Effect of calories-only vs physical activity calorie expenditure labeling on lunch calories purchased in worksite cafeterias.

BACKGROUND: Calorie labeling on restaurant menus is a public health strategy to guide consumer ordering behaviors, but effects on calories purchased have been minimal. Displaying labels communicating the physical activity required to burn calories may be a more effective approach, but real-world comparisons are needed. METHODS: In a quasi-experimental study, we examined the effect of physical activity calorie expenditure (PACE) food labels compared to calorie-only labels on point-of-decision food purchasing in three worksite cafeterias in North Carolina. After a year of quarterly baseline data collection, one cafeteria prominently displayed PACE labels, and two cafeterias prominently displayed calorie-only labels. Calories from foods purchased in the cafeteria during lunch were assessed over 2 weeks every 3 months for 2 years by photographs of meals. We compared differences in purchased calorie estimates before and after the labeling intervention was introduced using longitudinal generalized linear mixed model regressions that included a random intercept for each participant. RESULTS: In unadjusted models comparing average meal calories after vs before labeling, participants exposed to PACE labels purchased 40.4 fewer calories (P = 0.002), and participants exposed to calorie-only labels purchased 38.2 fewer calories (P = 0.0002). The small difference of 2 fewer calories purchased among participants exposed to PACE labeling vs calorie-only labeling was not significant (P = 0.90). Models adjusting for age, sex, race, occupation, numeracy level, and health literacy level did not change estimates appreciably. CONCLUSION: In this workplace cafeteria setting, PACE labeling was no more effective than calorie-only labeling in reducing lunchtime calories purchased.

Association of ambulatory blood pressure variability with coronary artery calcium.

Blood pressure (BP) variability is associated with progression to clinical atherosclerosis. The evidence is inconclusive if BP variability predicts cardiovascular outcomes in low-risk populations. The aim of this study was to analyze the association of 24-hour BP variability with coronary artery calcium (CAC) among a group of individuals without coronary artery disease. The Masked Hypertension Study targeted patients with borderline high BP (120-149 mm Hg systolic and/or 80-95 mm Hg diastolic). Ambulatory blood pressure monitoring (ABPM) was performed at two time-points, 8 days apart. CAC was measured at exit visit via cardiac CT and reported as Agatston Score. Weighted standard deviations and average real variability were calculated from ABPM. Of the 322 participants who underwent cardiac CT, 26% (84) had CAC present, 52% (168) were female, and 21% (64) were black. BP variability did not differ by CAC group. In this low cardiovascular risk group, CAC was not associated with 24-hour ambulatory BP variability.

Effects of physical activity calorie expenditure (PACE) labeling: study design and baseline sample characteristics.

BACKGROUND: Obesity and physical inactivity are responsible for more than 365,000 deaths per year and contribute substantially to rising healthcare costs in the US, making clear the need for effective public health interventions. Calorie labeling on menus has been implemented to guide consumer ordering behaviors, but effects on calories purchased has been minimal. METHODS: In this project, we tested the effect of physical activity calorie expenditure (PACE) food labels on actual point-of-decision food purchasing behavior as well as physical activity. Using a two-group interrupted time series cohort study design in three worksite cafeterias, one cafeteria was assigned to the intervention condition, and the other two served as controls. Calories from food purchased in the cafeteria were assessed by photographs of meals (accompanied by notes made on-site) using a standardized calorie database and portion size-estimation protocol. Primary outcomes will be average calories purchased and minutes of moderate to vigorous physical activity (MVPA) by individuals in the cohorts. We will compare pre-post changes in study outcomes between study groups using piecewise generalized linear mixed model regressions (segmented regressions) with a single change point in our interrupted time-series study. The results of this project will provide evidence of the effectiveness of worksite cafeteria menu labeling, which could potentially inform policy intervention approaches. DISCUSSION: Labels that convey information in a more readily understandable manner may be more effective at motivating behavior change. Strengths of this study include its cohort design and its robust data capture methods using food photographs and accelerometry.

Patients' confidence in methods of blood pressure assessment and their reported adherence to antihypertensive medications.

