A study of nutrition promotion in and consumer nutrition environments of hospitals

Dietary intake is a complex, health-related behavior, and although individual-level theoretical models explain some variation in dietary intake, comprehensive theoretical models such as the ecological framework describe the multiple levels which influence diet-related behaviors. Thus, the ecological framework is a preferred model for designing comprehensive nutrition interventions. While ecological-based nutrition interventions have been described, little work has focused on interventions in the hospital setting. Because hospitals are considered the hallmarks of health, it might seem that hospitals would regularly engage in worksite nutrition promotion; however, recent publications and other anecdotal evidence have indicated otherwise. The first paper of this dissertation systematically reviewed the scientific literature between 1996 and 2012 and identified 13 outcome evaluation trials for hospital-based worksite nutrition interventions. Of these 13 interventions, only one intervention targeted three of the four levels of the ecological framework and no intervention targeted all four levels. Only half of the interventions targeted the physical environment of hospitals, thus warranting more investigation into this specific level of the ecological framework in this setting. ^ A critical type of nutrition-related physical environments is the consumer nutrition environment. Although other tools measure the consumer nutrition environments of stores and restaurants, no tool specifically measured the consumer nutrition environments of hospitals until the CDC developed the Healthy Hospital Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HHES-CVG). The HHES-CVG, a tool which measures the consumer nutrition environments of hospital cafeterias, vending machines, and gifts shops, was released in November 2011, and in the second paper of this dissertation, the reliability of this tool was investigated. Two trained raters visited 39 hospitals across Southern California between February and May 2012, and based on analyses of the raters' findings, the HHES-CVG exhibited strong reliability metrics (inter-observer agreement between 74 and 100%, and an intraclass correlation coefficient of 0.961 for the overall nutrition composite score). Because the HHES-CVG was found to be a reliable tool, the third paper of this dissertation presented HHES-CVG results from the 39 hospitals. Overall, hospitals only scored about one-fourth of the total possible points for the nutrition composite score, indicating that most facilities do not have acceptable consumer nutrition environments. Some of the best practices observed in cafeterias were significantly associated with having a large facility and with having a contracted foodservice operation, but overall nutrition composite score was not associated with any specific facility or operation type. ^ The dissertation concluded that much work is needed in order to improve the consumer nutrition environments of hospitals. Practitioners and healthcare administrators should consider starting with ecological-based interventions addressing all levels including the physical environment.^

Identification and characterization of genes encoding phospholipid biosynthetic enzymes of {\it Saccharomyces cerevisiae\/}

Phospholipids are the major component of cellular membranes. In addition to its structural role, phospholipids play an active and diverse role in cellular processes. The goal of this study is to identify the genes involved in phospholipid biosynthesis in a model eukaryotic system, Saccharomyces cerevisiae. We have focused on the biosynthetic steps localized in the inner mitochondrial membrane; hence, the identification of the genes encoding phosphatidylserine decarboxylase (PSD1), cardiolipin synthase (CLS1), and phosphatidylglycerophosphate synthase (PGS1).^ The PSD1 gene encoding a phosphatidylserine decarboxylase was cloned by complementation of a conditional lethal mutation in the homologous gene in Escherichia coli strain EH150. Overexpression of the PSD1 gene in wild type yeast resulted in 20-fold amplification of phosphatidylserine decarboxylase activity. Disruption of the PSD1 gene resulted in 20-fold reduction of decarboxylase activity, but the PSD1 null mutant exhibited essentially normal phenotype. These results suggest that yeast has a second phosphatidylserine decarboxylation activity.^ Cardiolipin is the major anionic phospholipid of the inner mitochondrial membrane. It is thought to be an essential component of many biochemical functions. In eukaryotic cells, cardiolipin synthase catalyzes the final step in the synthesis of cardiolipin from phosphatidylglycerol and CDP-diacylglycerol. We have cloned the gene CLS1. Overexpression of the CLS1 gene product resulted in significantly elevated cardiolipin synthase activity, and disruption of the CLS1 gene, confirmed by PCR and Southern blot analysis, resulted in a null mutant that was viable and showed no petite phenotype. However, phospholipid analysis showed undetectable cardiolipin level and an accumulation of phosphatidylglycerol. These results support the conclusion that CLS1 encodes the cardiolipin synthase of yeast and that normal levels of cardiolipin are not absolutely essential for survival of the cell.^ Phosphatidylglycerophosphate (PGP) synthase catalyzes the synthesis of PGP from CDP-diacylglycerol and glycerol-3-phosphate and functions as the committal and rate limiting step in the biosynthesis of cardiolipin. We have identified the PGS1 gene as encoding the PGP synthase. Overexpression of the PGS1 gene product resulted in over 15-fold increase in in vitro PGP synthase activity. Disruption of the PGS1 gene in a haploid strain of yeast, confirmed by Southern blot analysis, resulted in a null mutant strain that was viable but had significantly altered phenotypes, i.e. inability to grow on glycerol and at $37\sp\circ$C. These cells showed over a 10-fold decrease in PGP synthase activity and a decrease in both phosphatidylglycerol and cardiolipin levels. These results support the conclusion that PGS1 encodes the PGP synthase of yeast and that neither phosphatidylglycerol nor cardiolipin are absolutely essential for survival of the cell. ^

The association of area socioeconomic status and cancer screening: A systematic review and multilevel study

Background. The gap between actual and ideal rates of routine cancer screening in the U.S., particularly for colorectal cancer screening (CRCS) (1;2), is responsible for an unnecessary burden of morbidity and mortality, particularly for disadvantaged groups. Knowledge about the effects of individual and area influences is being advanced by a growing body of research that has examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES. The findings from this emerging and heterogeneous research in the cancer screening literature have been mixed. Moreover, multilevel studies in this area have not yet adequately explored the possibility of differential associations by population subgroup, despite some evidence suggesting gender-specific effects. ^ Objectives and methods. This dissertation reports on a systematic review of studies on the association of area SES and cancer screening and a multilevel study of the association between area SES and CRCS. The specific aims of the systematic review are to: (1) describe the study designs, constructs, methods, and measures; (2) describe the association of area SES and cancer screening; and (3) identify neglected areas of research. ^ The empiric study linked a pooled sample of respondents aged ≥50 years without a personal history of colorectal cancer from the 2003 and 2005 California Health Interview Surveys with a comprehensive set of census-tract level area SES measures from the 2000 U.S. Census. Two-level random intercept models were used to test 2 hypotheses: (1) area SES will be associated with adherence to two modalities of CRCS after controlling for individual SES; and (2) gender will moderate the relationship between area socioeconomic status and adherence to both modalities of CRCS. ^ Results. The systematic review identified 19 eligible studies that demonstrated variability in study designs, methods, constructs, and measures. The majority of tested associations were either not statistically significant or significant and in the positive direction, indicating that as area SES increased, the odds of CRCS increased. The multilevel study demonstrated that while multiple aspects of area SES were associated with CRCS after controlling for individual SES, associations differed by screening modality and in the case of endoscopy, they also differed by gender. ^ Conclusions. Conceptual and methodologic heterogeneity and weaknesses in the literature to date limit definitive conclusions about the underlying relationships between area SES and cancer screening. The multilevel study provided partial support for both hypotheses. Future research should continue to explore the role of gender as a moderating influence with the aim of identifying the mechanisms linking area SES and cancer prevention behaviors. ^