Effectiveness of dietary intervention in children and adolescents with elevated blood pressure

Hypertension is a known risk factor for cardiovascular disease in adults. Essential hypertension in children and adolescents is increasing in prevalence in the United States, and hypertension in children may track into adulthood. This increasing prevalence is attributed to the trends of increasing overweight and obese children and adolescents. Family history and being of African-American/black descent may predispose youth to elevated blood pressure. Interventions targeted to reduce and treat hypertension in youth include non-pharmaceutical interventions such as weight reduction, increased physical activity, and dietary changes and pharmaceutical treatment when indicated. The effectiveness of non-pharmaceutical interventions is well documented in adults, but there are limited studies with regards to children and adolescents, specifically in the arena of dietary interventions. Lifestyle modifications such as dietary interventions are the mainstay of recommended treatment for those children and adolescents with prehypertension or stage 1 hypertension. Given the association of being overweight and hypertension, efficacy of dietary interventions are of interest because of reduced cost, easy implementation and potential for multiple beneficial outcomes such as reduced weight and reduction of other metabolic or cardiovascular derangements. Barriers to dietary interventions often include socioeconomic status, ethnicity, personal, and external factors. The goal of this systematic review of the literature is to identify interventions targeted to children and adolescents that focus on recommended dietary changes related to blood pressure. Dietary interventions found for this review mostly focused on a particular nutrient or food group with the one notable exception that focused on the DASH pattern of eating. The effects of the interventions on blood pressure varied, but overall dietary modifications can be achieved in youth and can serve a role in producing positive outcomes on blood pressure. Increasing potassium and following a DASH diet seemed to provide the most clinically significant results. Further studies are still needed to evaluate long-term effectiveness and to contribute more supporting evidence for particular modifications in these age cohorts.^

An epidemiologic evaluation of a worksite based intervention

The healthcare industry spends billions on worker injury and employee turnover. Hospitals and healthcare settings have one of the highest rates of lost days due to injuries. The occupational hazards for healthcare workers can be classified into biological, chemical, ergonomic, physical, organizational, and psychosocial. Therefore, interventions addressing a range of occupational health risks are needed to prevent injuries and reduce turnover and reduce costs. ^ The Sacred Vocation Program (SVP) seeks to change the content of work, i.e., the meaningfulness of work, to improve work environments. The SVP intervenes at both the individual and organizational level. First the SVP attempts to connect healthcare workers with meaning from their work through a series of 5 self-discovery group sessions. In a sixth session the graduates take an oath recommitting them to do their work as a vocation. Once motivated to connect with meaning in their work, a representative employee group meets in a second set of five meetings. This representative group suggests organizational changes to create a culture that supports employees in their calling. The employees present their plan in the twelfth session to management beginning a new phase in the existing dialogue between employees and management. ^ The SVP was implemented in a large Dallas hospital (almost 1000 licensed beds). The Baylor University Medical Center (BUMC) Pastoral Care department invited front-line caregivers (primarily Patient Care Assistants, PCAs, or Patient Care Technicians, PCTs) to participate in the SVP. Participants completed SVP questionnaires at the beginning and following SVP implementation. Following implementation, employer records were collected on injury, absence and turnover to further evaluate the program's effectiveness on metrics that are meaningful to managers in assessing organizational performance. This provided an opportunity to perform an epidemiological evaluation of the intervention using the two sources of information: employee self-reports and employer administrative data. ^ The ability to evaluate the effectiveness of the SVP on program outcomes could be limited by the strength of the measures used. An ordinal CFA performed on baseline SVP questionnaire measurements examined the construct validity and reliability of the SVP scales. Scales whose item-factor structure was confirmed in ordinal CFA were evaluated for their psychometric properties (i.e., reliability, mean, ceiling and floor effects). CFA supported the construct validity of six of the proposed scales: blocks to spirituality, meaning at work, work satisfaction, affective commitment, collaborative communication, and MHI-5. Five of the six scales confirmed had acceptable measures of reliability (all but MHI-5 had α>0.7). All six scales had a high percentage (>30%) of the scores at the ceiling. These findings supported the use of these items in the evaluation of change although strong ceiling effects may hinder discerning change. ^ Next, the confirmed SVP scales were used to evaluate whether the intervention improved program constructs. To evaluate the SVP a one group pretest-posttest design compared participants’ self-reports before and after the intervention. It was hypothesized that measurements of reduced blocks to spirituality (α = 0.76), meaning at work (α = 0.86), collaborative communication (α = 0.67) and SVP job tasks (α = 0.97) would improve following SVP implementation. The SVP job tasks scale was included even though it was not included in the ordinal CFA analysis due to a limited sample and high inter-item correlation. Changes in scaled measurements were assessed using multilevel linear regression methods. All post-intervention measurements increased (increases <0.28 points) but only reduced blocks to spirituality was statistically significant (0.22 points on a scale from 1 to 7, p < 0.05) after adjustment for covariates. Intensity of the intervention (stratifying on high participation units) strengthened effects; but were not statistically significant. The findings provide preliminary support for the hypothesis that meaning in work can be improved and, importantly, lend greater credence to any observed improvements in the outcomes. (Abstract shortened by UMI.)^