OBJECTIVE: Adherence to antihypertensive medications is often less than optimal. Research suggests that patients have limited confidence regarding whether office blood pressure (BP) assessments represent their 'true' BP, which may further promote poor adherence to BP-lowering medication. We assessed peoples' confidence in the methods of BP assessment and examined the associations between patients' confidence levels and medication adherence comparing office and home BP-monitoring techniques. METHODS: We surveyed US adults aged 30 years or older (N=1010), all of whom had undergone an office BP measurement within the past 6 months. Respondents who indicated being prescribed antihypertensive medication (N=429) were asked to indicate their level of confidence on a 1-9 scale that BP measurements represented their true BP, and their adherence to antihypertensive medication using the eight-item Morisky Medical Adherence Scale (MMAS-8). RESULTS: Respondents had equal confidence that both office BP measurements and home monitoring measurements reflected their true BP (median=7). Respondents indicated that they would have slightly more confidence in ambulatory BP monitoring (median=8). As respondents' confidence in the assessments of BP from office measurements and home monitoring increased from 1 to 9, the mean MMAS-8 score, adjusted for age, race, and education, increased from 5.38 to 6.25 (P=0.053) and from 5.50 to 6.14 (P=0.25), respectively. CONCLUSION: As patients' confidence in a BP assessment method increases, so too does their reported adherence to prescribed antihypertensive medications. This finding further supports the incorporation of methods in which patients can feel confident that the measurements are representative of their 'true' BP.

The Reproducibility of Racial Differences in Ambulatory Blood Pressure Phenotypes and Measurements.

BACKGROUND: We examined the reproducibility of differences in ambulatory blood pressure (BP) monitoring (ABPM) phenotypes and other parameters (sustained hypertension, masked hypertension, nocturnal hypertension, and nondipping) between African Americans and Whites. METHODS: A total of 420 participants untreated for hypertension attended 2 research visits 1 week apart during which traditional office BP averages and ABPM session averages were determined. We computed percent agreement in ABPM phenotypes across the 2 visits stratified by race and associated kappa statistics with 95% confidence intervals. RESULTS: Whites on average were older, more likely to be male, and had a higher body mass index. There was no significant difference in sleep quality as defined by sleep diary between the 2 races. There were also no significant differences between races in the proportions of participants with sustained hypertension, sustained normotension, or masked hypertension at either testing session. The prevalence of nocturnal hypertension was 59% vs. 75% (P = 0.012) at session 1 and 59% vs. 73% (P = 0.024) at session 2 for Whites and African Americans, respectively, with moderate reproducibility for both (kappas 0.45 and 0.44). Nocturnal BP nondipping had a prevalence 29% vs. 53% (P < 0.001) at session 1 and 29% vs. 47% (P = 0.004) at session 2 for Whites and African Americans, respectively, with fair reproducibility (kappas 0.28 and 0.29). CONCLUSIONS: Our findings support that African Americans indeed exhibit a greater preponderance of abnormal nocturnal BP patterns than Whites. Our work is some of the first to demonstrate that these abnormal patterns are modestly reproducible.

Dedicated Three-dimensional Breast Computed Tomography: Lesion Characteristic Perception by Radiologists.

