Association of obesity and chronic diseases in Taiwan.

Two systems were used to classify weight status based on body mass index (BMI) of 3,178 Taiwanese adults who participated in the 1993-1996 Nutrition and Health Survey and to explore associations of BMI categories and disease. In the system proposed by the International Association for the Study of Obesity and the International Obesity Taskforce for Asian adults, overweight was associated with one disease (hypertension) and obesity was associated with four diseases: diabetes (OR = 2.66; 95% CI = 1.39-5.09; p < 0.01); gout (OR = 4.33; 95% CI = 1.92-9.75; p < 0.01); hypertension (OR = 4.92; 95% CI = 2.87-8.42; p < 0.01); thyroid disease (OR = 2.29; 95% CI = 1.12-4.67; p < 0.05). In the system devised by Taiwan Health Department for Taiwanese adults, overweight was associated with four diseases (arthritis, diabetes, gout, hypertension), and obesity was associated with three diseases: diabetes (OR = 2.11; 95% CI = 1.07-4.19; p < 0.05); gout (OR = 4.06; 95% CI = 1.77-9.28; p < 0.01); hypertension (OR = 5.28; 95% CI = 3.23-8.63; p < 0.01). The Obesity Taskforce may underestimate the association of excess weight and disease in Taiwan.

The vaccines for children program. Policies, satisfaction, and vaccine delivery.

OBJECTIVES: Characterize the Vaccines for Children (VFC) programs in Minnesota and Pennsylvania, assess providers' satisfaction with each state's program, and examine changes in doses administered in the public sector since implementation of the VFC. METHODS: Primary care providers participating in the VFC in Minnesota and Pennsylvania were surveyed. Doses administered were based on data from the National Immunization Survey. Outcome measures included satisfaction, ease of use of VFC, doses of immunizations administered through public health departments, and overall immunization coverage for the two states. RESULTS: Most participating providers in each state (80% to 94%) reported overall satisfaction with the VFC. Pennsylvania physicians were less satisfied with quarterly ordering of immunizations than were Minnesota providers with monthly ordering (56% vs 80%, p<0.05). The most common recommendation was to reduce paperwork. Doses administered in the public sector declined in Minnesota from approximately 146,000 in 1994 to 65,400 in 1999, and in Pennsylvania from approximately 250,000 to 79,300 during the same period. CONCLUSIONS: The VFC appears to increase the numbers of poor and uninsured children who receive necessary childhood immunizations within their medical homes. Providers are generally satisfied with the program.

A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program.

OBJECTIVE: To use two different exercise programs over a 2-year period to reduce falls and their sequelae among residents of two long-term care facilities. DESIGN: Randomized, controlled trial. SETTING: The study took place at two long-term care facilities with services ranging from independent living to skilled nursing. PARTICIPANTS: One hundred and ten participants whose average age was 84 and who were capable of ambulating with or without assistive devices and could follow simple directions. INTERVENTION: Participants were randomized to one of two exercise groups (resistance/endurance plus basic enhanced programming or tai chi plus basic enhanced programming) or to a control group (basic enhanced programming only). Exercise classes were held three times per week throughout the study. MEASUREMENTS: Participants were evaluated for cognitive and physical functioning at baseline and 6, 12, and 24 months. Falls were determined from incident reports filed by the nursing staffs at the facilities. RESULTS: Time to first fall, time to death, number of days hospitalized, and incidence of falls did not differ among the treatment and control groups (P>.05). Among all participants, those who fell had significantly lower baseline Folstein Mini-Mental State Examination and instrumental activities of daily living scores and experienced significantly greater declines in these measures over the 2-year program. CONCLUSION: There were no significant differences in falls among the two exercise groups and the control group. Lack of treatment differences and low adherence rates suggest that residents of long-term care facilities may require individualized exercise interventions that can be adapted to their changing needs.

A comprehensive investigation of barriers to adult immunization: a methods paper.

