Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association

A Systematic Review of Culturally Specific Interventions to Increase Physical Activity for Older Asian Americans

BACKGROUND

Physical activity (PA) is a significant modifiable risk factor for cardiovascular disease. For older adults, engaging in PA is shown to improve cardiac status, reduce cognitive, and functional decline, and improve overall quality of life. However, only 17% of Asian American adults meet the 2008 federal recommended guidelines for aerobic and muscle strengthening activity; and there is a paucity of data reporting on older Asian Americans - a rapidly growing, underserved group. While data pertaining to Asian Americans is frequently reported at the aggregate level, this masks differences (eg, language, culture, income) among Asian ethnic subgroups that may impact health behaviors. The purpose of this review was to identify intervention, and cultural adaptation strategies in studies promoting PA for older Asian Americans.

METHODS

A comprehensive literature search was performed to identify interventions published between 1996-2016 focused on improving PA among older Asian Americans (> 60 years old). Data were abstracted to examine intervention study designs, cultural adaptation strategies, theoretical frameworks, and physical activity measures.

RESULTS

Nine studies met the review's inclusion criteria. Community-based recruitment approaches were widely used, and all studies employed cultural adaptation to varying degrees. Most studies reported improvements in PA outcomes, focused on Chinese Americans, and relied on self-reports of PA, while few aimed to increase PA using a multi-component approach.

CONCLUSIONS

Future studies would benefit from larger sample sizes, a wider representation of Asian ethnic subgroups, and concentrated efforts to implement deep level adaptations that may increase the salience and sustainability of these interventions.

A Mobile-Based Comprehensive Weight Reduction Program for the Workplace (Health-On): Development and Pilot Study

BACKGROUND

There is a growing interest in mobile technology for obesity management. Despite the known effectiveness of workplace-based weight loss programs, there are few studies on mobile phone-delivered interventions.

OBJECTIVE

This study aimed to develop and verify an integrated and personalized mobile technology-based weight control program, named Health-On, optimized for workplaces.

METHODS

A weight reduction algorithm was developed for calorie prescription, continuous monitoring, periodic feedback and reevaluation, goal resetting, and offline intervention with behavior-changing strategies. A total of 30 obese volunteers (body mass index ≥25 kg/m²) participated in the 12-week Health-On pilot program. The primary outcome was weight reduction, and secondary outcomes were improved anthropometric measures, metabolic profiles, and fat computed tomography measures, all assessed pre- and postintervention.

RESULTS

Health-On incorporated proprietary algorithms and several strategies intended to maximize adherence, using compatible online and offline interventions. The mean weight of 30 participants decreased by 5.8%, and median weight also decreased from 81.3 kg (interquartile range [IQR] 77.1-87.8) before intervention to 76.6 kg (IQR 70.8-79.5) after the 12-week intervention period (P<.001). The metabolic profiles and fat measures (blood pressure, glycosylated hemoglobin, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, alanine aminotransferase, and visceral and subcutaneous adipose tissue; P<.05) also improved significantly.

CONCLUSIONS

In this single-group evaluation of 30 participants before and after the Health-On program, body weight decreased and metabolic profiles and fat measures improved. Follow-up studies are needed to assess effectiveness and long-term adherence.

The use of information and communication technologies to promote healthy lifestyle behaviour: a systematic scoping review

INTRODUCTION

Health-promoting lifestyle behaviours are part of the activities of daily living that influence individual happiness, values and well-being. They play a crucial role in prevention and control of non-communicable diseases (NCDs) among all age groups. Current statistics on mortality, disability and morbidity associated with NCDs are alarming globally. The use of information and communication technology (ICT) for a health-promoting lifestyle behaviour programme enhances health behaviours that are important in the prevention and control of both communicable and non-communicable diseases. Our study aimed to map evidence on the use of ICT in comprehensive health-promoting lifestyle behaviour among healthy adults.

METHODS

Eleven electronic databases were searched for the study. We included studies published in English between January 2007 and December 2018 reporting on healthy adults, ICT and any subscales of the health-promoting lifestyle profile (HPLP). Studies focusing on diseases or disease management and studies that combine monitoring tools in the form of hardware (accelerometer or pedometer) with ICT or computer games were excluded. Data were summarised numerically and thematically.

RESULTS

All the studies reviewed were conducted in developed countries. Most of the studies reported on physical activity, and findings of one study covered all the subscales of HPLP. The use of ICT for health-promoting lifestyle behaviours was reported to be effective in ensuring health behaviours that can improve physical and mental health.

CONCLUSION

Our findings showed that there is a dearth of knowledge on comprehensive health-promoting lifestyle behaviour that can be beneficial for the control and prevention of NCDs. There is a need to carry out primary studies on the use of ICT and comprehensive health-promoting lifestyle, especially among adults in low-income and middle-income countries where there are alarming statistics for mortality and disability associated with NCDs.

PROSPERO REGISTRATION NUMBER

CRD42016042568.

Determinants of effective nurse-patient communication based on the health action process approach in Yazd hospitals

Background Nurse-patient communication is one of the most important care relationships that affects the treatment process. The health action process approach (HAPA) has been used to explain a number of behaviors. However, this approach has not been used to explain nurse-patient communication. Therefore, this study was conducted to investigate effective nurse-patient communication using this approach. Materials and methods In this cross-sectional study, 300 nurses from public hospitals in the center of Iran were enrolled in the study. A researcher-developed questionnaire was used to measure the HAPA constructs. The data were analyzed using Pearson's correlation coefficient and one-way analysis of variance with least significant difference (LSD) post hoc tests in SPSS as well as structural equation modeling using AMOUS software. Results In the motivation phase, risk perception, outcome expectancies and task self-efficacy predicted 19% of variance in intention to communicate effectively. In the volitional phase, planning and action self-efficacy predicted 22% of variance in effective communication. The scores of HAPA constructs were different depending on the levels of effective communication. Conclusions The model can serve as a reference framework to promote effective nurse-patient communication.

