Medical advice, diabetes self-management, and health outcomes of a multi-ethnic population from the National Health and Nutrition Examination Survey 2007--2008

Diabetes self-management, an essential component of diabetes care, includes weight control practices and requires guidance from providers. Minorities are likely to have less access to quality health care than White non-Hispanics (WNH) (American College of Physicians-American Society of Internal Medicine, 2000). Medical advice received and understood may differ by race/ethnicity as a consequence of the patient-provider communication process; and, may affect diabetes self-management. ^ This study examined the relationships among participants’ report of: (1) medical advice given; (2) diabetes self-management, and; (3) health outcomes for Mexican-Americans (MA) and Black non-Hispanics (BNH) as compared to WNH (reference group) using data available through the National Health and Nutrition Examination Survey (NHANES) for the years 2007–2008. This study was a secondary, single point analysis. Approximately 30 datasets were merged; and, the quality and integrity was assured by analysis of frequency, range and quartiles. The subjects were extracted based on the following inclusion criteria: belonging to either the MA, BNH or WNH categories; 21 years or older; responded yes to being diagnosed with diabetes. A final sample size of 654 adults [MA (131); BNH (223); WNH (300)] was used for the analyses. The findings revealed significant statistical differences in medical advice reported given. BNH [OR = 1.83 (1.16, 2.88), p = 0.013] were more likely than WNH to report being told to reduce fat or calories. Similarly, BNH [OR = 2.84 (1.45, 5.59), p = 0.005] were more likely than WNH to report that they were told to increase their physical activity. Mexican-Americans were less likely to self-monitor their blood glucose than WNH [OR = 2.70 (1.66, 4.38), p<0.001]. There were differences among ethnicities for reporting receiving recent diabetes education. Black, non-Hispanics were twice as likely to report receiving diabetes education than WNH [OR = 2.29 (1.36, 3.85), p = 0.004]. Medical advice reported given and ethnicity/race, together, predicted several health outcomes. Having recent diabetes education increased the likelihood of performing several diabetes self-management behaviors, independent of race. ^ These findings indicate a need for patient-provider communication and care to be assessed for effectiveness and, the importance of ongoing diabetes education for persons with diabetes.^

Effect of the Supplemental Nutrition Assistance Program (SNAP) and nutrition education on nutrition and health outcomes of HIV+ individuals

Factors associated with and barriers to participation in Supplemental Nutrition Assistance Program (SNAP) and the effect participation has on food security, nutrition status, disease status and quality of life was investigated in a cross-sectional study including 175 HIV infected individuals. In addition, the effect of a targeted nutrition education on nutrition knowledge, readiness to dietary behavior change, nutrition status, disease status and quality of life was also investigated among a subset of the population (N = 45) in a randomized clinical control trial. ^ SNAP participation rate was 70.3%, similar to the State of Florida and national participation rates. SNAP participation was positively and independently associated with being born in the US (P < 0.001), having monthly income less than $1000 (P = 0.006), and receiving antiretroviral treatment (P < 0.001). Participation barriers include denial of participation by program, recent incarceration, living in a shelter where participation is not allowed and unawareness of eligibility status. In regression analyses, SNAP participation was not significantly associated with improved food security, nutrition status, disease status and health related quality of life (HRQOL). Over half (56%) of the population experienced food insecurity and had inadequate intakes of half of the nutrients assessed. Illicit drug, alcohol and cigarette use were high in this population (31%, 55% and 63% respectively), and affected food security, nutrients intake, disease status and HRQOL. The nutrition education intervention resulted in a trend towards improvements nutrition knowledge, self-efficacy, and readiness to change without impacting nutrition status, disease state and quality of life. ^ Food insecurity and other nutrition related issues, with implications for treatment, management and cost of HIV disease, continue to plague infected individuals living in poverty. More resources, including food and nutrition programs, specifically targeted towards this population are needed to address these issues.^

Hospital discharge planning in the provision of food and nutrition services for older adults post discharge