Investigating the structure and form of condom decisional balance in an alternative school sample using confirmatory factor analysis

Teen pregnancy is a continuing problem, bringing with it a host of associated health and social risks. Alternative school students are especially at risk, but are historically under-represented in research. This is especially problematic in that instruments are needed to guide effective intervention development, but psychometrics for these instruments cannot be assumed when used in new populations. Decisional balance from the transtheoretical model offers a framework for understanding condom decision making, but has not been tested with alternative school students. Using responses from 640 subjects from Safer Choices 2 (a school-based HIV/STD/pregnancy prevention program implemented in 10 urban, southwestern alternative schools), a decisional balance scale for condom use was examined. A two-factor, mildly correlated model fit the data well. Tests of invariance examined scale functioning within gender and racial/ethnic groups. The underlying structure varied slightly based on subgroup, but on a practical level the impact on the use of scales was minimal. The structure and loadings were invariant across experimental condition. The pro scale was associated with a lower probability of having engaged in unprotected sexual behavior for sexually active subjects, and this association remained significant while controlling for demographic variables. The con scale did not show a significant association with engagement in unprotected sexual behaviors. Limitations and directions for future research were also discussed.^

Physical activity among breast and prostate cancer survivors: Barriers, facilitators and maintenance following the FRESH START trial

Research provides evidence of the positive health effects associated with regular physical activity participation in all populations. Activity may prove to be especially beneficial in those with chronic conditions such as cancer. However, the majority of cancer patients and survivors do not participate in the recommended amount of physical activity. The purpose of this dissertation was to identify factors associated with physical activity participation, describe how these factors change as result of a diet and exercise intervention, and to evaluate correlates of long term physical activity maintenance. ^ For this dissertation, I analyzed data from the FRESH START trial, a randomized, single-blind, phase II clinical trial focused on improving diet and physical activity among recently diagnosed breast and prostate cancer survivors. Analyses included both parametric and non-parametric statistical tests. Three separate studies were conducted, with sample sizes ranging from 400 to 486. ^ Common barriers to exercise, such as “no willpower,” “too busy,” and “I have pain,” were reported among breast and prostate cancer survivors; however, these barriers were not significantly associated with minutes of physical activity. Breast cancer survivors reported a greater number of total barriers to exercise as well as higher proportions reporting individual barriers, compared to prostate cancer survivors. Just less than half of participants reduced their total number of barriers to exercise from baseline to 1-year follow-up, and those who did reduce barriers reported greater increases in minutes of physical activity compared to those who reported no change in barriers to exercise. Participants in both the tailored and standardized intervention groups reported greater minutes of physical activity at 2-year follow-up compared to baseline. Overall, twelve percent of participants reached recommended levels of physical activity at both 1- and 2-year follow-up. Self-efficacy was positively associated with physical activity maintenance, and the number of total barriers to exercise was inversely associated with physical activity maintenance. ^ Results from this dissertation are novel and informative, and will help to guide future physical activity interventions among cancer survivors. Thoughtfully designed interventions may encourage greater participation in physical activity and ultimately improve overall quality of life in this population. ^