Prevalence and patterns of cognitive impairment in acute coronary syndrome patients: A systematic review

BACKGROUND

Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood.

DESIGN

This study was based on a systematic review.

METHODS

A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality.

RESULTS

From 747 potential studies, nine were included. The total sample size was 6457 (range 53-2174), mean age range was 51.3-77.4 years, and range of proportions of males was 57-100%. Reported cognitive impairment prevalence rates varied substantially (9-85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools (n = 9), cut-off scores and screening timepoints.

CONCLUSIONS

Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.

Mobile phone text-messaging interventions aimed to prevent cardiovascular diseases (Text2PreventCVD): systematic review and individual patient data meta-analysis

Background

A variety of small mobile phone text-messaging interventions have indicated improvement in risk factors for cardiovascular disease (CVD). Yet the extent of this improvement and whether it impacts multiple risk factors together is uncertain. We aimed to conduct a systematic review and individual patient data (IPD) meta-analysis to investigate the effects of text-messaging interventions for CVD prevention.

Methods

Electronic databases were searched to identify trials investigating a text-messaging intervention focusing on CVD prevention with the potential to modify at least two CVD risk factors in adults. The main outcome was blood pressure (BP). We conducted standard and IPD meta-analysis on pooled data. We accounted for clustering of patients within studies and the primary analysis used random-effects models. Sensitivity and subgroup analyses were performed.

Results

Nine trials were included in the systematic review involving 3779 participants and 5 (n=2612) contributed data to the IPD meta-analysis. Standard meta-analysis showed that the weighted mean differences are as follows: systolic blood pressure (SBP), -4.13 mm Hg (95% CI -11.07 to 2.81, p<0.0001); diastolic blood pressure (DBP), -1.11 mm Hg (-1.91 to -0.31, p=0.002); and body mass index (BMI), -0.32 (-0.49 to -0.16, p=0.000). In the IPD meta-analysis, the mean difference are as follows: SBP, -1.3 mm Hg (-5.4 to 2.7, p=0.5236); DBP, -0.8 mm Hg (-2.5 to 1.0, p=0.3912); and BMI, -0.2 (-0.8 to 0.4, p=0.5200) in the random-effects model. The impact on other risk factors is described, but there were insufficient data to conduct meta-analyses.

Conclusion

Mobile phone text-messaging interventions have modest impacts on BP and BMI. Simultaneous but small impacts on multiple risk factors are likely to be clinically relevant and improve outcome, but there are currently insufficient data in pooled analyses to examine the extent to which simultaneous reduction in multiple risk factors occurs.

PROSPERO registration number

CRD42016033236.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

The Contribution of Diet Quality to Socioeconomic Inequalities in Obesity: A Population-based Study of Swiss Adults

Socioeconomically disadvantaged people are disproportionally more likely to develop obesity and obesity-related diseases. However, it remains unclear to what extent diet quality contributes to socioeconomic inequalities in obesity. We aimed to assess the role of diet quality in the association between socioeconomic status (SES) and obesity. Data originated from the national nutrition survey, a cross-sectional sample of the adult Swiss population (N = 1860). We used education and income as proxies for SES; calculated the Alternate Healthy Eating Index (AHEI) as a measure of diet quality; and used body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) as obesity markers. We applied counterfactual mediation modelling to generate odds ratios, 95% confidence intervals, and the proportion mediated by diet quality. Individuals with less than a tertiary education were two to three times more likely to be obese, regardless of the marker (OR (95% CI): 3.36 (2.01, 5.66) using BMI; 2.44 (1.58, 3.75) using WC; 2.48 (1.63, 3.78) using WHR; and 2.04 (1.43, 2.96) using WHtR). The proportion of the association between educational level and obesity that was mediated by diet quality was 22.1% using BMI, 26.6% using WC, 31.4% using WHtR, and 35.8% using WHR. Similar findings were observed for income. Our findings suggest that diet quality substantially contributes to socioeconomic inequalities in obesity while it does not fully explain them. Focusing efforts on improving the diet quality of disadvantaged groups could help reduce social inequalities in obesity.

Factors influencing physical activity participation among older people with low activity levels

Despite the well-documented health benefits of physical activity in older adults, participation levels remain low. With rapid global population ageing, intensive efforts are needed to encourage higher levels of participation to ameliorate the negative effects of physical inactivity for older individuals and society as a whole. The aim of this qualitative study was to inform future physical activity promotion interventions by examining factors contributing to low activity levels among older people undertaking less than half the recommended level of moderate-to-vigorous physical activity (MVPA). Semi-structured interviews were conducted with 102 (65% female) community-dwelling Western Australians aged 60+ years (mean = 71.52, standard deviation = 6.26) who engaged in ⩽75 minutes of MVPA per week as measured by accelerometers. Several modifiable and unmodifiable barriers were identified, of which poor health featured most prominently. Lifetime physical inactivity, caring duties, low motivation, misperceptions of physical activity and ageing, and a lack of affordable and attractive options were the other barriers identified. The results suggest that strategies are needed to raise awareness of current physical activity guidelines, normalise engagement in MVPA throughout the lifespan, develop initiatives to motivate participation, improve the availability of affordable physical activity programmes that are attractive to this population segment, and facilitate participation among those with intensive caring responsibilities.

Experiences of a nutrition intervention-A qualitative study within a randomised controlled trial in men undergoing radiotherapy for prostate cancer

AIM

Men with prostate cancer undergoing radiotherapy may experience acute and late bowel symptoms. Nutrition interventions have shown some benefits, however, adherence tends to decline over time. Qualitative studies, carried out after an intervention, are important to help explain trial results. The aim of the present study was to explore patient experience of participating in a nutrition intervention in a randomised controlled trial, with a focus on facilitators and barriers to adherence.

METHODS

Semistructured interviews were conducted with 15 men with prostate cancer recruited from a randomised controlled trial on a nutrition intervention during radiotherapy. Interviews were analysed with content analysis with an inductive approach.

