Evaluation of a pilot diabetes educational intervention using the American Diabetes Association's Risk Assessment form with the patrons of The Health Museum, Houston Texas

Diabetes Mellitus is not a disease, but a group of diseases. Common to all types of diabetes is high levels of blood glucose produced from a variety of causes. In 2006, the American Diabetes Association ranked diabetes as the fifth leading cause of death in the United States. The complications and consequences are serious and include nephropathy, retinopathy, neuropathy, heart disease, amputations, pregnancy complications, sexual dysfunction, biochemical imbalances, susceptibility and sensitivity to many other diseases and in some cases death. ^ The serious nature of diabetes mellitus and its complications has compelled researchers to devise new strategies to reach population segments at high risk. Various avenues of outreach have been attempted. This pilot program is not unique in using a health museum as a point of outreach. However health museums have not been a major source of interventions, either. Little information was available regarding health museum visitor demographics, visitation patterns, companion status and museum trust levels prior to this pilot intervention. This visitor information will improve planning for further interventions and studies. ^ This thesis also examined prevalence data in a temporal context, the populations at risk for diabetes, the collecting agencies, and other relevant collected data. The prevalence of diabetes has been rapidly increasing. The increase is partially explained by refinement of the definition of diabetes as the etiology has become better understood. Increasing obesity and sedentary lifestyles have contributed to the increase, as well as the burdensome increase on minority populations. ^ Treatment options are complex and have had limited effectiveness. This would lead one to conclude that prevention and early diagnosis are preferable. However, the general public has insufficient awareness and education regarding diabetes symptoms and the serious risks and complications the disease can cause. Reaching high risk, high prevalence, populations is challenging for any intervention. During its “free family Thursdays” The Health Museum (Houston, Texas) has attracted a variety of ethnic patrons; similar to the Houston and Harris County demographics. This research project explored the effectiveness of a pilot diabetes educational intervention in a health museum setting where people chose to visit. ^

'Your Heart Can't Wait'---A worksite program: Increasing the effectiveness of worksite coordinators to implement a community-wide health education program

A worksite health education program called “Your Heart Can't Wait,” was designed by the American Heart Association Gulf Coast Area (AHA). The objectives were to educate individuals about the signs and symptoms of heart attacks and the actions they should take to improve heart attack victims' chances for survival. AHA volunteers agreed to serve as mentors for this program. ^ A study was designed to determine if worksite coordinators who had the assistance of experienced AHA volunteers had higher rates of program adoption and implementation than worksite coordinators without assistance. Ninety-seven companies participated in the study. Twelve AHA volunteers were randomly assigned to work with forty-three of the worksite coordinators. Mentor/mentee contact forms were used to assess the mentoring process during the course of the study. Program adoption forms were used to measure rates of program adoption and follow-up questionnaires were used to measure rates of program implementation after the study was completed. The twelve mentors were interviewed to provide information for improving future mentoring efforts. ^ Thirty-eight companies completed program adoption forms and fifty-one companies reported using YHCW program components. For the most part, the volunteer mentors did not spend a significant amount of time contacting or working with their assigned worksite coordinators. As a result, the planned analysis comparing the implemented programs between worksite coordinators with and without assistance could not be completed. ^ Additional analyses were performed comparing the implemented programs based upon whether the companies had existing health education/health promotion programs and whether the worksite coordinators had experience using AHA Heart At Work program components. ^ Recommendations based on the mentor interviews were made to improve the success of volunteer assistance programs in the future. ^

A formative evaluation of the American Diabetes Association's Choosing Health and Sensible Exercise childhood obesity intervention