This descriptive study examined whether discharge planning ensures that food and nutrition services are provided to older adults following hospital discharge. The questionnaire was distributed to discharge planning professionals in 11 South Florida hospitals. Of the 84 respondents (88% response rate), most were female nurse case managers. Almost all reported job barriers including excessive patient loads, too many responsibilities, and limited community services. While physicians, registered nurses, social workers, physical therapists, were deemed "very important" in discharge planning,registered dietitians were not, and almost half consulted them infrequently, if at all. Over 84% said nutrition-related medical conditions/factors, "strongly influenced" discharge planning. Many did not have adequate information about nutrition-related community resources, eg, home delivered meals, food stamps, outpatient registered dietitians. Therewere no universal approaches in meeting the nutrition needs in 6 case scenarios. More communication among community services and hospitals is needed.

Physical activity and nutrition related variables in hispanic and non-hispanic college students

It has been estimated that one in four adults have sedentary lifestyles. In addition there appears to be an increase in obesity across the life span. It is of great importance to the health of this nation to understand how to promote more active lifestyles through the identification of lifestyle behaviors of active individuals and potential predictors of physical activity (PA). Seven hundred and seventy-seven college students were surveyed to investigate the relationship between nutrition related variables (i.e., dietary restraint, nutrition knowledge, food choice and body weight concerns) and PA. In this study, over half of the students reported doing 30 minutes of moderate intensity PA daily. Vigorously active males and females chose low fat foods more often than the less active group. Exercisers and non-exercisers had similar nutrition knowledge. The results of this study suggest that students who are more active are more conscience about making healthier food choices.

A content analysis of food and nutrition television advertisements

Television (TV) reaches more people than any other medium which makes it an important source of health information. Since TV ads often offer information obliquely, this study investigated implied health messages found in food and nutrition TV ads. The goals were to determine the proportion of food and nutrition ads among all TV advertising and to use content analysis to identify their implied messages and health claims. A randomly selected sample of TV ads were collected over a 28-day period beginning May 8, 1987. The sample contained 3547 ads; 725 (20%) were food-related. All were analyzed. About 10% of food-related TV ads contained a health claim. Twenty-five representative ads of the 725 food ads were also reviewed by 10 dietitians to test the reliability of the instrument. Although the dietitians agreed upon whether a health claim existed in a televised food ad, their agreement was poor when evaluating the accuracy of the claim. The number of food-related ads dropped significantly on Saturday, but the number of alcohol ads rose sharply on Saturday and Sunday. Snack ads were shown more often on Thursday, but snack commercials were also numerous on Saturday morning and afternoon, as were cereal ads. Ads for snack foods accounted for the greatest proportion of ads (20%) while fast food accounted for only 7%. Alcohol constituted about 9% of all food and nutrition ads.

Effect of the Supplemental Nutrition Assistance Program (SNAP) and Nutrition Education on Nutrition and Health Outcomes of HIV+ Individuals

Factors associated with and barriers to participation in Supplemental Nutrition Assistance Program (SNAP) and the effect participation has on food security, nutrition status, disease status and quality of life was investigated in a cross-sectional study including 175 HIV infected individuals. In addition, the effect of a targeted nutrition education on nutrition knowledge, readiness to dietary behavior change, nutrition status, disease status and quality of life was also investigated among a subset of the population (N = 45) in a randomized clinical control trial. SNAP participation rate was 70.3%, similar to the State of Florida and national participation rates. SNAP participation was positively and independently associated with being born in the US (P < 0.001), having monthly income less than $1000 (P = 0.006), and receiving antiretroviral treatment (P < 0.001). Participation barriers include denial of participation by program, recent incarceration, living in a shelter where participation is not allowed and unawareness of eligibility status. In regression analyses, SNAP participation was not significantly associated with improved food security, nutrition status, disease status and health related quality of life (HRQOL). Over half (56%) of the population experienced food insecurity and had inadequate intakes of half of the nutrients assessed. Illicit drug, alcohol and cigarette use were high in this population (31%, 55% and 63% respectively), and affected food security, nutrients intake, disease status and HRQOL. The nutrition education intervention resulted in a trend towards improvements nutrition knowledge, self-efficacy, and readiness to change without impacting nutrition status, disease state and quality of life. Food insecurity and other nutrition related issues, with implications for treatment, management and cost of HIV disease, continue to plague infected individuals living in poverty. More resources, including food and nutrition programs, specifically targeted towards this population are needed to address these issues.