RESULTS

The informants were motivated to make dietary changes to avoid bowel symptoms. Social support, a feeling of contributing to the greater good, prior knowledge, dietary information and a small need for behaviour change facilitated adherence. Feeling limited, wanting to decide for themselves, the timing of the intervention, unmet expectations of dietary advice and loss of motivation, were described as barriers for adherence.

CONCLUSIONS

Future nutrition intervention trials may benefit from involving significant others to a greater degree, as well as offering pre-set recipes and strategies to manage social events, and more sessions with the dietitian for patients in need of more support. Tailored interventions based on the individual's preferences, context and prior knowledge about food may further facilitate adherence.

Prevalence and Correlates of Receiving Medical Advice to Increase Physical Activity in U.S. Adults: National Health and Nutrition Examination Survey 2013-2016

INTRODUCTION

National objectives recommend healthcare professionals provide physical activity advice. This study examined health and demographic characteristics associated with receipt of medical advice to increase physical activity among U.S. health care-utilizing adults and differences in associations by age group.

METHODS

Analyses included 8,410 health care-utilizing adults aged ≥20 years from the 2013-2016 National Health and Nutrition Examination Surveys (analyzed in 2018). Logistic regression was used to examine associations between receipt of medical advice to increase physical activity in the past year and measured health conditions, reported health behaviors, and demographic characteristics. Models were stratified by age group (20-39, 40-59, and ≥60 years).

RESULTS

Physical activity medical advice was received by 42.9% (95% CI=40.8, 44.9) of adults overall. By age group, 32.7% of younger adults, 46.7% of middle-aged adults, and 48.9% of older adults received advice. Among all adults and across all age groups, receipt of advice was higher among adults with chronic health conditions: obesity (63.0%, 95% CI=60.3, 65.7), hypertension (56.5%, 95%=CI 53.8, 59.2), diabetes (69.8%, 95% CI=66.5, 72.8), hypercholesterolemia (55.6%, 95% CI=52.3, 59.0), and low high-density lipoprotein cholesterol (53.8%, 95% CI=50.1, 57.4). Among all adults, those with obesity, hypertension, and diabetes had significantly greater odds of receipt of advice after adjustment. Stronger associations between diabetes and hypercholesterolemia and receiving physical activity advice were observed among younger adults.

CONCLUSIONS

Receipt of physical activity medical advice was highest among adults with specific chronic health conditions, and this pattern was stronger among younger adults with diabetes and hypercholesterolemia. However, most health care-utilizing adults did not receive physical activity medical advice.

Association of Vitamin D Status and Metabolic Syndrome Components in Iranian Children

Background:

Recently, it has been found that Vitamin D can affect cardiometabolic risk factors. However, these findings have not been confirmed in younger population. We aimed to assess the associations of serum 25-hydroxyvitamin D (25(OH)D) and metabolic syndrome (MetS) components in Iranian children.

Methods:

This cross-sectional study was conducted on 240 children aged 6–9 years old. Anthropometric indices (weight, height, waist circumference, and body fat), biochemical parameters (low-density lipoprotein, high-density lipoprotein, triglyceride [TG], fasting blood sugar, and serum 25(OH)D), systolic blood pressure (SBP) and diastolic blood pressure (DBP) blood pressure, and dietary intake and physical activity were measured. Multivariate linear regression analysis was used to assess the association of MetS components and serum 25(OH)D.

Results:

Mean age of children was 7.8 ± 1.06 year. Mean serum 25(OH)D concentration was 14.6 ± 10.64 ng/ml, and the prevalence of Vitamin D deficiency (serum 25(OH)D lower than 10 ng/ml) was 41.66%. Dietary intake of Vitamin D was 1.91 ± 1.8 mcg/day. Serum 25(OH)D was inversely associated with TG (β = −0.16; CI: −0.27, −0.04) after adjusting by age, gender, body mass index, physical activity, and some dietary components. Serum 25(OH)D was negatively associated with SBP (β = −0.02; CI: (−0.05, −0.004), and DBP (β = −0.02; CI: −0.05, −0.003); however, it was not significant anymore after adjustment for sodium, potassium, and fiber.

Conclusions:

Vitamin D deficiency is alarming among Iranian children. Among the components of MetS, lower serum Vitamin D concentration was only associated with TG that could contribute in onset and progression of cardiometabolic disorders later in life.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

[Effects of a Daily Life-Based Physical Activity Enhancement Program for Middle-Aged Women at Risk for Cardiovascular Disease]

PURPOSE

The purpose of this study was to examine the effects of a daily life-based physical activity enhancement program performed by middle-aged women at risk for cardiovascular disease.

METHODS

This study used a randomized control group pretest-posttest design. Middle-aged women aged 45 to 64 were recruited from two outpatient cardiology departments, and randomly assigned to an experimental group (n=28) and a control group (n=30). For the experimental group, after providing one-on-one counseling and education, we provided customized text messages to motivate them in daily life. To monitor the practice of physical activity, they also used an exercise diary and mobile pedometer for 12 weeks. Subjects' physical activities (MET-min/week) were measured using the International Physical Activity Questionnaire (IPAQ). Their physiological data were obtained by blood tests using a portable analyzer, and the data were analyzed using the SPSS 21.0/WIN program.

RESULTS

There were significant differences in exercise self-efficacy, health behavior, IPAQ score, body fat, body muscle, and fasting blood sugar between the two groups. However, there were no significant differences in total cholesterol, hemoglobin A1c, high-density lipoprotein cholesterol, and waist-to-hip ratio.

CONCLUSION

Strengthening physical activity in daily life without being limited by cost burden and time and space constraints. Therefore, it is essential to motivate middle-aged women at risk for cardiovascular disease to practice activities that are easily performed in their daily lives.

Metabolic syndrome in rural Australia: An opportunity for primary health care

OBJECTIVE

To measure the impact of a 6-month home-based behaviour change intervention on reducing the risk of chronic disease as determined by metabolic syndrome status and cardiovascular risk score, and discuss implications for primary care in rural areas.