A COMPARISON OF COUNTY HOSPITAL UTILIZATION BEFORE AND AFTER INTERVENTION BY THE HOSPITAL'S ALCOHOLISM SERVICES PROGRAM

This study examines the reduction in hospital utilization of 393 public hospital patients who were referred to the hospital's alcoholism screening program for intervention. The 393 patients were the total patient population of the alcoholism screening program for the period of September through December, 1982. Medical records of these patients were investigated to assess the total number of hospital days six months before and six months after intervention. The findings support the hypothesis of decreased utilization. The total number of hospital days for 393 patients before intervention of the alcoholism program was 3,458, with a mean length of stay of 8.80 days. The total number of hospital days after intervention was 458 days, with a mean length of stay of 6.50 days. The average individual difference (decrease) was 7.63 days for one year. From a total of 393 patients counseled by the alcoholism program, 106 (27%) went to treatment for their alcoholism. Other aims were to examine the referral sources (physicians, nurses, social workers and the MAST); study the impact of familial history of alcoholism on referrals, and explore the MAST scores of patients successfully referred. Implications of the study are that it would benefit the public hospital, with their disproportionate numbers of alcoholics, to intervene in the behavioral patterns of alcoholism. Such intervention would be a factor in reducing the overall hospitalization of the alcoholic. ^

The heart challenge: The effect of regular aerobic exercise on body fat distribution in third and fourth grade school children: A randomized clinical trial

The pattern of body fat distribution known as "centralized", and characterized by a predominance of subcutaneous fat on the trunk and a "pot belly", has been associated with an increased risk of chronic disease. These patterns of fat distribution, as well as the lifestyle habit variables associated with adult fatness and chronic morbidity clearly begin to develop during childhood, indicating the need for intervention and primary prevention of obesity, particularly the centralized form, during childhood or adolescence. The purpose of this study was to determine whether regular aerobic exercise could beneficially alter the distribution of body fat in 8 and 9 year old children. One hundred and eighty-eight participants were randomized into either a regular aerobic exercise treatment group or a standard physical education program control group. A variety of aerobic activities was used for intervention 5 days per week during physical education class for a period of 12 weeks. Fat distribution was measured by a number of the most commonly used indices, including ratios of body circumferences and skinfolds and indices derived from a principal components analysis. Change over time in average pulse rate was used to determine if intervention actually occurred. Approximately 10% of the students were remeasured, allowing the calculation of intra- and interexaminer measurement reliability estimates for all indices.^ This study group was comparable to the U.S. population, though the study children were slightly larger for certain measures. No effect of the exercise intervention was found. The most likely explanation for this was inadequacy of the intervention, as indicated by the lack of any change in average pulse rate with treatment. The results of the measurement reliability analysis are reported and indicate that body circumference ratios are more precise than skinfold ratios, particularly when multiple observers are used. Reliability estimates for the principal component indices were also high.^ It remains unclear whether the distribution of body fat can be altered with exercise. It is likely that this issue will remain undecided until one highly reliable, valid, and sensitive measure of fat distribution can be found. ^

Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

Modulation of replicative senescence of skeletal muscle satellite cells by insulin -like growth factor-I (IGF-I)

