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.

Health education program effects on the management of hypertension in the elderly.

Because the elderly are viewed as having more difficulty in complying with therapy, this analysis was directed at the effects of a health education program on their control of primary hypertension when compared with a younger population. The program consisted of three sequential interventions introduced in a randomized factorial design. Depsite the fact that elderly patients had more chronic disease, more complications from hypertension, and were receiving more complex drug therapies than younger patients exposed to the same experimental interventions, they demonstrated significantly higher levels of compliance with drug therapy, significantly higher levels of appointment keeping, and no difference in the proportion having their BP under control at two-year-follow-up. Longitudinal data collected at five-year follow-up indicate no decay effect. These results indicate such programs can be successfully implemented and equally effective for an elderly population.

Determination of plutonium 240/239 ratios in Lake Ontario sediments.

A thermal ionization mass spectrometric procedure was developed for determination of 240/239 ratios in subpicogram quantities of plutonium (Pu), and was applied to Pu extracted from Lake Ontario sediment. The detection limit was ∼ 4 fg of Pu and the precision of 240/239 ratio measurement was ∼ 7% in the 0.07-0.42 pg range. Results of sediment analyses at various depths showed in all cases 240/239 ratios near the mean global fallout value of 0.176 ± 0.014. The lack of variability of the ratios with depth negated the use of Pu, present in excess in the near-surface samples due to leakage from a nearby reprocessing plant, as a geochronological meter. The 240/239 ratio of the leakage Pu appeared to be very similar to that of fallout Pu.

The validity of single-item, self-assessment questions as measures of adult physical activity.

Individual energy expenditure (kcal/kg/day) was calculated from a detailed set of questions from the Health Promotion and Disease Prevention Supplement of the 1985 National Health Interview Survey. Responses to three single-item, self-assessment questions were compared to the energy expenditure variable to test criterion validity. Spearman's correlation coefficient revealed moderate correlations between energy expenditure and corresponding levels of self-assessed leisure-time physical activity for each single-item question (r = 0.14 to 0.41). For purposes of measuring prevalence of physical activity, the energy expenditure variable was used to categorize individuals into activity levels. The single-item questions were found to have Spearman's correlations with the categorical measures ranging from 0.11 to 0.37 for leisure-time activities. Generally higher correlations were found for males and younger age groups (18-34 years). The relationships were interpreted as being weak relative to an expected correlation of 0.75 for criterion validation. However, the single-item questions show promise for obtaining proxy estimates of the degree of leisure-time physical activity in a population.

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

Evaluations of workplace smoking cessation programs: a critique.

This article reviews 21 published evaluations of workplace smoking cessation programs. Its purpose is to assess the quality of these evaluations and outline recommendations that may benefit such smoking cessation efforts. Issues that should be considered during the planning and evaluation of these smoking cessation programs include research design, behavior measurement and verification, employee recruitment strategies, nonsmoking behavior maintenance, and ethics.

Validation of a decision model for triaging hypertensive patients to alternate health education interventions.

The ability to assign patients to the most appropriate program of intervention would improve patient outcomes and reduce health care costs. This paper evaluates specific potentials of triaging patients into various combinations of health education treatments. Blood pressure improvement among hypertensive patients was measured and the associated treatment cost and savings were compared. Triaging rules were formed empirically from the relationship between patient characteristics selected before the study was conducted and their achieved blood pressure control within each combination of interventions. Patients randomly assigned to seven combinations of three interventions were studied in contrast to patients in a randomized control group. A combination of all three interventions was the most effective program for the undifferentiated (random) patient population, achieving a 49% increase over 18 months in patients with blood pressure under control. By triaging, 51-91% increases in patients with controlled blood pressure were achieved. Educational history of the patients which is a fairly reliable measure was the most efficient triaging variable, showing a 91% increase in patients with blood pressure under control and a relative cost saving of about 400%.

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.

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.

Setting the stage for health impact assessment.

Defining health impact assessment as any combination of procedures or methods by which a proposed policy or program may be judged as to the effect(s) it may have on the health of a population, we make recommendations about how to evaluate the health impact of all government-initiated policies. Such health impact cannot be assessed in the absence of a conceptual or organizing framework that provides the requisite guideposts--population health goals and targets. Health impact assessment offers an approach to ensuring that governments' program and policy initiatives align, or are congruent with, the agreed-upon health goals. It suggests that proposed national policies should be supported or resisted on the basis of their probable influence on the health of populations. In the current Canadian national policy framework, however, there are no underpinnings on which to situate such a process. The specification of consensus goals and objectives with measurable targets can provide the requisite guideposts and benchmarks for health impact assessment. Such an undertaking can set the stage and provide the necessary foundation for an effective health impact assessment process.

Ecological foundations of health promotion.

In this article, human ecology is defined; its historical and intellectual roots are traced through various disciplines to its applications in public health and health promotion today; its strengths and limitations are described; some potential contributions of systems theory are suggested; and some emerging ecological models of health promotion are anticipated.

Assessment of the integration of the ecological approach in health promotion programs.