DESIGN

A two-arm randomised controlled trial of rural adults.

SETTING

The rural town of Albany in the Great Southern region of Western Australia.

PARTICIPANTS

Participants (n = 401) aged 50-69 years who were classified with or at risk of metabolic syndrome and randomly assigned to intervention (n = 201) or waitlisted control (n = 200) group.

INTERVENTIONS

A 6-month intervention program incorporating goal setting, self-monitoring and feedback, with motivational interviewing was conducted.

MAIN OUTCOME MEASURES

Change in metabolic syndrome status and cardiovascular risk.

RESULTS

Significant improvements in metabolic syndrome status and cardiovascular disease risk score (-0.82) were observed for the intervention group relative to control group from baseline to post-test.

CONCLUSION

This home-based physical activity and nutrition intervention reduced participants' risk of experiencing a cardiovascular event in the next 5 years by 1%. Incorporating such prevention orientated approaches in primary care might assist in reducing the burden of long-term chronic diseases. However, for realistic application in this setting, hurdles such as current national health billing system and availability of resources will need to be considered.

Transforming the workplace environment to prevent non-communicable chronic diseases: participatory action research in a South African power plant

Background: The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment for occupational health and safety in South Africa have focused more on what to do and less on how to do it. There are no guidelines and little evidence on workplace-based interventions for NCDs.

Objective: The aim of this study was to learn how to transform the workplace environment in order to prevent and control cardio-metabolic risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa.

Methods: The study design utilized participatory action research in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a two-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning.

Results: Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%) and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice.

Conclusion: Transformation included a multifaceted approach and an engagement with the organization as a living system. Future studies will evaluate changes in the risk profile of the workforce, as well as the costs and consequences for the organization.

Randomized Controlled Trial of the SystemCHANGE Intervention on Behaviors Related to Cardiovascular Risk in HIV+ Adults

OBJECTIVE

To examine the effect of a lifestyle behavior intervention (SystemCHANGE) on physical activity and diet quality among sedentary people living with HIV (PLHIV). All participants expressed a desire to improve lifestyle health behaviors.

METHODS

One hundred and seven HIV+ adults were randomized to either the intervention (6, in-person, standardized group sessions focusing on improving lifestyle behaviors) or a control condition (general advice on AHA diet and exercise guidelines). All participants wore an ActiGraph accelerometer and completed 24-hour dietary recalls at baseline, 3, and 6 months. Generalized estimating equations were used to examine intervention effects. The primary activity outcome was time spent in moderate-to-vigorous physical activity, and the primary dietary outcome was Healthy Eating Index.

RESULTS

Mean age was 53 years, 65% were male, and 86% African American. Approximately 90% attended at least half of the sessions and 60% attended 5 or more sessions. The intervention did not significantly improve our primary lifestyle behavior endpoints (P ≥ 0.05); however, intervention participants consumed fewer carbohydrates-primarily sugar-sweetened beverages-per day and lost 0.732 kg body weight compared with a 0.153 weight gain in the control group (P = 0.03).

CONCLUSIONS

Among sedentary PLHIV at high risk of cardiovascular disease, the SystemCHANGE intervention reduced daily carbohydrate intake and body weight, but did not increase physical activity or improve overall diet quality. Future work should identify fundamental personal, interpersonal, and contextual factors that will increase physical activity and improve overall diet quality among this population, and integrate these factors into tailored, lifestyle interventions for aging PLHIV.

Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: A randomised trial

AIMS AND OBJECTIVES

To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients.

BACKGROUND

Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction.

DESIGN

A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours.

RESULTS

A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour.

CONCLUSIONS

Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes.

RELEVANCE TO PRACTICE

Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation.

Feasibility and acceptability of a Mediterranean-style diet intervention to reduce cardiovascular risk for low income Hispanic American women

OBJECTIVE

Evidence for the cardioprotective effects of a Mediterranean-style (Med-style) diet is strong, however few Med-style dietary interventions have been developed for and tested among Hispanic Americans (HAs), especially younger HAs of reproductive age whose dietary habits may strongly influence dietary intake for all family members.

DESIGN

We adapted a previously tested and evidence-informed lifestyle intervention to reduce CVD risk and evaluated its feasibility, acceptability, and effects on self-reported lifestyle behaviors in this study enrolling low-income HA women attending a Title X family planning clinic in eastern North Carolina. The 3-month long intervention, given to all participants, promoted a Med-style dietary pattern with a focus on increasing consumption of foods commonly consumed by HA that have high quality dietary fats (polyunsaturated and monounsaturated fats primarily from plant sources and fish) and carbohydrates (fruits, vegetables, and whole grains). The intervention also recommended increasing physical activity and was given during 2 face-to-face counseling sessions and 2 telephone counseling sessions. Major outcomes were engagement with study activities and intervention acceptability; lifestyle behavior change at 3-month follow-up is also reported.

RESULTS

Baseline characteristics (n = 36) were: mean age 33 years, 35 (97%) without health insurance, 32 (89%) born in Mexico, and mean BMI 30 kg/m2. Engagement was high among the 36 participants with 33 (92%) completing the intervention and follow-up measures. At follow-up, most participants thought the intervention was helpful (range: 85-100%) and acceptable (100% agreed 'I would recommend the program to others'). The mean dietary fat quality score improved by 0.5 units (95% CI: 0.0-1.1) and the mean fruit-vegetable servings/day improved by 0.7/day (95% CI: 0.1-1.3).

CONCLUSION

Intervention engagement and acceptability were high and there was improvement in self-reported dietary behaviors. This type of Med-style dietary pattern intervention should be evaluated in randomized trials enrolling HAs at risk for CVD.