Growth and regeneration of postnatal skeletal muscle requires a population of mononuclear myogenic cells, called satellite cells to add/replace myonuclei, which are postmitotic. Wedged between the sarcolemma and the basal lamina of the skeletal muscle fiber, these cells function as the stem cells of mature muscle fibers. Like other normal diploid cells, satellite cells undergo cellular senescence. Investigations of aging in both rodents and humans have shown that satellite cell self-renewal capacity decreases with advanced age. As a consequence, this could be a potential reason for the characteristically observed age-associated loss in skeletal muscle mass (sarcopenia). This provided the rationale that any intervention that can further increase the proliferative capacity of these cells should potentially be able to either delay, or even prevent sarcopenia. ^ Using clonogenicity assays to determine a cell's proliferation potential, these studies have shown that IGF-I enhances the doubling potential of satellite cells from aged rodents. Using a transgenic model, where the mice express the IGF-I transgene specifically in their striated muscles, some of the underlying biochemical mechanisms for the observed increase in replicative life span were delineated. These studies have revealed that IGF-I activates the PI3/Akt pathway to mediate downregulation of p27KIP1, which consequently is associated with an increase in cyclin E-cdk2 kinase activity, phosphorylation of pRb, and upregulation of cyclin A protein. However, the beneficial effects of IGF-I on satellite cell proliferative potential appears to be limited as chronic overexpression of IGF-I in skeletal muscles did not protect against sarcopenia in 18-mo old mice, and was associated with an exhaustion of satellite cell replicative reserves. ^ These results have shown that replicative senescence can be modulated by environmental factors using skeletal muscle satellite cells as a model system. A better understanding of the molecular basis for enhancement of proliferative capacity by IGF-I will provide a rational basis for developing more effective counter-measures against physical frailty. However, the implications of these studies are that these beneficial effects of enhanced proliferative potential by IGF-I may only be over a short-term period, and other alternative approaches may need to be considered. ^

La época de raleo como factor de rentabilidad en duraznos conserveros de maduración temprana

Del total de la superficie implantada con duraznos conserveros en la provincia de Mendoza, el 27% corresponde a cultivares de maduración temprana, en los que el raleo de frutos es un factor crítico de manejo. Para determinar la incidencia de diferentes épocas de raleo sobre la rentabilidad del cultivo se realizó un ensayo en un monte comercial de durazneros cvs. Fortuna y Carson. Se utilizaron árboles injertados sobre portainjerto Nemaguard, conducidos en vaso tipo californiano e implantados a 6 m entre hileras y a 5 m entre plantas, que fueron raleados en tres épocas diferentes: a los 40 días después de plena floración, en inicio de endurecimiento de carozo y 10 días después, en la fecha de referencia. Se realizaron evaluaciones de producción por planta y calidad de frutos. También se determinó el valor de la producción y la relación entre éste y las distintas fechas de raleo. En ambos cultivares, los árboles raleados en época temprana obtuvieron mayor peso de frutos, producción total y producción destinada a mitades. En el cv. Fortuna, este tratamiento produjo un aumento significativo del porcentaje de frutos con carozo partido.El raleo temprano de frutos aumentó significativamente el valor de la cosecha, logrando un incremento de $ 3636.ha-1 y $ 3441.ha-1en los cvs. Fortuna y Carson, respectivamente, en relación con el tratamiento en fecha de referencia.

Evolution and treatment of vitamin B12 deficiency as a risk factor for (cognitive and functional) neurodegenerative diseases in institutionalized elderly = Evolución y tratamiento de la deficiencia de vitamina B12 como factor de riesgo de enfermedades neurodegenerativas (cognitivas y funcionales) en las personas mayores institucionalizadas.