OBJECTIVE: Immunization rates for influenza and pneumococcal vaccines among the elderly (especially minority elderly) are below desired levels. We sought to answer 4 questions: (1) What factors explain most missed immunizations? (2) How are patient beliefs and practices regarding adult immunization affected by racial or cultural factors? (3) How are immunizations and patient beliefs affected by physician, organizational, and operational factors? and (4) Based on the relationships identified, can typologies be created that foster the tailoring of interventions to improve immunization rates? STUDY DESIGN: A multidisciplinary team chose the PRECEDE-PROCEED framework, the Awareness-to-Adherence model of clinician response to guidelines, and the Triandis model of consumer decision making as the best models to assess barriers to and facilitators of immunization. Our data collection methods included focus groups, face-to-face and telephone interviews, self-administered surveys, site visits, participant observation, and medical record review. POPULATION: To encounter a broad spectrum of patients, facilities, systems, and interventions, we sampled from 4 strata: inner-city neighborhood health centers, clinics in Veterans Administration facilities, rural practices in a network, and urban/suburban practices in a network. In stage 1, a stratified random cluster sample of 60 primary care clinicians was selected, 15 in each of the strata. In stage 2, a random sample of 15 patients was selected from each clinician's list of patients, aiming for 900 total interviews. CONCLUSIONS: This multicomponent approach is well suited to identifying barriers to and facilitators of adult immunizations among a variety of populations, including the disadvantaged.

Nutrition intervention program of the Modification of Diet in Renal Disease Study: a self-management approach.

OBJECTIVE: To characterize the Modification of Diet in Renal Disease (MDRD) Study nutrition intervention program by determining the frequency of intervention strategies used by the dietitians and the usefulness of program components as rated by participants. DESIGN: Dietitians recorded which of 32 intervention strategies they used at each monthly visit. Participants rated the usefulness of 19 program components. SUBJECTS: 840 adults with renal insufficiency. INTERVENTION: Participants were assigned randomly to usual-, low-, or very-low-protein diet groups. Each eating pattern also specified a phosphorus intake goal. Each participant met monthly with a dietitian for an average of 26 months. STATISTICAL ANALYSES: Analyses of variance and chi 2 analyses. RESULTS: Dietitians used the following intervention strategies most often in all groups: providing feedback based on self-monitoring and/or food records, reviewing adherence or biochemistry data, providing low-protein foods, and reviewing graphs of adherence progress. In general, the dietitians used feedback, modeling, and support strategies more often, and knowledge and skills strategies less often, with participants who had to make the greatest reductions in protein intake and those with more advanced disease. In all groups, the dietitians' use of knowledge and skills, feedback, and modeling strategies decreased over time (P < .001), whereas use of support strategies was maintained. The type and frequency of intervention strategies used by dietitians and the usefulness ratings of participants did not vary by educational level of the participant. Both self-monitoring and dietitian support were rated as "very useful" by 88% of the participants. CONCLUSIONS: Three features were central to the MDRD Study nutrition intervention program: feedback, particularly from self-monitoring and from measures of adherence; modeling, particularly by providing low-protein food products; and dietitian support. We recommend the self-management approach.

Factors associated with adherence to the dietary protein intervention in the Modification of Diet in Renal Disease Study.

OBJECTIVE: To determine the characteristics and behaviors associated with adherence to dietary protein interventions among participants with chronic renal disease in the Modification of Diet in Renal Disease (MDRD) Study. DESIGN: Participants were categorized as consistent adherers or nonadherers on the basis of urinary urea nitrogen excretion and dietary protein intake data from self-reports. Psychosocial and behavioral factors were compared between groups. SUBJECTS: Subgroups of consistently adherent and non-adherent participants in the MDRD Study. SETTING: 15 clinical centers in the United States. INTERVENTION: In the nutrition intervention program, participants were assigned randomly to a usual-, low-, or very-low-protein diet group. Each eating pattern also specified a phosphorus goal. STATISTICAL ANALYSIS: Analysis of variance. RESULT: Psychosocial factors significantly related to adherence included participant knowledge, attitude, support, satisfaction, and self-perception of success. Behavioral strategies including participant self-monitoring of protein intake and the provision of feedback by the dietitian were also significantly related to adherence. APPLICATION: Nutrition interventions for patients with renal disease should focus on psychosocial factors and behavioral approaches. Such approaches can be successfully incorporated into treatment programs and will assist the dietitian in promoting adherence to usual-, low-, and very-low-protein eating patterns.

Exercise in a behavioural weight control programme for obese patients with Type 2 (non-insulin-dependent) diabetes.

Two studies were conducted to determine whether adding exercise to a diet programme promotes weight loss or glycaemic control in Type 2 (non-insulin-dependent) diabetic subjects. In Study 1, 25 subjects were randomly assigned to diet plus moderate exercise or diet plus placebo exercise. All subjects exercised twice a week as a group and once a week on their own; the diet plus moderate exercise group walked a 3-mile route at each session while the diet plus placebo exercise group did very low intensity exercises such as stretching and light calisthenics. All subjects followed a calorie-counting diet and were taught behaviour modification strategies. Weight losses and improvements in glycaemic control did not differ significantly between the two treatment groups at the end of the 10-week treatment or at 1-year follow-up. In Study 2, more extreme conditions were compared: a diet only group and a diet plus exercise group. The diet plus exercise group walked a 3-mile route with the group 3 times/week and once a week on their own, while the diet only group was instructed to maintain their current low level of activity. Both groups received comparable diet and behaviour modification instruction and therapist contacts. The diet plus exercise group had significantly (p less than 0.01) better weight losses than the diet only condition at the end of the 10 week programme (-9.3 kg vs -5.6 kg) and at 1 year follow-up (-7.9 kg vs -3.8 kg).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effects of modest weight loss in type II diabetic patients.

