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].

Can we say what diet is best for health?

Diet is established among the most important influences on health in modern societies. Injudicious diet figures among the leading causes of premature death and chronic disease. Optimal eating is associated with increased life expectancy, dramatic reduction in lifetime risk of all chronic disease, and amelioration of gene expression. In this context, claims abound for the competitive merits of various diets relative to one another. Whereas such claims, particularly when attached to commercial interests, emphasize distinctions, the fundamentals of virtually all eating patterns associated with meaningful evidence of health benefit overlap substantially. There have been no rigorous, long-term studies comparing contenders for best diet laurels using methodology that precludes bias and confounding, and for many reasons such studies are unlikely. In the absence of such direct comparisons, claims for the established superiority of any one specific diet over others are exaggerated. The weight of evidence strongly supports a theme of healthful eating while allowing for variations on that theme. A diet of minimally processed foods close to nature, predominantly plants, is decisively associated with health promotion and disease prevention and is consistent with the salient components of seemingly distinct dietary approaches. Efforts to improve public health through diet are forestalled not for want of knowledge about the optimal feeding of Homo sapiens but for distractions associated with exaggerated claims, and our failure to convert what we reliably know into what we routinely do. Knowledge in this case is not, as of yet, power; would that it were so.

Unfattening our children: forks over feet.

Childhood obesity rates have risen alarmingly for decades, and although recent data suggest a possible plateau, obesity is seen in ever younger children, and is increasingly severe. The proximal cause of obesity is energy imbalance; the root cause is modern living. Throughout most of human history, calories were relatively scarce and hard to get, and physical activity unavoidable. We have devised a modern world, in which physical activity is scarce and hard to get and calories are unavoidable. Although both sides of the energy balance equation matter, forced to pick sides, we should prioritize forks over feet for weight control based on both science and sense. The modern world makes it very easy to out-eat exercise, and nearly impossible to out-exercise excessive eating.

The effect of the addition of daily fruit and nut bars to diet on weight, and cardiac risk profile, in overweight adults.

BACKGROUND: The frequency of unhealthful snacking has increased dramatically over the last three decades. Fruits and nuts have been shown to have positive health effects. No study has investigated the aggregate effects of various fruits combined with nuts in the form of snack bars on cardiovascular risk factors. The aim of this randomised trial was to investigate the effects of a fruit and nut snack bar on anthropomorphic measures, lipid panel and blood pressure in overweight adults. METHODS: Ninety-four overweight adults (body mass index > 25 kg m(-2)) were randomly assigned to add two fruit and nut bars totalling 1421.9 kJ (340 kcal) to their ad libitum diet (intervention group) or to continue with their ad libitum diet (control group). Subjects underwent assessment for weight (primary outcome measure), as well as waist circumference, lipid panel and blood pressure (secondary outcome measures), before and at the end of the 8-week treatment. RESULTS: Weight did not change from baseline after snack bar addition compared to controls (P = 0.44). Waist circumference (P = 0.69), blood pressure (systolic, P = 0.83; diastolic, P = 0.79) and blood lipid panel (total cholesterol, P = 0.72; high-density lipoprotein, P = 0.11; total cholesterol/high-density lipoprotein, P = 0.37; triglycerides, P = 0.89; low-density lipoprotein, P = 0.81) also did not change from baseline compared to controls. CONCLUSIONS: Two daily fruit and nut bars, totalling 1421.9 kJ (340 kcal), did not cause weight gain. The role of habitual snacking on nutrient dense and satiating foods on both weight over time, and diet quality, warrants further study. Satiating snacks rich in fibre may provide a means to weight stabilisation.

Dietary assessment can be based on pattern recognition rather than recall.

