Considering the daunting and, at best, slow process of changing the same risk factors through health promotion interventions on food policy, dietary and physical activity behaviors, and urban planning to make less prevalent the sedentary lifestyles developed over decades, the argument here is to view the Polypill as a harm reduction strategy that would complement health promotion, as Nicotine Replacement Therapy did for tobacco control, seat belts did for traffic injuries, and needle exchange programs did for secondary complications of injection drug use.

Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities?

Responding to growing impatience with the limited application of research findings to health practices and policies, both funding bodies and communities are demanding that research show greater sensitivity to communities' perceptions, needs, and unique circumstances. One way to assure this is to employ participatory research-to engage communities at least in formulating research questions and interpreting and applying research findings and possibly also in selecting methods and analyzing data. "Community" should be interpreted broadly as all who will be affected by the research results, including lay residents of a local area, practitioners, service agencies, and policymakers. Participatory research should not be required of every project, but when results are to be used for, in, and by communities, those communities should collaborate not only in applying findings but also in determining the ways in which the findings are produced and interpreted.

Reconciling concept and context: the dilemma of implementation in school-based health promotion.

The researchers used grounded theory methodology to study the implementation of a school-based alcohol and drug prevention project in secondary schools in British Columbia, Canada. Prevention workers (PWs) were responsible for working with school and community personnel in a collaborative process to develop, implement, and evaluate prevention strategies in the school using an adaptation of the Precede-Proceed Model for health promotion planning. Before they could begin to do this, PWs had to establish their credibility in the school. Once accepted, the focus of the PWs' work was to reconcile the goals, values, and philosophy of the project with those of the school. In doing so, PWs encountered many practical dilemmas. The challenges in resolving these dilemmas are presented, and the implications for policy and practice are discussed.

From research to "best practices" in other settings and populations.

OBJECTIVE: To review the genesis and current status of best practices" thinking, its application in health promotion practice, and in generalizing research to alternate populations, places and times. METHODS: A presbyopic eye is cast over the recent evolution of the concept of "best practices" from medicine to public health. RESULTS: Some discontinuities are found in the migration of this concept from medicine, where it applies with some consistency to the relatively homogeneous physiology of the human species, to health behaviorwhere social, cultural, economic, and other heterogeneities make the generalizability of any research more suspect. CONCLUSIONS: Health promotion and other applications of health behavioral research need to replace "best practices" with "best processes."

Lipids and psychosocial status in aboriginal persons with and at risk for Type 2 diabetes: implications for tertiary prevention.

This study assessed psychosocial correlates of dyslipidemia, towards enabling improved tertiary prevention of macrovascular complications of diabetes mellitus (DM). We tested the hypothesis that psychosocial measures are related to high-density lipoprotein cholesterol (HDL-C) and triglyceride concentrations in a rural aboriginal population in British Columbia, Canada. Persons sampled were on-reserve registered Indians (n=198) with and at risk for Type 2 DM. Relationships between HDL-C and psychosocial variables were associated with glycemic status. For persons with diabetes and impaired glucose tolerance (n=44), quality of life and mastery were positively related (P<0.001), and depression inversely related (P<0.001), to HDL-C. An apparent lack of effect of behavior suggests the influence of emotional pathways involving autonomic-neuroendocrine axes. We recommend assessing mental health, and promoting mastery and diabetes quality of life through empowerment oriented diabetes management strategies, in negotiating culturally acceptable treatment of diabetic dyslipidemia for aboriginal people.

Downsizing and industrial restructuring in related to changes in psychosocial conditions of work in British Columbia sawmills.

OBJECTIVES: This paper investigates changes in the psychosocial and physical work conditions of the sawmill industry in British Columbia, Canada, over the past 35 years. METHODS: Shifts in work conditions were examined within the context of historical changes in sawmill labor demography and job taxonomy as the industry was both downsized and restructured, largely in response to an economic recession in the early 1980s. RESULTS AND CONCLUSIONS: Downsizing eliminated approximately 60% of the work force and 1/4 of sawmill job titles. Although all the job categories in restructured sawmills showed increased levels of control, the gradient in control across job categories was steeper in 1997 than in 1965; this change may have important health implications particularly for the unskilled workers in the restructured mills.

Commentary on the emerging Guide to Community Preventive Services from a health promotion perspective.

PIP: This paper presents the comments of authors Lawrence Green and Marshall Kreuter on the emerging Guide to Community Preventive Services of the Task Force on Community Preventive Services from a health promotion perspective. In terms of the framework, the authors discerned a shift of behavior from its previous position of risk factors to the position of intermediate outcome. This was found to be a refreshing departure from the single-minded focus other professions and sectors have come to expect of the health professions and sciences. The considerable emphasis placed on the intended practitioner and policy-maker audiences has pleased the authors. However, effective implementation can be a challenge to the partners involved in the process. In addition, limitations have been identified in the Task Force's methods. The limitation in the time frame for published studies tends to extend to modest time frames of most grants. This could be addressed by constructing a continuous, interactive system for gathering information about prevention research and practice as part of the infrastructure of the public health system.^ieng

What can we generalize from research on patient education and clinical health promotion to physician counseling on diet?