Sources of nutrition information for persons living in Trinidad and Tobago

Health consumers worldwide obtain nutrition information from various sources; however, the sources Trinidadians and Tobagonians accessed were unclear. This cross-sectional, descriptive study ascertained from which sources Trinidadians and Tobagonians obtained nutrition information. Participants (n = 845) were surveyed with questions regarding demographics and nutrition information sources. Nearly 100% agreed nutrition information was important. Persons 18-64 years old mainly accessed print media (p<0.01) and ≥ 65years old predominantly accessed the non-print media. Significantly more tertiary educated people, ≥ 35 years old, retrieved information from print media (p=0.001), health care professionals (p=0.001), food labels (p=0.006), and non-print media (p=0.03) when compared to those < 35 years with similar education. Tertiary educated people (67%), selected the Internet when compared to those with without tertiary education (33%) (p<0.001). Knowing the nutrition information sources accessed, dietitians will be able to provide consistent, accurate, age specific nutrition information and promote healthy eating among Trinidadians and Tobagonians.

The effect of a breakfast program on nutritional status, quality of life, and health care use among frail homebound older adults

The population of older adults is rapidly increasing, creating a need for community services that assist vulnerable older adults in maintaining independence and quality of life. Recent evidence confirms the importance of food and nutrition in reaching this objective. The Elderly Nutrition Program (ENP) is part of a system of federally funded community based programs, authorized through the Older Americans Act. ENP services include the home-delivered meals program, which targets frail homebound older adults at nutritional risk. Traditionally, ENP services provide a noon meal 5 days/week. This study evaluated the impact of expanding the home-delivered meals service to include breakfast + lunch, on the nutritional status, quality of life and health care utilization of program participants. ^ This cross-sectional study compared 2 groups. The Breakfast group (n = 167) received a home-delivered breakfast + lunch, 5 days/week. The Comparison group (n = 214) received lunch 5 days/week. Participants, recruited from 5 ENP programs, formed a geographically, racially/ethnically diverse sample. Participants ranged in age from 60–100 years, they were functionally limited, at high nutritional risk, low income, and they lived alone and had difficulty shopping or preparing food. Participant data were collected through in-home interviews and program records. A 24-hour food recall and information on participant demographics, malnutrition risk, functional status, health care use, and applicable quality of life factors were obtained. Service and cost data were collected from program administrators. ^ Breakfast group participants had greater energy/nutrient intakes (p < .05), fewer health care contacts (p < .05), and greater quality of life measured as food security (p < .05) and fewer depressive symptoms (p < .05), than comparison group participants. These benefits were achieved for $1.30/person/day. ^ The study identified links from improvements in nutritional status to enhanced quality of life to diminished health care utilization and expenditures. A model of health, loneliness, food enjoyment, food insecurity, and depression as factors contributing to quality of life for this population, was proposed and tested (p < .01). ^ The breakfast service is an inexpensive addition to traditional home-delivered meals services and can improve the lives of frail homebound older adults. Agencies should be encouraged to expand meals programs to include a breakfast service. ^