Since most obese patients with type II diabetes are unable to achieve ideal body weight, this study examined whether more modest weight losses would provide a long-term benefit. Type II diabetic patients (N = 114) were treated in a behavioral weight control program and followed up for one year. Weight loss was significantly correlated with improvements in glycosylated hemoglobin values at posttreatment (r = .55) and one year (r = .51). Patients who lost more than 6.9 kg or had more than 5% reduction in body weight had significant improvements in glycosylated hemoglobin values at one year, while patients losing less weight had nonsignificant changes and those gaining weight had significant worsening. Thus, modest weight loss can have a long-term impact on glycemic control. However, the improvement in glycemic control for a given weight loss was greater initially than at one year, suggesting that energy restriction, in addition to weight loss, may contribute to initial improvement. Neither percent overweight nor diabetes treatment affected weight loss.

Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes?

Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control. To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients, 50 obese patients with type II diabetes were randomly assigned either to a standard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship. Both groups lost significant amounts of weight and maintained their losses for at least one year; reductions in medication could be made for 70 percent of patients. These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes. However, there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss, reduction in medication, dietary compliance, or mood state.

Subclinical eating disorders and glycemic control in adolescents with type I diabetes.

Several recent case reports have shown that anorexia nervosa and bulimia negatively affect glycemic control in diabetic patients. However, there have been no systematic studies to assess the prevalence of clinical or subclinical eating disorders among diabetic patients or to determine the impact of such disturbances on glycemic control. This study reports a survey of 202 adolescents, aged 12-18 yr, seen in the Diabetes Clinic, Children's Hospital of Pittsburgh, who were asked to complete the Binge Eating Scale (BES) and the EAT-26 questionnaire. Responses of diabetic patients to the EAT-26 questionnaire were compared with those of a nondiabetic control group and were related to measures of glycemic control. Diabetic subjects scored higher on the total EAT-26 than nondiabetic control subjects, ordinarily indicative of more eating pathology. However, diabetic subjects scored higher only on the dieting subscale of this questionnaire, probably reflecting adherence to the diabetes dietary regimen. Subjects with diabetes scored lower, or did not differ significantly, from nondiabetic control subjects on measures of oral control and bulimia. Among diabetic subjects, self-reported bulimic behaviors were related to poorer glycemic control. Patients with the highest scores on the BES had an average HbA1 of 13.1% compared with 11.8% for age- and sex-matched patients at the 50th percentile, and 10.8% for patients in the lowest 10th percentile. Further studies are needed to determine whether modification of these eating behaviors would improve glycemic control.

Calorie-counting compared to exchange system diets in the treatment of overweight patients with type II diabetes.

Patients with diabetes are usually placed on exchange system diets to ensure a nutritionally adequate intake. However, there have been few studies which have actually compared the nutritional adequacy of diets selected by patients on exchange system diets, with that selected by patients on the calorie-counting diets typically used in behavioral weight control programs. This study compared the nutritional adequacy of the diets selected by overweight patients with Type II diabetes who had been randomly assigned to either an exchange system diet or a calorie-counting diet. Three-day food diaries were completed by all patients at the start and end of a 16-week weight control program. No significant differences were observed between patients on the calorie-counting diet compared to those on the exchange system diet with respect to nutrient intake, macronutrient distribution, or percent of the RDA obtained. Patients on both types of diet reported decreases in the proportion of calories from fat. The average intake exceeded 100% of the RDA for all nutrients except calcium. This study suggests that patients are able to improve the nutritional adequacy of their intake while following either a calorie-counting or an exchange system diet.

Psychologic stress and blood glucose levels in nondiabetic subjects.

This study analyzed the effect of a standardized psychologic stressor on blood glucose levels in nondiabetic subjects. Subjects participated in a stress and nonstress session, presented in counterbalanced order. At each session, subjects were fed a carbohydrate load and blood glucose responses were measured 0, 30, 60, 90, and 120 min after the load. On nonstress days, subjects relaxed after drinking the load, while on stress days subjects participated in 30 min of competitive tasks immediately after the drink. The stress impaired the subjects' ability to handle the carbohydrate load; whereas on nonstress days, blood glucose levels peaked at 30 min after the load, on stress days the peak blood glucose response was delayed until 60 min after the drink.