Longitudinal Changes in Allostatic Load during a Randomized Church-based, Lifestyle Intervention in African American Women

Introduction

African American (AA) women have disproportionately higher risk of cardiovascular disease than White women, which may be explained by the uniquely higher allostatic load (AL) found in AA women. No studies have tested the effect of lifestyle interventions on AL in AA women. Our objectives were to assess the change in allostatic load following a lifestyle intervention and explore the roles of lifestyle behaviors and socioeconomic factors on allostatic load change.

Methods

Participants were non-diabetic (mean age and SD: 48.8±11.2 y) AA women (n=221) enrolled in a church-based, cluster randomized trial testing a standard diabetes prevention program (DPP) and a faith-enhanced DPP with 4-months of follow-up. We assessed the relationships of changes in diet, physical activity, neighborhood disadvantage, individual socioeconomic factors, and other lifestyle variables to changes in AL at 4-months using a multilevel multinomial logistic regression model.

Results

Average AL decreased (-.13±.99, P=.02) from baseline to 4-months. After adjusting for other variables, a high school education or less (OR:.1, CI:.02-.49) and alcohol use (OR: .31, CI: .09-.99) contributed to increased AL. Living in a disadvantaged neighborhood was responsible for increased AL, though it was not statistically significant. There were no statistically significant associations between AL and other health behavior changes.

Conclusions

Lower education levels may dampen the benefits of lifestyle interventions in reducing AL. Although a significant reduction in AL was found after participation in a lifestyle intervention, more research is needed to determine how lifestyle behaviors and socioeconomic factors influence AL in AA women.

Effectiveness and Feasibility of a Remote Lifestyle Intervention by Dietitians for Overweight and Obese Adults: Pilot Study

Background

To tackle the problem of obesity and related diseases in Switzerland, cost-efficient, effective, and innovative primary health care interventions for weight management are required. In this context, Oviva has developed a scalable technology for registered dietitians to counsel overweight and obese patients via a mobile phone app.

Objective

The aim of this study was to evaluate the effectiveness and feasibility of weight loss counseling by dietitians using a mobile phone app for patients with overweight and obesity.

Methods

In this pre- and posttest pilot study, overweight and obese adults participated in a 1-year behavioral intervention to lose weight through remote counseling by dietitians in the German-speaking part of Switzerland. The study started in April 2016 and finished in May 2018. Participants received individual counseling through the app and the exchange with the dietitian focused on regular feedback on photo-based food log, motivation, and education. The contents were tailored to the individual lifestyle goal set. The predefined intensity of remote counseling decreased during the year. Group chat could be used. The outcomes examined were changes in weight (primary outcome), hemoglobin A_1c, fasting glucose, fasting insulin, triglyceride, high-density lipoprotein cholesterol, blood pressure (BP), body mass index (BMI), waist circumference, body fat, and responses to a self-administered questionnaire with questions regarding participants’ physical activity, dietary assessment, and health-related quality of life. Changes were tested at baseline, after 3 months, and after 12 months, as well as between the third and the 12th month.

Results

In total, 36 women and 7 men, with a mean age of 40.6 years, participated and 36 participants completed the study. Median weight change after the first 12 weeks was −3.8 kg (range: −15 to 2.4 and P<.001), between week 12 and week 52 it was −1.1 kg (range: −9.7 to 7 and P=.08), and the median change during the entire period of intervention was −4.9 kg (range: −21.9 to 7.5 and P<.001). Furthermore, changes in BMI, waist circumference, body fat, and BP between baseline and 12 weeks and between baseline and 52 weeks were also significant. Significant changes in certain eating habits were also demonstrated (higher frequency of vegetable, fruit, and breakfast consumption and lower frequency of alcohol, sweet, and fat consumption).

Conclusions

In addition to the professional skills of a dietitian, a profession-specific app such as Oviva can provide effective support that meets the needs of dietitians and clients on the long path of behavioral change and sustainable weight reduction.

Trial Registration

ClinicalTrials.gov NCT02694614; https://clinicaltrials.gov/ct2/show/NCT02694614 (Archived by WebCite at http://www.webcitation.org/76gYkGOIc)

To Text or Not to Text: Electronic Message Intervention to Improve Treatment Adherence Versus Matched Historical Controls

Background

Ensuring treatment adherence is important for the internal validity of clinical trials. In intervention studies where touch points decrease over time, there is even more of an adherence challenge. Trials with multiple cohorts offer an opportunity to innovate on ways to increase treatment adherence without compromising the integrity of the study design, and previous cohorts can serve as historical controls. Electronically delivered nudges offer low-cost opportunities to increase treatment adherence.

Objective

This study aimed to evaluate the effectiveness of electronic messages (e-messages) on treatment adherence to the last cohort of a parent weight loss intervention during the second half of a year-long trial, when intervention checkpoint frequency decreases. Treatment adherence is measured by intervention class attendance and adherence to the intervention diet.

Methods

All participants in the last cohort (cohort 5, n=128) of a large randomized weight loss study were offered an e-message intervention to improve participant adherence during the last 6 months of a 1-year weight loss program. Overall, 3 to 4 electronic weekly messages asked participants about intervention diet adherence. A propensity score model was estimated using 97 participants who opted to receive e-messages and 31 who declined in cohort 5 and used to pair match cohort 5 e-message participants to a historical control group from cohorts 1 to 4. Moreover, 88 participants had complete data, yielding 176 participants in the final analyses. After matching, intervention and matched control groups were compared on (1) proportion of class attendance between the 6 and 12 month study endpoints, (2) diet adherence, as measured by total carbohydrate grams for low-carbohydrate (LC) and total fat grams for low-fat (LF) diets at 12 months, and (3) weight change from 6 to 12 months. The dose-response relationship between the proportion of text messages responded to and the 3 outcomes was also investigated.