OBJECTIVES: To assess radiologist confidence in the characterization of suspicious breast lesions with a dedicated three-dimensional breast computed tomography (DBCT) system in comparison to diagnostic two-dimensional digital mammography (dxDM). MATERIALS AND METHODS: Twenty women were recruited who were to undergo a breast biopsy for a Breast Imaging-Reporting and Data System (BI-RADS) 4 or 5 lesion evaluated with dxDM in this Institutional Review Board-approved study. The enrolled subjects underwent imaging of the breast(s) of concern using DBCT. Seven radiologists reviewed the cases. Each reader compared DBCT to the dxDM and was asked to specify the lesion type and BI-RADS score for each lesion and modality. They also compared lesion characteristics: Shape for masses or morphology for calcifications; and margins for masses or distribution for calcifications between the modalities using confidence scores (0-100). RESULTS: Twenty-four biopsied lesions were included in this study: 17 (70.8%) masses and 7 (29.2%) calcifications. Eight (33.3%) lesions were malignant, and 16 (66.7%) were benign. Across all lesions, there was no significant difference in the margin/distribution (Δ = -0.99, P = 0.84) and shape/morphology (Δ = -0.10, P = 0.98) visualization confidence scores of DBCT in relation to dxDM. However, analysis by lesion type showed a statistically significant increase in reader shape (Δ =11.34, P = 0.013) and margin (Δ =9.93, P = 0.023) visualization confidence with DBCT versus dxDM for masses and significant decrease in reader morphology (Δ = -29.95, P = 0.001) and distribution (Δ = -28.62, P = 0.002) visualization confidence for calcifications. CONCLUSION: Reader confidence in the characterization of suspicious masses is significantly improved with DBCT, but reduced for calcifications. Further study is needed to determine whether this technology can be used for breast cancer screening.

Dollars and Discomfort: What Will People Be Willing to Give for Better Blood Pressure Assessment?

Recently, the US Preventive Services Task Force issued a draft recommendation to utilize 24-hour ambulatory blood pressure (BP) monitoring (ABPM) to confirm the diagnosis of hypertension after screening. However, ABPM can be inconvenient and has some adverse effects such as pain and bruising from the repeated cuff inflations. In this national survey, we asked adults 30 years and older how much physical discomfort they would be willing to undergo to have the most accurate test available for evaluating possible high BP. We also asked how much they would be willing to pay to have the test. Among 1010 respondents, 95% of participants indicated willingness to undergo at least mild physical discomfort. The median amount people would be willing to pay was $25. These findings suggest that people are willing to undergo a bit of discomfort, and even pay a small amount, for the benefit of accurate BP assessment.

Examination of Several Physiological and Psychosocial Factors Potentially Associated With Masked Hypertension Among Low-Risk Adults.

The authors examined the association of factors, in addition to prehypertensive office blood pressure (BP) level, that might improve detection of masked hypertension (MH), defined as nonelevated office BP with elevated out-of-office BP average, among individuals at otherwise low risk. This sample of 340 untreated adults 30 years and older with average office BP <140/90 mm Hg all had two sets of paired office BP measurements and 24-hour ambulatory BP monitoring (ABPM) sessions 1 week apart. Other than BP levels, the only factors that were associated (at P<.10) with MH at both sets were male sex (75% vs 66%) and working outside the home (72% vs 59% for the first set and 71% vs 45% for the second set). Adding these variables to BP level in the model did not appreciably improve detection of MH. No demographic, clinical, or psychosocial measures that improved upon prehypertension as a potential predictor of MH in this sample were found.

Comparison of patients' confidence in office, ambulatory, and home blood pressure measurements as methods of assessing for hypertension.

OBJECTIVE: Uncertainty exists when relying on office (clinic) blood pressure (BP) measurements to diagnose hypertension. Home BP monitoring and ambulatory BP monitoring (ABPM) provide measurements that are more strongly associated with cardiovascular disease. The degree to which patients exhibit uncertainty about office BP measurements is unknown, as is whether they would have less uncertainty about other BP measurement methods. We therefore assessed people's confidence in methods of BP measurement, comparing perceptions about office BP monitoring, home BP monitoring, and ABPM techniques. METHODS: We surveyed adults who were 30 years or older (n=193), all whom had undergone office BP measurements, two sessions of 24-h ABPM, and two 5-day periods of home BP monitoring. Respondents were asked to indicate their level of confidence on a 1 to 9 scale that BP measurements represented their 'usual' BP. RESULTS: Respondents had least confidence that assessments of BP made by office measurements (median 6) represented usual BP and greater confidence that assessments made by home BP monitoring (median 7, P<0.0001 vs. office) and ABPM (median 8, P<0.0001 vs. office) did so. Confidence levels did not vary significantly by BP levels, age, sex, race, or education level. CONCLUSION: The finding that patients do not have a great deal of confidence in office BP measurements, but have a higher degree of confidence in home BP and ambulatory BP assessment methods may be helpful in guiding strategies to diagnose hypertension and improve antihypertensive medication adherence.