OBJECTIVE: This paper explores the status of knowledge development from clinical trials and other studies of patient education and clinical health promotion. DESIGN: It asks what this cumulative literature has to offer dietary counseling of patients by family doctors. A series of meta-analyses of drug education and preventive health education research in clinical settings provide a starting framework for guidelines on dietary counseling. CONCLUSIONS: Smoking cessation studies, in particular, have mounted in quantity and quality to the greatest extent and offer the clearest statement on what can be achieved, under what conditions, and with what support beyond the physician's counseling session or sessions. The Precede-Proceed Model offers a further guide to assuring the comprehensiveness of approaches to dietary change-enabling and reinforcing the change, not just predisposing it through admonitions and altering of knowledge, attitudes and beliefs. The specific evidence supporting the application of a patient counseling algorithm based on the Precede-Proceed model is reviewed here.

A four week residential program for primary health care patients to control obesity and related heart risk factors: effective application of principles of learning and lifestyle change.

OBJECTIVE: To test the short and long-term effectiveness of a four week residential program for primary health care patients to control obesity and related risk factors for cardio-vascular disease (CVD), especially blood pressure (BP). DESIGN: Prospective clinical study, with follow up after 1 and 5 y. SETTING: Vindeln Patient Education Centre, Vindeln, and Department of Social Medicine, University of Umea, Sweden. SUBJECTS: Approximately 2500 individuals, with two or more of the traditional risk factors for CVD, participated in the program. This report describes a subsample of 100 consecutive patients, 52+/-9 y, 53 men, with obesity and/or high BP. INTERVENTION: Four week residential program with lectures and group discussions as well as practical sessions in smaller groups (meal preparations, physical exercise, etc). The patients were followed-up medically in their home area. OUTCOME MEASURES: Weight and blood pressure. RESULTS: Dramatic reductions of weight and, especially, of blood pressure (BP) occurred during the residential weeks, and the reductions were pronounced also after 1 y. After 5 y, the total mean weight among men with initial BMI > or = 30 kg/m2 was still 5 kg lower, and diastolic and systolic BP among those with hypertension was 15 and 20 mm Hg lower, respectively, than before the program. CONCLUSIONS: The full-time participation in the residential program and the enrollment and commitment of the patients may explain the clinical outcome. A level of predisposition greater than that required of most weight- and BP-control programs was confirmed and a great preventive or therapeutic potential was indicated. The study illustrates an effective application of the Precede-Proceed model of health promotion planning.

Health education's contributions to public health in the twentieth century: a glimpse through health promotion's rear-view mirror.

A lesson of the first half of the century was that growth and technological development brought new health problems and challenges in their wake, many of which were to prove more intractable to technological fixes than the ones that had been so dramatically fixed before. Massive expansions of resources in support of the extension of these medical fixes resulted in an escalation of costs that had to be reigned in by breaking from the resource-based planning cycle that had prevailed through two eras of expansion. The 1970s ushered in an era of cost containment as the central theme of new policies. They included provisions for health promotion that sought to find new handles on the intractable social and behavioral aspects of the demand for health care resources, especially through primary prevention and building of capacity for community, family, and individual self-management of health problems and programs. Lessons from this era for public health in the next century are considered.

Effectiveness of community-directed diabetes prevention and control in a rural Aboriginal population in British Columbia, Canada.

This report presents the process and summative evaluation results from a community-based diabetes prevention and control project implemented in response to the increasing prevalence and impact of non-insulin-dependent diabetes mellitus (NIDDM) in the Canadian Aboriginal population. The 24-month project targeted the registered Indian population in British Columbia's rural Okanagan region. A participatory approach was used to plan strategies by which diabetes could be addressed in ways acceptable and meaningful to the intervention community. The strategies emphasised a combination of changing behaviours and changing environments. The project was quasi-experimental. A single intervention community was matched to two comparison communities. Workers in the intervention community conducted interviews of individuals with or at risk for diabetes during a seven-month pre-intervention phase (n = 59). Qualitative analyses were conducted to yield strategies for intervention. Implementation began in the eighth month of the project. Trend measurements of diabetes risk factors were obtained for 'high-risk' cohorts (persons with or at familial risk for NIDDM) (n = 105). Cohorts were tracked over a 16-month intervention phase, with measurements at baseline, the midpoint and completion of the study. Cross-sectional population surveys of diabetes risk factors were conducted at baseline and the end of the intervention phase (n = 295). Surveys of community systems were conducted three times. The project yielded few changes in quantifiable outcomes. Activation of the intervention community was insufficient to enable individual and collective change through dissemination of quality interventions for diabetes prevention and control. Theory and previous research were not sufficiently integrated with information from pre-intervention interviews. Interacting with these limitations were the short planning and intervention phases, just 8 and 16 months, respectively. The level of penetration of the interventions mounted was too limited to be effective. Attention to process is warranted and to the feasibility of achieving effects within 24 months.