Results

Compared with matched controls, receiving e-messages had no effect on (1) treatment adherence; class attendance after 6 months +4.6% (95% CI −4.43 to 13.68, P=.31), (2) adherence; LC −2.5 g carbohydrate, 95% CI −29.9 to 24.8, P=.85; LF +6.2 g fat, 95% CI −4.1 to 17.0, P=.26); or on (3) the secondary outcome of weight change in the last 6 months; +0.3 kg (95% CI −1.0 to 1.5, P=.68). There was a positive significant response correlation between the percentage of messages to which participants responded and class attendance (r=.45, P<.001).

Conclusions

Although this e-message intervention did not improve treatment adherence, future studies can learn from this pilot and may incorporate more variety in the prompts and more interaction to promote more effective user engagement. Uniquely, this study demonstrated the potential for innovating within a multicohort trial using propensity score–matched historical control subjects.

Trial Registration

ClinicalTrials.gov NCT01826591; https://clinicaltrials.gov/ct2/show/NCT01826591

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2016.12.021

Racial Differences in Maintaining Optimal Health Behaviors Into Middle Age

INTRODUCTION

Earlier development of cardiovascular disease risk factors in blacks versus whites may result from differences in maintaining health behaviors. Age-specific racial differences in maintaining health behaviors from ages 18 to 50 years were determined.

METHODS

In 1985-1986, the population-based Coronary Artery Risk Development in Young Adults study enrolled 5,115 participants aged 18-30 years. In 2017, a total of 2,485 blacks and 2,407 whites with one or more optimal health behaviors at baseline who attended one or more of seven follow-up exams over 25 years (i.e., through 2010-2011) were analyzed. The primary outcome, maintaining four or more optimal health behaviors, included BMI <25; never smoking; ≥150 minutes/week of moderate to vigorous physical activity; no/moderate alcohol intake (women/men: zero to seven/zero to 14 drinks per week); and Dietary Approaches to Stop Hypertension diet adherence score ≥15 (i.e., baseline highest quartile). Hazard ratios comparing blacks with whites for maintaining optimal health behaviors were calculated among participants with each optimal behavior at baseline.

RESULTS

From ages 18 to 50 years, 2.6% of blacks and 9.2% of whites maintained four or more optimal health behaviors (for optimal BMI: 16.0% and 30.1%, smoking status: 74.6% and 78.4%, physical activity: 17.7% and 21.4%, alcohol intake: 68.4% and 64.6%, diet adherence: 3.9% and 10.3%, respectively). The multivariable adjusted hazard ratio comparing blacks with whites was 0.63 (95% CI=0.56, 0.72) for maintaining four or more optimal health behaviors (for optimal BMI: 0.82 [95% CI=0.66, 1.01], smoking status: 0.57 [95% CI=0.52, 0.62], physical activity: 0.83 [95% CI=0.75, 0.91], alcohol intake: 1.19 [95% CI=1.03, 1.37], diet adherence: 0.71 [95% CI=0.61, 0.82]).

CONCLUSIONS

Fewer blacks than whites maintained four or more optimal health behaviors until age 50 years, but maintenance was low among both races.

Sedentary behavior and cardiovascular disease in older women: The Objective Physical Activity and Cardiovascular Health (OPACH) Study

Background

Evidence that higher sedentary time is associated with higher risk for cardiovascular disease (CVD) is based mainly on self-reported measures. Few studies have examined whether patterns of sedentary time are associated with higher risk for CVD.

Methods

Women from the Objective Physical Activity and Cardiovascular Health (OPACH) Study (n=5638, aged 63-97, mean age=79±7) with no history of myocardial infarction (MI) or stroke wore accelerometers for 4-to-7 days and were followed for up to 4.9 years for CVD events. Average daily sedentary time and mean sedentary bout duration were the exposures of interest. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for CVD using models adjusted for covariates and subsequently adjusted for potential mediators (body mass index (BMI), diabetes, hypertension, and CVD-risk biomarkers [fasting glucose, high-density lipoprotein, triglycerides, and systolic blood pressure]). Restricted cubic spline regression characterized dose-response relationships.

Results

There were 545 CVD events during 19,350 person-years. Adjusting for covariates, women in the highest (≥ ~11 hr/day) vs. the lowest (≤ ~9 hr/day) quartile of sedentary time had higher risk for CVD (HR=1.62; CI=1.21-2.17; p-trend <0.001). Further adjustment for potential mediators attenuated but did not eliminate significance of these associations (p-trend<.05, each). Longer vs. shorter mean bout duration was associated with higher risks for CVD (HR=1.54; CI=1.27-2.02; p-trend=0.003) after adjustment for covariates. Additional adjustment for CVD-risk biomarkers attenuated associations resulting in a quartile 4 vs. quartile 1 HR=1.36; CI=1.01-1.83; p-trend=0.10). Dose-response associations of sedentary time and bout duration with CVD were linear (P-nonlinear >0.05, each). Women jointly classified as having high sedentary time and long bout durations had significantly higher risk for CVD (HR=1.34; CI=1.08-1.65) than women with both low sedentary time and short bout duration. All analyses were repeated for incident coronary heart disease (MI or CVD death) and associations were similar with notably stronger hazard ratios.

Conclusions

Both high sedentary time and long mean bout durations were associated in a dose-response manner with increased CVD risk in older women, suggesting that efforts to reduce CVD burden may benefit from addressing either or both component(s) of sedentary behavior.

The Current State of Mobile Phone Apps for Monitoring Heart Rate, Heart Rate Variability, and Atrial Fibrillation: Narrative Review

Background

Mobile phone apps capable of monitoring arrhythmias and heart rate (HR) are increasingly used for screening, diagnosis, and monitoring of HR and rhythm disorders such as atrial fibrillation (AF). These apps involve either the use of (1) photoplethysmographic recording or (2) a handheld external electrocardiographic recording device attached to the mobile phone or wristband.

Objective

This review seeks to explore the current state of mobile phone apps in cardiac rhythmology while highlighting shortcomings for further research.

Methods

We conducted a narrative review of the use of mobile phone devices by searching PubMed and EMBASE from their inception to October 2018. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) mobile phone monitoring, (2) AF, (3) HR, and (4) HR variability (HRV).