Prevalence of vitamin B12 deficiency is very common in elderly people and can reach values as high as 40.5% of the population. It can be the result of the interaction among several factors. Vitamin B12 deficiencies have been associated with neurological, cognitive deterioration, haematological abnormalities and cardiovascular diseases that have an important influence on the health of the elderly and their quality of life. It is necessary to approach the problems arisen from the lack of data relative to them. The main objective of this thesis was to analyse the evolution of vitamin B12 status and related parameters, lipid and haematological profiles and their relationship to health risk factors, and to functional and cognitive status over one year and to determine the effect of an oral supplementation of 500 μg of cyanocobalamin for a short period of 28 days. An additional objective was to analyze the possible effects of medicine intakes on vitamin B status. Three studies were performed: a) a one year longitudinal follow-up with four measure points; b) an intervention study providing an oral liquid supplement of 500 μg of cyanocobalamin for a 28 days period; and c) analysis of the possible effect of medication intake on vitamin B status using the ATC classification of medicines. The participants for these studies were recruited from nursing homes for the elderly in the Region of Madrid. Sixty elders (mean age 84 _ 7y, 19 men and 41 women) were recruited for Study I and 64 elders (mean age 82 _ 7y, 24 men and 40 women) for Study II. For Study III, baseline data from the initially recruited participants of the first two studies were used. An informed consent was obtained from all participants or their mentors. The studies were approved by the Ethical Committee of the University of Granada. Blood samples were obtained at each examination date and were analyzed for serum cobalamin, holoTC, serum and RBC folate and total homocysteine according to laboratory standard procedures. The haematological parameters analyzed were haematocrit, haemoglobin and MCV. For the lipid profile TG, total cholesterol, LDL- and HDLcholesterol were analyzed. Anthropometric measures (BMI, skinfolds [triceps and subscapular], waist girth and waist to hip ratio), functional tests (hand grip, arm and leg strength tests, static balance) and MMSE were obtained or administered by trained personal. The vitamin B12 supplement of Study II was administered with breakfast and the medication intake was taken from the residents’ anamnesis. Data were analyzed by parametric and non-parametric statistics depending on the obtained data. Comparisons were done using the appropriate ANOVAs or non-parametric tests. Pearsons’ partial correlations with the variable “time” as control were used to define the association of the analyzed parameters. XIII The results showed that: A) Over one year, in relationship to vitamin B status, serum cobalamin decreased, serum folate and mean corpuscular volumen increased significantly and total homocysteine concentrations were stable. Regarding blood lipid profile, triglycerides increased and HDL-cholesterol decreased significantly. Regarding selected anthropometric measurements, waist circumference increased significantly. No significant changes were observed for the rest of parameters. B) Prevalence of hyperhomocysteinemia was high in the elderly studied, ranging from 60% to 90 % over the year depending on the cut-off used for the classification. LDL-cholesterol values were high, especially among women, and showed a tendency to increase over the year. Results of the balance test showed a deficiency and a tendency to decrease; this indicates that the population studied is at high risk for falls. Lower extremity muscular function was deficient and showed a tendency to decrease. A highly significant relationship was observed between the skinfold of the triceps and blood lipid profile. C) Low cobalamin concentrations correlated significantly with low MMSE scores in the elderly studied. No correlations were observed between vitamin B12 status and functional parameters. D) Regarding vitamin B12 status, holo-transcobalamin seems to be more sensitive for diagnosis; 5-10% of the elderly had a deficiency using serum cobalamin as a criterion, and 45-52% had a deficiency when using serum holotranscobalamin as a criterion. E) 500 μg of cyanocobalamin administered orally during 28 days significantly improved vitamin B12 status and significantly decreased total homocysteine concentrations in institutionalized elderly. No effect of the intervention was observed on functional and cognitive parameters. F) The relative change (%) of improvement of vitamin B12 status was higher when using serum holo-transcobalamin as a criterion than serum cobalamin. G) Antiaenemic drug intake normalized cobalamin, urologic drugs and corticosteroids serum folate, and psychoanaleptics holo-transcobalamin levels. Drugs treating pulmonary obstruction increased total homocysteine concentration significantly. H) The daily mean drug intake was 5.1. Fiftynine percent of the elderly took medication belonging to 5 or more different ATC groups. The most prevalent were psycholeptic (53%), antiacid (53%) and antithrombotic (47%) drugs.