The relationship of fear of intimacy, body image avoidance and body mass index

Issues of body image and ability to achieve intimacy are connected to body weight, yet remain largely unexplored and have not been evaluated by gender. The underlying purpose of this research was to determine if avoidant attitudes and perceptions of one's body may hold implications toward its use in intimate interactions, and if an above average body weight would tend to increase this avoidance. The National Health and Nutrition Examination Survey (NHANES, 1999-2002) finds that 64.5% of US adults are overweight, with 61.9% of women and 67.2% of men. The increasing prevalence of overweight and obesity in men and women shows no reverse trend, nor have prevention and treatment proven effective in the long term. The researcher gathered self-reported age, gender, height and weight data from 55 male and 58 female subjects (determined by a prospective power analysis with a desired medium effect size (r=.30) to determine body mass index (BMI), determining a mean age of 21.6 years and mean BMI of 25.6. Survey instruments consisted of two scales that are germane to the variables being examined. They were (1) Descutner and Thelen of the University of Missouri‘s (1991) Fear-of-Intimacy scale; and (2) Rosen, Srebnik, Saltzberg, and Wendt's (1991) Body Image Avoidance Questionnaire. Results indicated that as body mass index increases, fear of intimacy increases (p<0.05) and that as body mass index increases, body image avoidance increases (p<0.05). The relationship that as body image avoidance increases, fear of intimacy increases was not supported, but approached significance at (p<0.07). No differences in these relationships were determined between gender groups. For age, the only observed relationship was that of a difference between scores for age groups [18 to 22 (group 1) and ages 23 to 34 (group 2)] for the relationship of body image avoidance and fear of intimacy (p<0.02). The results suggest that the relationship of body image avoidance and fear of intimacy, as well as age, bear consideration toward the escalating prevalence of overweight and obesity. An integrative approach to body weight that addresses issues of body image and intimacy may prove effective in prevention and treatment.

Glycemic control: Risk factors, quality of life, workforce participation, and mortality among US adults with type 2 diabetes

Despite research showing the benefits of glycemic control, it remains suboptimal among adults with diabetes in the United States. Possible reasons include unaddressed risk factors as well as lack of awareness of its immediate and long term consequences. The objectives of this study were to, using cross-sectional data, (1) ascertain the association between suboptimal (Hemoglobin A1c (HbA1c) .7%), borderline (HbA1c 7-8.9%), and poor (HbA1c .9%) glycemic control and potentially new risk factors (e.g. work characteristics), and (2) assess whether aspects of poor health and well-being such as poor health related quality of life (HRQOL), unemployment, and missed-work are associated with glycemic control; and (3) using prospective data, assess the relationship between mortality risk and glycemic control in US adults with type 2 diabetes. Data from the 1988-1994 and 1999-2004 National Health and Nutrition Examination Surveys were used. HbA1c values were used to create dichotomous glycemic control indicators. Binary logistic regression models were used to assess relationships between risk factors, employment status and glycemic control. Multinomial logistic regression analyses were conducted to assess relationships between glycemic control and HRQOL variables. Zero-inflated Poisson regression models were used to assess relationships between missed work days and glycemic control. Cox-proportional hazard models were used to assess effects of glycemic control on mortality risk. Using STATA software, analyses were weighted to account for complex survey design and non-response. Multivariable models adjusted for socio-demographics, body mass index, among other variables. Results revealed that being a farm worker and working over 40 hours/week were risk factors for suboptimal glycemic control. Having greater days of poor mental was associated with suboptimal, borderline, and poor glycemic control. Having greater days of inactivity was associated with poor glycemic control while having greater days of poor physical health was associated with borderline glycemic control. There were no statistically significant relationships between glycemic control, self-reported general health, employment, and missed work. Finally, having an HbA1c value less than 6.5% was protective against mortality. The findings suggest that work-related factors are important in a person’s ability to reach optimal diabetes management levels. Poor glycemic control appears to have significant detrimental effects on HRQOL.^