Diet is the leading predictor of health status, including all-cause mortality, in the modern world, yet is rarely measured; whereas virtually every adult in a developed country knows their approximate blood pressure, hardly any knows their objective diet quality. Leading authorities have called for the inclusion of nutrition in every electronic health record as one of the many remedial steps required to give dietary quality the routine attention it warrants. Existing tools to capture dietary intake are based on either real-time journaling or recall. Journaling, or logging, is time and labor intensive. Recall is notoriously unreliable, as humans are notably bad at remembering detail. Even allowing for the challenge of recall, these dietary intake methods are labor and time intensive, and require analysis at the n-of-1 level. We hypothesize that dietary intake assessment can be "reverse engineered"-predicating assessment on the recognition of fully formed dietary patterns-rather than endeavoring to assemble such a representation one food, meal, dish, or day at a time. This pattern recognition-based method offers potential advantages over existing methods, including speed, efficiency, cost, and applicability. We have developed and provisionally tested such a system, and the results thus far support our hypothesis. We are convinced that leveraging pattern recognition to make dietary assessment quick, user-friendly, economical, and scalable can allow for the conversion of dietary quality into a universally measured and routinely managed vital sign. In this paper, we present the supporting case.

School-based interventions for health promotion and weight control: not just waiting on the world to change.

Controversy persists regarding the utility of school-based interventions for obesity prevention and control and for related health promotion. This article reviews the pertinent evidence, based partly on a recent systematic review and meta-analysis by the author and colleagues. Of 64 relevant papers, 21 papers representing 19 distinct studies met quality criteria; half of these were published since 2000. Despite marked variation in measures, methods, and populations that handicap interpretation of this literature, evidence clearly demonstrated that school-based interventions had significant effects on weight. Thus available research evidence does present a case for school-based interventions. Despite the fact that such evidence is limited to date, the urgency of the obesity and diabetes epidemics cries out for action. Intervention is warranted on the basis of both extant evidence and common sense, with methodologically robust evaluation concomitantly to test our assumptions and verify our intuition.

Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of school-based strategies for obesity prevention and control using methods of systematic review and meta-analysis. METHODS: Peer-reviewed studies published between 1966 and October 2004 were considered for review. Studies meeting eligibility criteria were published in English, targeted children aged 3-18 in a school setting, reported weight-related outcomes, included a control measurement and had at least a 6-month follow-up period. Studies employed interventions related to nutrition, physical activity, reduction in television viewing or combinations thereof. Weight related data were analyzed using RevMan software. RESULTS: Sixty-four studies were considered for inclusion. Fourteen did not meet inclusion criteria; 29 were excluded due to poor methodological quality. Twenty-one papers describing 19 studies were included in the systematic review and 8 of these were included in the meta-analysis. Nutrition and physical activity interventions resulted in significant reductions in body weight compared with control ((standardized mean difference, SMD=-0.29, 95% confidence interval (CI)=-0.45 to -0.14), random effects model). Parental or family involvement of nutrition and physical activity interventions also induced weight reduction ((SMD=-0.20, 95%CI=-0.41 to 0.00), random effects model). CONCLUSION: Combination nutrition and physical activity interventions are effective at achieving weight reduction in school settings. Several promising strategies for addressing obesity in the school setting are suggested, and warrant replication and further testing.

WITHDRAWN: Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis.

The authors hereby retract the e-publication dated July 31, 2007, entitled, 'Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis,' and are submitting a revised version with the same title. A secondary review of the manuscript took place following its initial acceptance, resulting in additional statistical analyses along with some pertinent revisions to the accompanying narrative.

Psychiatric and medical effects of anabolic-androgenic steroid use. A controlled study of 160 athletes.