Paradigm change and uncertainty about funding of public health research: social and scientific implications.

Since the 1970s two fundamental shifts have occurred in health research funding: a reduction in the buying power of research dollars, and an increase in the competition for resources. Most fields have also seen a decrease in the dollars available for research. Pressures for justifying the relevance of research activities have become increasingly pragmatic. The thesis of this paper is that scientific creativity and innovation are compromised by the highly uncertain and competitive funding environment of contemporary health research. This is largely because criteria of scientific excellence predicated on an investigation's presumed future impact support the status quo of methods and subject matter in funded research. Extraordinary rationality among scientists seeking and allocating resources promotes the survival of the existing system over time, yet inhibits progressive development through the transformation of conceptual models. Therefore, despite a growing unrest about the way research on population health is conducted, new conceptions of the relationship between theory and methods have been slow to emerge. Amelioration of a disjunction between the institutionalized rules governing science and the culturally sanctioned goals of science requires commitment to a dialectic between orthodoxy and dissent.

Understanding suicide among indigenous adolescents: a review using the PRECEDE model.

AIM: To use the available literature to identify the causes of suicide among indigenous adolescents. METHOD: The PRECEDE model provided a framework to organize the material and identify the areas where relatively little research had been reported. RESULTS: The epidemiological diagnosis showed that suicide was greater in indigenous than non-indigenous populations and particularly high among adolescent males. Environments of native persons are characterized by remoteness, poverty, cultural displacement, and family disintegration. The educational and organizational diagnosis identified predisposing factors reflecting the social environments previously identified, the enabling factors of televised suicides, and firearm and alcohol availability, in conjunction with an absence of positive expectations. Finally the administrative and policy diagnosis identified a piecemeal, short term perspective, often lacking cultural sensitivity. Although there was more literature from the United States than from Canada, Australia or New Zealand, the pictures emerging were consistent, with problems being identified across continents. Literature was more abundant in relation to the epidemiological, environmental, and educational/ organizational diagnoses than in relation to policy and administration. CONCLUSION: The increased suicide rates among indigenous adolescents were not a product of their native origins, but of the social milieu in which these people generally found themselves.

Application of Karasek's demand/control model a Canadian occupational setting including shift workers during a period of reorganization and downsizing.

PURPOSE: To apply Karasek's Job Content Model to an analysis of the relationships between job type and perceived stress and stress behaviors in a large company during a period of reorganization and downsizing. DESIGN: Cross-sectional mail-out, mail-back survey. SETTING: A large Canadian telephone/telecommunications company. SUBJECTS: Stratified random sample (stratified by job category) of 2200 out of 13,000 employees with a response rate of 48.8%. MEASURES: Responses to 25 of Karasek's core questions were utilized to define four job types: low-demand and high control = "relaxed"; high demand and high control = "active"; low demand and low control = "passive", and high demand and low control = "high strain." These job types were compared against self-reported stress levels, perceived general level of health, absenteeism, alcohol use, exercise level, and use of medications and drugs. Similar analyses were performed to assess the influence of shift work. RESULTS: Employees with "passive" or "high strain" job types reported higher levels of stress (trend test p < .0001); poorer health (trend test P = .006); and higher levels of absenteeism (trend test p < .0001). More shift workers reported themselves in poor or fair health (chi-square p = .018) and reported high levels of stress at home (chi-square p = .002) than nonshift workers. The relationships between job type and levels of stress, health and absenteeism, however, held for nonshift workers as well. CONCLUSIONS: Job types with high demand and low control were associated with increased stress, increased absenteeism, and poorer self-concept of health. The demand/control model of Karasek and Theorell was validated in this setting with respect to stress and some stress-associated attitudes and behaviors.

Taxes and the tobacco wars.

In this issue (see pages 187 to 191) Dr. Vivian H. Hamilton and associates demonstrate that tax reductions introduced in 5 Canadian provinces in 1994 slowed the rate of decline in cigarette consumption in those jurisdictions. Although both reductions and increases in taxation have been shown to influence tobacco consumption, changes in smoking habits must also be understood in the context of battles being waged on other fronts in the tobacco wars. In addition, more finely detailed analyses are needed to determine the impact of taxation and other factors on the smoking habits of specific subgroups of the population, particularly teenagers.