Whole Breast Ultrasound: Comparison of the Visibility of Suspicious Lesions with Automated Breast Volumetric Scanning Versus Hand-Held Breast Ultrasound.

RATIONALE AND OBJECTIVES: To assess how well radiologists visualize relevant features of lesions seen with automated breast volumetric scanning (ABVS) in comparison to hand-held breast ultrasound in women going to breast biopsy. MATERIALS AND METHODS: Twenty-five subjects were recruited from women who were scheduled to undergo a breast biopsy for at least one Breast Imaging-Reporting and Data System four or five lesion identified in a diagnostic setting. In this institutional review board-approved study, the subjects underwent imaging of the breast(s) of concern using a dedicated system that allowed both hand-held breast ultrasound and ABVS. Five experienced breast radiologists reviewed the 30 lesions in 25 subjects in a reader study. Each reader was asked to specify the lesion type, size, imaging features, Breast Imaging-Reporting and Data System, and suspicion of malignancy and to compare the lesion characteristics of shape and margins between the two modalities. RESULTS: Seven (23.3%) masses were malignant and 23 (76.4%) were benign. Across all lesions regardless of size or final pathology, there was no significant difference in sensitivity or specificity (P > .15) between the two modalities. For malignant lesions, the reader visualization confidence scores between the two ultrasound modalities were not significantly different (P > .1). However, analysis for nonmalignant cases showed a statistically significant increase in reader visualization confidence in lesion shape and margins (P < .001). CONCLUSIONS: Radiologists showed increased confidence in visualization of benign masses and equal confidence in suspicious masses with ABVS imaging. This information could help decrease the need for additional hand-held imaging after automated whole breast ultrasound.

The effect of numeracy level on completeness of home blood pressure monitoring.

Home blood pressure monitoring (HBPM) readings predict the increased risks of cardiovascular events and end-organ damage independent of office blood pressure (BP). Numeracy (the ability to handle numbers) may limit the feasibility of patients' performing HBPM. The authors analyzed data from 409 adults recruited from 12 North Carolina primary care clinics who completed a three-item numeracy assessment, the Rapid Estimate of Adult Literacy in Medicine-Short Form health literacy assessment, and HBPM over 2 weeks. Among the 409 participants, 73% were college graduates and 69% had adequate numeracy. Completion of HBPM was greater among those with adequate numeracy (96.2% vs 93.7%; P=.009) and did not correlate with health literacy scores. More participants with adequate numeracy reported completion of ≥85% of readings than those with low numeracy (95% vs 88%; P=.018). Adequate numeracy, but not high literacy, is associated with more complete HBPM reporting. Whether higher numeracy is associated with more accurate self-reported readings is an area of future research.

Levels of office blood pressure and their operating characteristics for detecting masked hypertension based on ambulatory blood pressure monitoring.

BACKGROUND: Masked hypertension (MH)--nonelevated office blood pressure (BP) with elevated out-of-office BP average--conveys cardiovascular risk similar to or approaching sustained hypertension, making its detection of potential clinical importance. However, it may not be feasible or cost-effective to perform ambulatory BP monitoring (ABPM) on all patients with a nonelevated office BP. There likely exists a level of office BP below which ABPM is not warranted because the probability of MH is low. METHODS: We analyzed data from 294 adults aged ≥ 30 years not on BP-lowering medication with office BP <140/90 mm Hg, all of whom underwent 24-hour ABPM. We calculated sensitivity, false-positive rate, and likelihood ratios (LRs) for the range of office BP cutoffs from 110 to 138 mm Hg systolic and from 68 to 88 mm Hg diastolic for detecting MH. RESULTS: The systolic BP cutoff with the highest +LR for detecting MH (1.8) was 120 mm Hg, and the diastolic cutoff with the highest +LR (2.4) was 82 mm Hg. However, the systolic level of 120 mm Hg had a false-positive rate of 42%, and the diastolic level of 82 mm Hg had a sensitivity of only 39%. CONCLUSIONS: The cutoff of office BP with the best overall operating characteristics for diagnosing MH is approximately 120/82 mm Hg. However, this cutoff may have an unacceptably high false-positive rate. Clinical risk tools to identify patients with nonelevated office BP for whom ABPM should be considered will likely need to include factors in addition to office BP.