BACKGROUND: We sought to expand on preliminary findings suggesting that anabolic-androgenic steroids produce psychiatric effects in some athletes who use them. METHODS: We compared 88 athletes who were using steroids with 68 nonusers, using the Structured Clinical Interview for DSM-III-R to diagnose psychiatric syndromes occurring in association with steroid use (if applicable) and in the absence of steroid use. Demographic, medical, and laboratory measures were also performed. RESULTS: Steroid users displayed more frequent gynecomastia, decreased mean testicular length, and higher cholesterol-high-density lipoprotein ratios than nonusers. Most strikingly, 23% of steroid users reported major mood syndromes--mania, hypomania, or major depression--in association with steroid use. Steroid users displayed mood disorders during steroid exposure significantly more frequently than in the absence of steroid exposure (P < .001) and significantly more frequently than nonusers (P < .01). Users rarely abused other drugs simultaneously with steroids. CONCLUSION: Major mood disturbances associated with anabolic-androgenic steroids may represent an important public health problem for athletes using steroids and sometimes for the victims of their irritability and aggression.

Parental IQ and cognitive development of malnourished Indonesian children.

A cross-sectional study of children in West Kalimantan, Indonesia, was conducted to examine the relationship between malnutrition history, child IQ, school attendance, socioeconomic status, parental education and parental IQ. In unadjusted analyses, severely stunted children had significantly lower IQ scores than mild-moderately stunted children. This effect was significant when stunting, school attendance and parental education were included in multivariable models but was attenuated when parental IQ was included. Our research underscores the importance of accounting for parental IQ as a critical covariate when modeling the association between childhood stunting and IQ.

Affective and psychotic symptoms associated with anabolic steroid use.

To assess the frequency of affective and psychotic symptoms in athletes taking anabolic steroids, the authors performed structured interviews of 41 body-builders and football players who had used steroids. According to DSM-III-R, nine subjects (22%) displayed a full affective syndrome, and five (12%) displayed psychotic symptoms in association with steroid use. These findings suggest that major psychiatric symptoms may be a common adverse effect of these drugs.

Pelvic lipomatosis: diagnosis by computerized tomography scan.

Pelvic lipomatosis is a rare, relatively self-limiting disease characterized by the overgrowth of unencapsulated lipomatous tissue within the pelvis. The diagnosis is suggested, but not substantiated, by the striking roentgenographic changes noted on barium enema and intravenous pyelogram. Previously, pelvic laparotomy with tissue diagnosis was essential for documenting the disease. We report three cases in which computerized tomography was utilized as a safe, noninvasive and accurate method of diagnosis. The role played by partial venous obstruction is discussed in addition to rectal bleeding as a mode of presentation.

Homicide and near-homicide by anabolic steroid users.

The authors describe three men, all with benign premorbid psychiatric histories, no evidence of antisocial personality disorder, and no history of violence, who impulsively committed violent crimes--including murder--while taking anabolic steroids. Structured psychiatric interviews of each man suggested that steroids played a necessary, if not primary, role in the etiology of the violent behavior. Although the men conceivably might have exaggerated their reports of the effects of steroids in the hopes of improving their legal positions, information from external sources consistently corroborated their accounts in each case. These observations raise the possibility that steroid-induced violence may pose a little-recognized public health problem.

Health risk behaviors and health perceptions in the Peruvian Amazon.

Behavioral health risk factor and health belief data for the indigenous population of the Peruvian Amazon are unavailable. Therefore, we conducted structured interviews of adults living in 5 towns in the remote Amazon region of Peru. Respondents (n = 179) were 67% women with a mean age of 35.4 years. The average household size was 6.7 people. A majority (72%) were unable to see a doctor when needed because of lack of money and distance. Only 6% reported excellent health, and nearly half (49%) reported fair health. Forty-eight percent drank alcohol and 73% smoked. Only 34% thought mosquitoes cause malaria, but 98% were using mosquito nets. In conclusion, our findings indicate the indigenous population of the Peruvian Amazon has limited access to basic health care. Although most of those surveyed use mosquito netting, few know that mosquitoes transmit malaria. Tobacco and alcohol use are major behavioral health risk factors.

American College of Preventive Medicine Practice Policy Statement: perimenopausal and postmenopausal hormone replacement therapy.

Based on a review of current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on perimenopausal hormone replacement therapy.