Results

The findings of this narrative review suggest that there is a role for mobile phone apps in the diagnosis, monitoring, and screening for arrhythmias and HR. Photoplethysmography and handheld electrocardiograph recorders are the 2 main techniques adopted in monitoring HR, HRV, and AF.

Conclusions

A number of studies have demonstrated high accuracy of a number of different mobile devices for the detection of AF. However, further studies are warranted to validate their use for large scale AF screening.

Effectiveness of a Tailored Lifestyle Management Program for Middle-Aged Women With Coronary Artery Disease: A Preliminary Study

BACKGROUND

Coronary artery disease (CAD) is a leading cause of death in women. Many of the risk factors for CAD relate to lifestyle and thus may be influenced by lifestyle modification. However, middle-aged women often find it difficult to adjust their lifestyle behaviors. Thus, providing individualized treatment is crucial to reducing the risk and incidence of CAD in this population.

PURPOSE

The aim of this study was to explore the effectiveness of a tailored lifestyle management program (TLMP) for middle-aged women with CAD.

METHODS

An experimental design was employed. Thirty-five middle-aged women with CAD (with stenosis [> 50%] of at least one main artery as determined by cardiac catheterization examination results) were recruited. The 35 women were randomlyassigned to the experimental group (n = 17) or the control group (n = 18). Both groups received regular health education during their hospitalization. After discharge, the experimental group received the 12-week, home-based TLMP. A generalized estimating equation was used to examine the effects of the TLMP on metabolic and biomarker indicators for CAD.

RESULTS

The average age of participants was 56.1 ± 5.6 years. No significant demographic differences were identified between the two groups. Compared with the control group, the experimental group had a significantly higher high-density lipoprotein level (B = 7.83, p < .001), a lower level of total cholesterol (B = -49.21, p = .04), and a lower waist circumference (B = -6.42, p < .001).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This study suggests that using tailored interventions is an effective approach to improving high-density lipoprotein, total cholesterol, and waist circumference in middle-aged women with CAD. This result is expected to have important implications for women's healthcare, particularly in terms of preventing the incidence of CAD.

CE: Caring for Survivors of Hodgkin Lymphoma

: Hodgkin lymphoma (HL) is a highly curable cancer. Advances in diagnosis and treatment have resulted in excellent cure rates, producing an ever-increasing number of HL survivors who live decades beyond their initial cancer treatment. These survivors, however, are at risk for late effects secondary to the cancer treatments they received years earlier, most notably, subsequent primary cancers, cardiovascular disease, pulmonary toxicity, and endocrine dysfunction. Monitoring and managing such late treatment effects may significantly challenge survivors' long-term health care providers, who may need to take on increased survivorship care. For physicians and nurses working outside of oncology settings, who are increasingly called upon to collaborate with oncologists when caring for HL survivors, understanding the late treatment effects and potential risk factors facing this growing patient population is essential to the provision of comprehensive long-term care. The authors provide an overview of HL, review the most commonly encountered late adverse effects of treatment, and discuss current recommendations for survivor surveillance and screening.

Ethnic minority members may be at risk for state hopelessness following hospitalization for ischemic heart disease

OBJECTIVE

To examine differences in state and trait hopelessness between ethnic minority and White patients hospitalized with ischemic heart disease (IHD).

METHODS

A descriptive cross-sectional design was used to enroll 517 patients at one Midwestern U.S. hospital. The State-Trait Hopelessness Scale measured hopelessness.

RESULTS

State hopelessness was higher in ethnic minority patients compared to Whites. Ethnic minority patients who had never been married had higher state hopelessness than those who were married or separated/divorced. There were no differences in trait hopelessness.

CONCLUSIONS

Ethnic minority patients with IHD, who have never been married, may be at higher risk for state hopelessness.

Measurement of health literacy in patients with cardiovascular diseases: A systematic review

BACKGROUND

While many instruments have been developed, validated, and used to assess health literacy skills, their use and appropriateness among patients with cardiovascular diseases (CVDs) are not widely studied.

OBJECTIVE

To identify, appraise, and synthesize available health literacy assessment instruments used in patients with CVDs.

METHODS

Electronic databases were searched for studies that used validated measures to assess health literacy in patients with CVDs. Included studies were assessed for risk of bias and the identified instruments were evaluated based on their psychometric properties. Data were synthesized using a narrative approach.

RESULTS

Forty-three studies were included in the review, of which 20 were cross-sectional studies and 12 were randomized controlled trials. Eleven health literacy assessment instruments were identified, of which only one was disease-specific. The Abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA) (n = 19) and the Rapid Estimate of Adult Literacy in Medicine (REALM) (n = 13) were found to be the most commonly used instruments to assess health literacy in CVDs.

CONCLUSIONS

The S-TOFHLA and the REALM are the most widely used instruments to evaluate health literacy in CVD population. More CVD-specific health literacy screening instruments are warranted. Assessment of health literacy should be a standard of care in patients with CVDs and effective interventions should be developed to improve the impact of limited health literacy on health outcomes in this population.

Nutrition and Cardiovascular Health

Cardiovascular disease (CVD) is the leading cause of death in Western countries, representing almost 30% of all deaths worldwide. Evidence shows the effectiveness of healthy dietary patterns and lifestyles for the prevention of CVD. Furthermore, the rising incidence of CVD over the last 25 years has become a public health priority, especially the prevention of CVD (or cardiovascular events) through lifestyle interventions. Current scientific evidence shows that Western dietary patterns compared to healthier dietary patterns, such as the ‘Mediterranean diet’ (MeDiet), leads to an excessive production of proinflammatory cytokines associated with a reduced synthesis of anti-inflammatory cytokines. In fact, dietary intervention allows better combination of multiple foods and nutrients. Therefore, a healthy dietary pattern shows a greater magnitude of beneficial effects than the potential effects of a single nutrient supplementation. This review aims to identify potential targets (food patterns, single foods, or individual nutrients) for preventing CVD and quantifies the magnitude of the beneficial effects observed. On the other hand, we analyze the possible mechanisms implicated in this cardioprotective effect.