Reproducibility of masked hypertension among adults 30 years or older.

OBJECTIVE: Masked hypertension (MH) refers to nonelevated office blood pressure (BP) with elevated out-of-office BP, but its reproducibility has not been conclusively established. We examined 1-week reproducibility of MH by home BP monitoring (HBPM) and ambulatory BP monitoring (ABPM). METHODS: We recruited 420 adults not on BP-lowering medication, with recent clinic BP between 120/80 and 149/95 mmHg. For main comparisons, participants with office average less than 140/90 mmHg were considered to have MH if awake ABPM average was 135/85 mmHg or higher; they were considered to have MH by HBPM if the average was 135/85 mmHg or higher. Percentage agreements were quantified in terms of κ. We also examined the prevalence of MH, defined as office average less than 140/90 mmHg, with a 24-h ABPM average of 130/80 mmHg or higher. We carried out sensitivity analyses using different threshold BP levels for ABPM-office pairings and HBPM-office pairings for defining MH. RESULTS: Prevalence rates of MH based on office-awake ABPM pairings were 44 and 43%, with an agreement of 71% (κ=0.40; 95% confidence interval 0.31-0.49). MH was less prevalent (15 and 17%) using HBPM-office pairings, with agreement of 82% (κ=0.30; 95% confidence interval 0.16-0.44), and more prevalent when considering the 24-h average (50 and 48%). MH was also less prevalent when more stringent diagnostic criteria were applied. Office-HBPM pairings and office-awake ABPM pairings had fair agreement on MH classification on both occasions, with κ-values of 0.36 and 0.30. CONCLUSION: MH has fair short-term reproducibility, providing further evidence that for some people, out-of-office BP is systematically higher than that measured in the office setting.

Oral chemotherapy handling and storage practices among Veterans Affairs oncology patients and caregivers.

PURPOSE: This questionnaire-based study was designed to identify the oral chemotherapy medication handling, storage, and disposal practices among cancer patients and their caregivers. METHODS: This was a single-center observational survey study approved by the Investigational Review Board and VA Research & Development Committee. Patients were eligible for inclusion if they had an active order for an oral antineoplastic medication and an appointment at the oncology clinic. A questionnaire related to the storage, handling, disposal, patient education and counseling, and patients' perception of safety of oral antineoplastic medications was developed and given to patients in the clinic. Survey responses were analyzed using descriptive statistics. RESULTS: A total of 45 surveys were given to eligible patients in the oncology clinic and 42 surveys were returned to the study team. The majority, 40 participants (95%) were male. Participants ranged in age from 51 to 85 years (median, 65 years). Thirty-eight patients (90.5%) responded that the medication was stored away from extreme heat, cold, and humidity. Thirty-two patients (76%) reported keeping their medications in the original container. Hand washing was not a consistent practice among patients. Eleven patients (26%) reported always washing their hands after handling their anticancer medication; another 6 (14%) responded "sometimes". Of the 42 participants who answered, only 6 patients (14%) reported always or sometimes wearing gloves. CONCLUSION: The majority of patients responding to this survey store their oral anticancer medications appropriately, but patients' and caregivers' handling and disposal practices are inconsistent and frequently do not follow the published recommendations.

Hypertension.

Hypertension is the most common modifiable risk factor for cardiovascular disease. Antihypertensive treatment substantially reduces the risk of heart failure, stroke, and myocardial infarction. Current guidelines recommend screening all adults for high blood pressure (BP). Lifestyle modifications to help control high BP include weight loss, exercise, moderation of alcohol intake, and a diet low in sodium and saturated fats and high in fruits and vegetables. Out-of-office BP monitoring should be used to confirm suspected white coat effect, especially in patients with apparent resistant hypertension.