Background. The increasing prevalence of overweight among youth in the United States, and the parallel rise in related medical comorbidities has led to a growing need for efficient weight-management interventions. Purpose. The aim of this study was to evaluate the effects of the Choosing Health and Sensible Exercise (C.H.A.S.E.) childhood obesity prevention program on Body Mass Index (BMI), physical activity and dietary behaviors. Methods. This study utilized de-identified data collected during the fall 2006 session of the C.H.A.S.E. program. A total of 65 students at Woodview Elementary School and Deepwater Elementary School participated in this intervention. The C.H.A.S.E. program is a 10-week obesity prevention program that focuses on nutrition and physical activity education. Collection of height and weight data, and a health behavior survey was conducted during the first and last week of the intervention. Paired t-tests were used to determine statistically significant differences between pre- and post-intervention measurements. One-way analysis of variance was used to adjust for potential confounders, such as gender, age, BMI category ("normal weight", "at risk overweight", or "overweight"), and self-reported weight loss goals. Data were analyzed using STATA, v. 9.2. Results. A significant decrease in mean BMI (p< 0.05) was found after the 10-week intervention. While the results were statistically significant for the group as a whole, changes in BMI were not significant when stratified by age, sex, or ethnicity. The mean overall scores for the behavior survey did not change significantly pre- and post-intervention; however, significant differences were found in the dietary intention scale, indicating that students were more likely to intend to make healthier food choices (p<0.05). No statistically significant decreases in BMI were found when stratified for baseline BMI-for-age percentiles or baseline weight loss efforts (p>0.05). Conclusion. The results of this evaluation provide information that will be useful in planning and implementing an effective childhood obesity intervention in the future. Changes in the self-reported dietary intentions and BMI show that the C.H.A.S.E. program is capable of modifying food choice selection and decreasing BMI. Results from the behavior questionnaire indicate that students in the intervention program were making changes in a positive direction. Future implementation of the C.H.A.S.E. program, as well as other childhood obesity interventions, may want to consider incorporating additional strategies to increase knowledge and other behavioral constructs associated with decreased BMI. In addition, obesity prevention programs may want to increase parental involvement and increase the dose or intensity of the intervention. ^

Population-level risks of physical activity: Saving bones and screening hearts

Documented risks of physical activity include reduced bone mineral density at high activity volume, and sudden cardiac death among adults and adolescents. Further illumination of these risks is needed to inform future public health guidelines. The present research seeks to 1) quantify the association between physical activity and bone mineral density (BMD) across a broad range of activity volume, 2) assess the utility of an existing pre-screening questionnaire among US adults, and 3) determine if pre-screening risk stratification by questionnaire predicts referral to physician among Texas adolescents. ^ Among 9,468 adults 20 years of age or older in the National Health and Nutrition Examination Survey (NHANES) 2007-2010, linear regression analyses revealed generally higher BMD at the lumbar spine and proximal femur with greater reported activity volume. Only lumbar BMD in women was unassociated with activity volume. Among men, BMD was similar at activity beyond four times the minimum volume recommended in the Physical Activity Guidelines. These results suggest that the range of activity reported by US adults is not associated with low BMD at either site. ^ The American Heart Association / American College of Sports Medicine Preparticipation Questionnaire (AAPQ) was applied to 6,661 adults 40 years of age or older from NHANES 2001-2004 by using NHANES responses to complete AAPQ items. Following AAPQ referral criteria, 95.5% of women and 93.5% of men would be referred to a physician before exercise initiation, suggesting little utility for the AAPQ among adults aged 40 years or older. Unnecessary referral before exercise initiation may present a barrier to exercise adoption and may strain an already stressed healthcare infrastructure. ^ Among 3181 athletes in the Texas Adolescent Athlete Heart Screening Registry, 55.2% of boys and 62.2% of girls were classified as high-risk based on questionnaire answers. Using sex-stratified contingency table analyses, risk categories were not significantly associated with referral to physician based on electrocardiogram or echocardiogram, nor were they associated with confirmed diagnoses on follow-up. Additional research is needed to identify which symptoms are most closely related to sudden cardiac death, and determine the best methods for rapid and reliable assessment. ^ In conclusion, this research suggests that the volume of activity reported by US adults is not associated with low BMD at two clinically relevant sites, casts doubts on the utility of two existing cardiac screening tools, and raises concern about barriers to activity erected through ineffective screening. These findings augment existing research in this area that may inform revisions to the Physical Activity Guidelines regarding risk mitigation.^