American College of Preventive Medicine Practice Policy statement. Weight management counseling of overweight adults.

On the basis of a review of the current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on weight management counseling of overweight adults.

Self-reported weight and height: implications for obesity research.

BACKGROUND: Self-reported weight and height are under- and over-reported, respectively, in epidemiologic studies. This tendency, which may adversely affect study operations, has not been evaluated among subjects being enrolled into a weight-loss program. METHODS: Self-reported weight, height, and body mass index (BMI) were compared to measured values in 97 overweight or obese (BMI>27.3) women being enrolled into a randomized, controlled trial of two behavioral interventions for weight loss. The effects of demographic factors, baseline weight, baseline height, and baseline BMI on weight and height reporting were assessed. RESULTS: There was a significant difference between measured and reported weight (mean difference=-3.75 lb, p=0.0001) and height (mean difference=+0.35 in., p=0.0007). The mean difference between measured and reported BMI was -1.14 kg/m(2) (p=0.0001). Unemployed, retired, or disabled women were more likely to under-report their BMI than employed women (p=0.001). Six percent of subjects who were initially considered eligible for the study on the basis of the self-report were eventually excluded from the study because they did not meet the inclusion criterion for BMI. CONCLUSIONS: Obese women who seek weight-loss assistance tend to under-report their weight and over-report their height, suggesting that self-reported data are likely to be inaccurate. Misreporting is apparently influenced by employment and disability and has the potential to complicate recruitment of subjects for research studies.

Acute effects of oats and vitamin E on endothelial responses to ingested fat.

OBJECTIVE: To assess the effects of oats and vitamin E on endothelial function following a high-fat meal in healthy adults as measured by brachial artery reactivity studies (BARS). METHODS: A total of 25 men and 25 women (N=50) were recruited from a community population to participate in this randomized, crossover study. All subjects were free of known vascular disease, and female subjects were postmenopausal. Subjects underwent BARS before and after a high-fat meal (50 gm fat) on three occasions 1 week apart, one each with vitamin E 800 IU, oatmeal containing 3 gm beta-glucan, or a comparable bowl of wheat cereal serving as a placebo, in random sequence. The ultrasonographer was blinded to treatment status. RESULTS: Endothelial function, as measured by brachial artery peak flow during one minute of post-occlusive hyperemia, declined significantly from baseline when the high-fat meal was consumed with the wheat cereal (-13.4%; p=0.02). There was no difference in brachial artery flow change before and after a high-fat meal with oats (+0.37%; p=0.77) or a high-fat meal with vitamin E (+1.87%; p=0.42). No significant differences in flow-mediated vasodilation before and after the high-fat meal were detected among the three supplements. CONCLUSIONS: Endothelial dysfunction induced by acute fat ingestion in healthy adults is apparently prevented by concomitant ingestion of oats or vitamin E, but not wheat. Nutrient distribution and meal composition may have important implications for cardiovascular health.

An integrated residency in internal and preventive medicine.

The importance of preventive and population-based principles in clinical practice is widely acknowledged. The challenge of imparting these principles in either undergraduate or postgraduate medical education has, however, not been fully met. The necessary skills are provided comprehensively by preventive medicine residency programs, but at the expense of clinical training. Sequential residencies in primary care and preventive medicine, the currently available means of obtaining thorough preparation in both clinical and population-based principles, represent an inefficient, generally unappealing, and non-integrated approach. In response to these concerns, and in an effort to make preventive medicine training appeal to a wider audience, the authors developed and implemented a residency program fully integrating internal and preventive medicine. The program meets, and generally exceeds, the requirements of both specialty boards over a four-year period. The program provides extensive training in clinical, preventive, and public health skills, along with case management and cost-effective care, conferring the MPH degree and leading to dual board eligibility. The model is ideally wed to the demands of the modern health care environment in the United States, is extremely attractive to applicants, and may warrant replication both to train academic and administrative leaders and to raise the standards of preventive and public health practice in primary care.