Compliance to self-monitoring of blood glucose: a marked-item technique compared with self-report.

This study compared subjects' self-reported rates of compliance to self-monitoring of blood glucose (SMBG) with an objective measure based on a "marked-item" technique. We followed 25 obese patients with type II diabetes who were participating in a behavorial weight control program and monitoring their blood glucose with Chemstrips bG (Bio-Dynamics, Inc., Indianapolis, Indiana). Subjects' self-report significantly overestimated actual compliance as assessed by the marked-item technique. Moreover, the self-report measure failed to identify 35-45% of the noncompliant patients. Compliance decreased steadily over the course of the 37-wk program. Accuracy of SMBG was less problematic than compliance; 85% of patients were able to read Chemstrips bG within 20% of actual blood sugar, and the average blood sugar reading obtained from 2 mo of SMBG correlated highly (r = 0.78, P less than 0.01) with HbA1. Our data suggest that objective measures such as the marked-item technique described in this article should be used to assess compliance to SMBG and behavioral strategies to improve compliance should be developed.

The measurement of sodium and potassium intake.

Single- vs multiple-day food records were compared for estimates of intake for sodium, potassium, and calories; and the correspondence was assessed between sodium and potassium intake and 24-h urinary excretion. Fifty-five middle-aged adults, participating in a prerandomization assessment for a nutritional/behavioral intervention program on blood pressure completed a six-day food record and a 24-h urine collection. The group average for sodium, potassium, and calories obtained from one-day food records proved to be as good an estimate of the six-day average as did values from multiple day records. Similarly the one-day food record proved a good estimate of the mean 24-h urinary values for sodium and potassium. If properly collected and analyzed, a one-day food record is a good estimate of a population's intake of sodium and potassium while multiple days of recording are necessary to characterize individual intake.

Changes in nutrient intake of hypertensives during a behavioral weight-control program.

To evaluate the nutritional adequacy of the diets selected by hypertensive patients participating in a behavioral weight-control program, 26 patients were asked to complete 3-day food records at the start and end of the 8-week program. These records were analyzed using the United States Department of Agriculture (USDA) Handbook 456 data base. Patients decreased their overall caloric intake by 39% during the course of the program and decreased consumption of all nutrients, but only calcium intake decreased to unacceptable levels. There was, however, a significant increase in the number of individuals consuming less than two thirds of the Recommended Dietary Allowances (RDA) for thiamin, niacin, calcium, and iron, and a significant increase in the number of patients who were deficient in three or more nutrients. Thus, although average intake in the behavioral weight-control program was adequate, there was a sizeable number of individuals who were consuming poor diets. Inadequate intake occurred primarily in patients eating less than 1000 calories a day. The simple behavior change of adding a cup of skim milk to the unstructured calorie-counting diet would help restore calcium, thiamin, and niacin to adequate levels.

Methodological issues related to age of onset of obesity.

Research related to age of onset of obesity may be hampered by two methodological problems: (a) inconsistencies across studies in the criteria used to define early-onset and maturity-onset obesity and (b) the failure to control for other differences between early-onset and maturity-onset obese patients. Analyzing data from 178 applicants to a behavioral weight control program, this study found that almost twice as many patients were classified as early-onset obese when the division was based on their answer to the question, "Were you overweight as a child or teenager?" than when the division was based on self-reported weight at age 21. Moreover, early-onset obese patients were younger and heavier than those with maturity-onset obesity. Further studies are needed to determine the most reliable and valid means of classifying patients as early- or maturity-onset obese.

Accuracy in estimating fasting blood glucose levels by patients with diabetes.

This study was designed to assess the accuracy with which diabetic patients can estimate their fasting blood sugars (FBS) and to determine whether experience with self-monitoring of blood glucose improves this ability. Twenty patients with type II diabetes who had no experience with self-monitoring of blood glucose were compared with 17 patients who had been monitoring blood sugar regularly for the previous 8 mo. All patients were asked to estimate FBS immediately before it was measured in the laboratory. Patients were very accurate in estimating their FBS; the average error in estimation was 2 mg/dl, and 65% of patients estimated FBS within 20% of actual FBS. However, there was no evidence that experience in self-monitoring of blood glucose improved the accuracy of estimation. Additional studies are needed to determine the types of cues that patients use in estimating blood sugar.