Ambulatory blood pressure and physical activity in heart failure

Background. Ambulatory blood pressure (ABP) measurement is a means of monitoring cardiac function in a noninvasive way, but little is known about ABP in heart failure (HF) patients. Blood pressure (BP) declines during sleep as protection from consistent BP load, a phenomenon termed "dipping." The aims of this study were (1) to compare BP dipping and physical activity between two groups of HF patients with different functional statuses and (2) to determine whether the strength of the association between ambulatory BP and PA is different between these two different functional statuses of HF. ^ Methods. This observational study used repeated measures of ABP and PA over a 24-hour period to investigate the profiles of BP and PA in community-based individuals with HF. ABP was measured every 30 minutes by using a SpaceLabs 90207, and a Basic Motionlogger actigraph was used to measure PA minute by minute. Fifty-six participants completed both BP and physical activity for a 24-hour monitoring period. Functional status was based on New York Heart Association (NYHA) ratings. There were 27 patients with no limitation of PA (NYHA class I HF) and 29 with some limitation of PA but no discomfort at rest (NYHA class II or III HF). The sample consisted of 26 men and 30 women, aged 45 to 91 years (66.96 ± 12.35). ^ Results. Patients with NYHA class I HF had significantly greater dipping percent than those with NYHA class II/III HF after controlling their left ventricular ejection fraction (LVEF). In a mixed model analysis (PROC MIXED, SAS Institute, v 9.1), PA was significantly related to ambulatory systolic and diastolic BP and mean arterial pressure. The strength of the association between PA and ABP readings was not significantly different for the two groups of patients. ^ Conclusions. These preliminary findings demonstrate differences between NYHA class I and class II/III of HF in BP dipping status and ABP but not PA. Longitudinal research is recommended to improve understanding of the influence of disease progression on changes in 24-hour physical activity and BP profiles of this patient population. ^ Key Words. Ambulatory Blood Pressure; Blood Pressure Dipping; Heart Failure; Physical Activity. ^

Factors associated with hospital admission of elder cardiovascular patients in an emergency center

Context. Healthcare utilization of elder cardiovascular patients in United States will increase in near future, due to an aging population. This trend could burden urban emergency centers, which have become a source of primary care. ^ Objective. The objective of this study was to determine the association of age, gender, ethnicity, insurance and other presenting variables on hospital admission in an emergency center for elder cardiovascular patients. ^ Design, setting and participants. An anonymous retrospective review of emergency center patient login records of an urban emergency center in the years 2004 and 2005 was conducted. Elder patients (age ≥ 65 years) with cardiovascular disease (ICD91 390-459) were included. Multivariate logistic regression analysis was used to identify independent factors for hospital admission. Four major cardiovascular reasons for hospitalisation – ischemic heart disease, heart failure, hypertensive disorders and stroke were analysed separately. ^ Results. The number of elder patients in the emergency center is increasing, the most common reason for their visit was hypertension. Majority (59%) of the 12,306 elder patients were female. Forty five percent were uninsured and 1,973 patients had cardiovascular disease. Older age (OR 1.10; CI 1.02-1.19) was associated with a marginal increase in hospital admission in elder stroke patients. Elder females compared to elder males were more likely to be hospitalised for ischemic heart disease (OR 2.71; CI 1.22-6.00) and heart failure (OR 1.58; CI 1.001-2.52). Furthermore, insured elder heart failure patients (OR 0.54; CI 0.31-0.93) and elder African American heart failure patients (OR 0.32; CI 0.13-0.75) were less likely to be hospitalised. Ambulance use was associated with greater hospital admissions in elder cardiovascular patients studied, except for stroke. ^ Conclusion. Appropriate health care distribution policies are needed for elder patients, particularly elder females, uninsured, and racial/ethnic minorities. These findings could help triage nurse evaluations in emergency centers to identify patients who were more likely to be hospitalised to offer urgent care and schedule appointments in primary care clinics. In addition, health care plans could be formulated to improve elder primary care, decrease overcrowding in emergency centers, and decrease elder healthcare costs in the future. ^