Women and development in Senegal: Microcredit and household well being

The challenging living conditions of many Senegalese families, and the absence of a providing spouse, have led women to covet new economic opportunities, such as microcredit loans. These loans offer Senegalese women the possibility to financially support their households and become active participants in their economies by starting or sustaining their micro businesses. The study takes place in Grand-Yoff, an overpopulated peri-urban area of the Senegalese capital city Dakar, where most people face daily survival issues. This research examines the impact of microcredit activities in the household of Senegalese female loan recipients in Grand-Yoff by examining socioeconomic indicators, in particular outcomes of health, education and nutrition.^ The research total sample is constituted of 166 female participants who engage in microcredit activities. The research combines both qualitative and quantitative methods. Data for the study were gathered through interviews, surveys, participant observation, focus-groups with the study participants and some of their household members, and document analysis.^ While some women in the study make steady profits from their business activities, others struggle to make ends meet from their businesses’ meager or unreliable profits. Some study participants who are impoverished have no choice but to invest their loans directly into their households’ dire needs, hence missing their business prerogative. Many women in the study end up in a vicious cycle of debt by defaulting on their loans or making late payments because they do not have the required household and socioeconomic conditions to take advantage of these loans. Therefore, microcredit does not make a significant impact in the households of the poorest female participants. The study finds that microcredit improves the household well-being - especially nutrition, health and education - of the participants who have acquired significant social capital such as a providing spouse, formal education, training, business experience, and belonging to business or social networks.^ The study finds that microcredit’s household impact is intimately tied to the female borrowers’ household conditions and social capital. It is recommended that microcredit services and programs offer their female clients assistance and additional basic services, financial guidance, lower interest rates, and flexible repayment schedules. ^

Relationship of Lifestyle Medical Advice and Non-HDL Cholesterol Control of a Nationally Representative US Sample with Hypercholesterolemia by Race/Ethnicity

Objective. The main purpose of this study was to evaluate the associations of lifestyle medical advice and non-HDL cholesterol control of a nationally representative US sample of adults with hypercholesterolemia by race/ethnicity. Methods. Data were collected by appending sociodemographic, anthropometric, and laboratory data from two cycles of the National Health and Nutrition Survey (2007-2008 and 2009-2010). This study acquired data from male and female adults aged ≥ 20 years (N = 11,577), classified as either Mexican American (MA), (), other Hispanic (OH) (), Black non-Hispanic (BNH) (), or White non-Hispanic (WNH) (). Results. Minorities were more likely to report having received dietary, weight management, and exercise recommendations by healthcare professionals than WNH, adjusting for confounders. Approximately 80% of those receiving medical advice followed the recommendation, regardless of race/ethnicity. Of those who received medical advice, reporting “currently controlling or losing weight” was associated with lower non-HDL cholesterol. BNH who reported “currently controlling or losing weight” had higher non-HDL cholesterol than WNH who reported following the advice. Conclusion. The results suggest that current methods of communicating lifestyle advice may not be adequate across race/ethnicity and that a change in perspective and delivery of medical recommendations for persons with hypercholesterolemia is needed.

Medical advice and diabetes self-management reported by Mexican-American, Black- and White-non-Hispanic adults across the United States

Background Diabetes has reached epidemic proportions in the United States, particularly among minorities, and if improperly managed can lead to medical complications and death. Healthcare providers play vital roles in communicating standards of care, which include guidance on diabetes self-management. The background of the client may play a role in the patient-provider communication process. The aim of this study was to determine the association between medical advice and diabetes self care management behaviors for a nationally representative sample of adults with diabetes. Moreover, we sought to establish whether or not race/ethnicity was a modifier for reported medical advice received and diabetes self-management behaviors. Methods We analyzed data from 654 adults aged 21 years and over with diagnosed diabetes [130 Mexican-Americans; 224 Black non-Hispanics; and, 300 White non-Hispanics] and an additional 161 with 'undiagnosed diabetes' [N = 815(171 MA, 281 BNH and 364 WNH)] who participated in the National Health and Nutrition Examination Survey (NHANES) 2007-2008. Logistic regression models were used to evaluate whether medical advice to engage in particular self-management behaviors (reduce fat or calories, increase physical activity or exercise, and control or lose weight) predicted actually engaging in the particular behavior and whether the impact of medical advice on engaging in the behavior differed by race/ethnicity. Additional analyses examined whether these relationships were maintained when other factors potentially related to engaging in diabetes self management such as participants' diabetes education, sociodemographics and physical characteristics were controlled. Sample weights were used to account for the complex sample design. Results Although medical advice to the patient is considered a standard of care for diabetes, approximately one-third of the sample reported not receiving dietary, weight management, or physical activity self-management advice. Participants who reported being given medical advice for each specific diabetes self-management behaviors were 4-8 times more likely to report performing the corresponding behaviors, independent of race. These results supported the ecological model with certain caveats. Conclusions Providing standard medical advice appears to lead to diabetes self-management behaviors as reported by adults across the United States. Moreover, it does not appear that race/ethnicity influenced reporting performance of the standard diabetes self-management behavior. Longitudinal studies evaluating patient-provider communication, medical advice and diabetes self-management behaviors are needed to clarify our findings.