PURPOSE: This article proposes a model of the ecological approach in health promotion programs. Based on system theory, the model identifies intervention settings and targets as two independent dimensions for assessing the integration of this approach in programs. Additional objectives are to present and pretest an analytical procedure that allows the assessment of integration of the ecological approach in programs. DESIGN: This was a descriptive study of the integration of the ecological approach in a sample of health promotion programs. SUBJECTS: Subjects were 44 health promotion programs drawn from the population of Canadian federally funded programs. MEASURES: Descriptions of programs were obtained by telephone interviews. A coding scheme was applied to the data to identify intervention settings and targets for each program. Using this information, a summative score of the integration of the ecological approach was estimated for each program. RESULTS: Single-setting programs were the dominant pattern in the sample. Individuals whose health was of concern were very frequently the direct targets of the programs. However, organizational and interpersonal environments were also often directly targeted. Single-setting or single-intervention strategy programs outnumbered ecological programs. CONCLUSION: The proposed model and analytical procedure is a useful framework for the assessment of integration of the ecological approach in health promotion programs. The pilot test having been conducted on a convenience sample, future work should replicate the study in a representative sample of programs.

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.

An epidemiological approach to targeting drug information.

Reliance on pharmaceuticals for medial therapy, especially for chronic conditions in an aging society, poses important questions regarding patient's understanding of and adherence to their drug regimens. Related policy issues have been debated chiefly in the context of regulations administered by the Food and Drug Administration (FDA), such as the once proposed 'patient package inserts'. A population-based analysis of the distribution of health risks and drug utilization errors--including errors of omission--identifies a set of allocation issues for improving use of medications for public health as well as medical and pharmacy practice. These issues center particularly on channels and targets of drug information, including mass media, community and private medical practices, age and sex groupings within the patient and non-patient populations, and selected diseases, conditions and drugs requiring more attention. A conceptual framework for determining information needs is developed with recommendations for a combined public health and patient education strategy for the reduction of drug errors and the enhancement of drug benefits.

Characteristics of controlled studies of patient education and counseling for preventive health behaviors.

To determine characteristics of controlled studies (quasi-experimental and randomized) of clinical patient education/counseling for behavior change to prevent disease, we conducted an extensive literature review of published and unpublished studies from 1971 to 1989. Sixty-four studies with 101 intervention groups met specific criteria for relevance and scientific acceptability. We examine these studies in terms of prevention area, subject source, intervention characteristics, and use of educational principles. Findings reveal many controlled clinical studies in smoking cessation, nutrition, and weight control but sparcity in other areas (injury prevention, exercise, stress, drug and alcohol misuse, STD prevention); an emphasis on communication by a single clinical practitioner; and varied use of educational principles. We recommend adhering to educational principles to enhance likelihood of success.

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.

A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors.

OBJECTIVES: To examine the overall effectiveness of patient education and counseling on preventive health behaviors and to examine the effects of various approaches for modifying specific types of behaviors. DATA SOURCES: Computerized databases (Medline, Healthline, Dissertation Abstracts, and Psychological Abstracts), bibliographies 1971-1994. Search terms (patient education, patient compliance, and self care) with modifiers (evaluation and specific preventive behaviors). STUDY SELECTION: Randomized and non-randomized controlled trials measuring behavior in clinical settings with patients without diagnosed disease. Abstracts and retrieved studies screened by multiple reviewers; 13% of retrieved studies met screening criteria. DATA EXTRACTION: Replicated coding by multiple observers. DATA SYNTHESIS: Behaviors were grouped based on whether the behavior is addictive and whether the desired change required subtraction of existing behaviors or adding new behaviors. The weighted average effect size from a random effects model for smoking/alcohol studies was 0.61 (CI = 0.45, 0.77), for nutrition/weight, 0.51 (CI = 0.20, 0.82) and for other behaviors, 0.56 (CI = 0.34, 0.77) indicating that the behavioral outcomes for these subgroups were significantly different from zero. Multiple regression models for the three groups indicated that using behavioral techniques, particularly self-monitoring, and using several communication channels, e.g., media plus personal communication, produces larger effects for the smoking/alcohol and nutrition/weight groups. CONCLUSIONS: Patient education and counseling contribute to behavior change for primary prevention of disease. Some techniques are more effective than others in changing specific behaviors.

Data-based planning for educational interventions through hypertension control programs for urban and rural populations in Maryland.

As part of a statewide effort to coordinate existing resources for high blood pressure (HBP) control, a public health HPB control program was planned and implemented in two high-risk communities in Maryland. The selection of the two communities was based on epidemiologic data. The planning of the educational intervention program in these communities (urban and rural) was guided by organizational theory and health education principles. The framework for development, implementation, and evaluation of the program utilizes an educational assessment model which identified factors that predispose, reinforce, and enable individual persons to practice positive health behavior. Multiple data sources were used in assessing the extent of the problem and relevant approaches in the development of the coordinated HPB control program. These include statewide vital statistics and a random statewide household survey to assess the prevalence rates of awareness, treatment, and control of HPB. To supplement these data, telephone surveys were carried out in the two communities to assess knowledge, beliefs, and practices related to HPB control. Medical record reviews provided baseline information on appointment keeping behavior and BP correlates of hypertensive patients. The planning and implementation of the program was carried out under the direction of representatives of the health care systems, community leaders, and residents, and representatives of communitywide organizations involved in HPB control.