The association between diabetes and hepatitis C: A systematic review of epidemiological evidence

Background. Several studies have proposed a link between type 2 Diabetes mellitus (DM2) and Hepatitis C infection (HCV) with conflicting results. Since DM2 and HCV have high prevalence, establishing a link between the two may guide further studies aimed at DM2 prevention. A systematic review was conducted to estimate the magnitude and direction of association between DM2 and HCV. Temporality was assessed from cohort studies and case-control studies where such information was available. ^ Methods. MEDLINE searches were conducted for studies that provided risk estimates and fulfill criteria regarding the definition of exposure (HCV) and outcomes (DM2). HCV was defined in terms of method of diagnosis, laboratory technique and method of data collection; DM2 was defined in terms of the classification [World Health Organization (WHO) and American Diabetes Association (ADA)] 1-3 used for diagnosis, laboratory technique and method of data collection. Standardized searches and data abstraction for construction of tables was performed. Unadjusted or adjusted measures of association for individual studies were obtained or calculated from the full text of the studies. Template designed by Dr. David Ramsey. ^ Results. Forty-six studies out of one hundred and nine potentially eligible articles finally met the inclusion and exclusion criteria and were classified separately based on the study design as cross-sectional (twenty four), case-control (fifteen) or cohort studies (seven). The cohort studies showed a three-fold high (confidence interval 1.66–6.29) occurrence of DM2 in individuals with HCV compared to those who were unexposed to HCV and cross sectional studies had a summary odds ratio of 2.53 (1.96, 3.25). In case control studies, the summary odds ratio for studies done in subjects with DM2 was 3.61 (1.93, 6.74); in HCV, it was 2.30 (1.56, 3.38); and all fifteen studies, together, yielded an odds ratio of 2.60 (1.82, 3.73). ^ Conclusion. The above results support the hypothesis that there is an association between DM and HCV. The temporal relationship evident from cohort studies and proposed pathogenic mechanisms also suggest that HCV predisposes patients to development of DM2. Further cohort or prospective studies are needed, however, to determine whether treatment of HCV infections prevents development of DM2.^

Prediction of sepsis in the burn intensive care unit patient

Sepsis is a significant cause for multiple organ failure and death in the burn patient, yet identification in this population is confounded by chronic hypermetabolism and impaired immune function. The purpose of this study was twofold: 1) determine the ability of the systemic inflammatory response syndrome (SIRS) and American Burn Association (ABA) criteria to predict sepsis in the burn patient; and 2) develop a model representing the best combination of clinical predictors associated with sepsis in the same population. A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single intensive care unit (ICU) was conducted for the period January 2005 to September 2010. Blood culture results were paired with clinical condition: "positive-sick"; "negative-sick", and "screening-not sick". Data were collected for the 72 hours prior to each blood culture. The most significant predictors were evaluated using logistic regression, Generalized Estimating Equations (GEE) and ROC area under the curve (AUC) analyses to assess model predictive ability. Bootstrapping methods were employed to evaluate potential model over-fitting. Fifty-nine subjects were included, representing 177 culture periods. SIRS criteria were not found to be associated with culture type, with an average of 98% of subjects meeting criteria in the 3 days prior. ABA sepsis criteria were significantly different among culture type only on the day prior (p = 0.004). The variables identified for the model included: heart rate>130 beats/min, mean blood pressure<60 mmHg, base deficit<-6 mEq/L, temperature>36°C, use of vasoactive medications, and glucose>150 mg/d1. The model was significant in predicting "positive culture-sick" and sepsis state, with AUC of 0.775 (p < 0.001) and 0.714 (p < .001), respectively; comparatively, the ABA criteria AUC was 0.619 (p = 0.028) and 0.597 (p = .035), respectively. SIRS criteria are not appropriate for identifying sepsis in the burn population. The ABA criteria perform better, but only for the day prior to positive blood culture results. The time period useful to diagnose sepsis using clinical criteria may be limited to 24 hours. A combination of predictors is superior to individual variable trends, yet algorithms or computer support will be necessary for the clinician to find such models useful. ^