Alterations in Glutathione Levels and Apoptotic Regulators Are Associated with Acquisition of Arsenic Trioxide Resistance in Multiple Myeloma

Arsenic trioxide (ATO) has been tested in relapsed/refractory multiple myeloma with limited success. In order to better understand drug mechanism and resistance pathways in myeloma we generated an ATO-resistant cell line, 8226/S-ATOR05, with an IC50 that is 2–3-fold higher than control cell lines and significantly higher than clinically achievable concentrations. Interestingly we found two parallel pathways governing resistance to ATO in 8226/S-ATOR05, and the relevance of these pathways appears to be linked to the concentration of ATO used. We found changes in the expression of Bcl-2 family proteins Bfl-1 and Noxa as well as an increase in cellular glutathione (GSH) levels. At low, clinically achievable concentrations, resistance was primarily associated with an increase in expression of the anti-apoptotic protein Bfl-1 and a decrease in expression of the pro-apoptotic protein Noxa. However, as the concentration of ATO increased, elevated levels of intracellular GSH in 8226/S-ATOR05 became the primary mechanism of ATO resistance. Removal of arsenic selection resulted in a loss of the resistance phenotype, with cells becoming sensitive to high concentrations of ATO within 7 days following drug removal, indicating changes associated with high level resistance (elevated GSH) are dependent upon the presence of arsenic. Conversely, not until 50 days without arsenic did cells once again become sensitive to clinically relevant doses of ATO, coinciding with a decrease in the expression of Bfl-1. In addition we found cross-resistance to melphalan and doxorubicin in 8226/S-ATOR05, suggesting ATO-resistance pathways may also be involved in resistance to other chemotherapeutic agents used in the treatment of multiple myeloma.

Beyond BMI: The “Metabolically healthy obese” phenotype & its association with clinical/subclinical cardiovascular disease and all-cause mortality -- a systematic review

Background A subgroup has emerged within the obese that do not display the typical metabolic disorders associated with obesity and are hypothesized to have lower risk of complications. The purpose of this review was to analyze the literature which has examined the burden of cardiovascular disease (CVD) and all-cause mortality in the metabolically healthy obese (MHO) population. Methods Pubmed, Cochrane Library, and Web of Science were searched from their inception until December 2012. Studies were included which clearly defined the MHO group (using either insulin sensitivity and/or components of metabolic syndrome AND obesity) and its association with either all cause mortality, CVD mortality, incident CVD, and/or subclinical CVD. Results A total of 20 studies were identified; 15 cohort and 5 cross-sectional. Eight studies used the NCEP Adult Treatment Panel III definition of metabolic syndrome to define “metabolically healthy”, while another nine used insulin resistance. Seven studies assessed all-cause mortality, seven assessed CVD mortality, and nine assessed incident CVD. MHO was found to be significantly associated with all-cause mortality in two studies (30%), CVD mortality in one study (14%), and incident CVD in three studies (33%). Of the six studies which examined subclinical disease, four (67%) showed significantly higher mean common carotid artery intima media thickness (CCA-IMT), coronary artery calcium (CAC), or other subclinical CVD markers in the MHO as compared to their MHNW counterparts. Conclusions MHO is an important, emerging phenotype with a CVD risk between healthy, normal weight and unhealthy, obese individuals. Successful work towards a universally accepted definition of MHO would improve (and simplify) future studies and aid inter-study comparisons. Usefulness of a definition inclusive of insulin sensitivity and stricter criteria for metabolic syndrome components as well as the potential addition of markers of fatty liver and inflammation should be explored. Clinicians should be hesitant to reassure patients that the metabolically benign phenotype is safe, as increased risk cardiovascular disease and death have been shown.