Diagnostic status and age at diagnosis of hypertension on adherence to lifestyle recommendations

Regular physical activity, smoking cessation, and moderate alcohol consumption are important lifestyle behaviors that can be modified when managing hypertension. This study examined the associations of diagnostic status and age at hypertension diagnosis with lifestyle behaviors among individuals with hypertension. Data came from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012 (N = 5231). Multinomial logistic regression models were used to estimate the relative risk (RR) of adopting lifestyle behaviors. A diagnosis of hypertension was associated with an individual being a past smoker (RR = 1.26, 95% CI: 1.05, 1.52). There was an association between duration since diagnosis and being a past smoker (RR = 1.01; 95% CI 1.01, 1.02; P = 0.004). Excessive drinking was inversely associated with duration since diagnosis (RR = 0.95; 95% CI 0.94, 0.96; P < 0.001). Older age at diagnosis was associated with the risk of being a past smoker (RR = 1.03; 95% CI 1.02, 1.04; P-value<0.001) and negatively associated with excessive drinking (RR = 0.96; 95% CI 0.95, 0.97; P < 0.001). Individuals who exercised, even though less than the recommended time, were more likely to have younger age at diagnosis (RR = 0.98; 95% CI 0.97, 0.99; P < 0.001) and shorter duration since diagnosis (RR = 0.98; 95% CI 0.96, 0.99; P < 0.001) compared to individuals with who did not engage in physical activity. Individuals with diagnosed hypertension were more likely to quit smoking, and those with younger age at diagnosis or shorter duration tended to exercise regularly. Regular visits to doctors should focus on hypertension control and health behavior modifications.

Associations Between Copper and Zinc and Risk of Hypertension in US Adults

Evidence linking copper and zinc to hypertension are limited and conflicting. Data from the National Health and Nutrition Examination Survey (NHANES) 2007-2014 were used. Zinc and copper intake from diet and supplements was assessed with 24-h dietary recall. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg/diastolic blood pressure (DBP) ≥ 90 mmHg/treatment with hypertensive medications. In a sensitivity analysis, according to the 2017 American College of Cardiology and American Heart Association guideline, hypertension was also defined as SBP ≥ 130 mmHg/DBP ≥ 80 mmHg/treatment with hypertensive medications. A total of 17,811 adults (8430 men and 9381 women) were included. After adjustment for age, gender, body mass index (BMI), race, educational level, smoking status, family income, and total daily energy intake, the OR of hypertension for highest vs. lowest quartile intake of copper, zinc, and copper/zinc ratio was 1.11 (0.90-1.37), 1.11 (0.90-1.35), and 0.95 (0.81-1.11), respectively. In stratified analysis by BMI (< 25 kg/m², 25-30 kg/m², > 30 kg/m²), no significant association was found between hypertension and intakes of copper, zinc, and copper/zinc ratio (highest vs. lowest quartile) in multivariate analysis. In multivariate analysis, the OR of hypertension for highest vs. lowest quartile levels of serum copper, zinc, and copper/zinc ratio was 1.11 (0.61-2.04), 1.43 (0.84-2.44), and 0.68 (0.34-1.33), respectively. Similar results were found in the sensitivity analysis. Zinc and copper might be not independently associated with hypertension in US adults.

Development of a Self-Efficacy Questionnaire for Walking in Patients with Mild Ischemic Stroke

PURPOSE

This study aimed to develop a self-efficacy questionnaire, which particularly focuses on walking in patients with mild ischemic stroke and transient ischemic attack.

METHODS

We enrolled patients with acute ischemic stroke and transient ischemic attack who scored 0-2 on the modified Rankin Scale. The process of development of questionnaire on self-efficacy for walking with 7 items (SEW-7) was composed of 3 steps: (1) item generation; (2) item reduction; and (3) testing the final version. The measurement properties were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

A total of 168 patients (mean age 69.4 ± 10.1 years) were enrolled for testing the questionnaire on SEW-7. The total score of the SEW-7 ranged from 7 to 35 points. Internal consistency was acceptable with the Cronbach's alpha coefficient of .93. Test-retest reliability was good with intraclass correlation coefficient of .83 (95% confidence interval: .67-.91). The smallest detectable changes at individual and group levels were 8.0 and 1.5, respectively. The results of principal component analysis showed a single factor explaining 71.8% of the total variance. The SEW-7 questionnaire showed moderate to strong correlation with physical activity parameters (step counts: r = .596, P < .001; physical activity-related energy expenditure: r = .615, P < .001; low-intensity physical activity: r = .449, P < .001; moderate- to vigorous-intensity physical activity: r = .581, P < .001).

CONCLUSIONS

We propose a simple self-report questionnaire for walking, with 7 items. The SEW-7 has adequate measurement properties and may serve as a time-saving tool for promoting physical activity in mild ischemic stroke patients.

Facing Multiple Barriers to Exercise: Does Stronger Efficacy Help Individuals with Arthritis?

BACKGROUND

Research about exercise adherence amongst adults with arthritis has been largely correlational, and theoretically based causal studies are needed. We used an experimental design to test the social cognitive theory premise that high self-efficacy helps to overcome challenging barriers to action.

METHODS

Exercising individuals (N = 86; female = 78%; M age = 53; BMI = 27) with differential self-regulatory efficacy for managing salient, non-disease barriers were randomly assigned to many or few barrier conditions. Individuals responded about the strength of their anticipated persistence to continue exercise, and their self-regulatory efficacy to use exercise-enabling coping strategies.

RESULTS

In the many barriers condition, higher barriers-efficacy individuals expressed (a) greater persistence (Cohen's d = 0.75 [-0.029, 1.79]) and (b) more confidence in their coping solutions (Cohen's d = 0.65 [-0.30, 1.60]) than lower barriers-efficacy counterparts.

CONCLUSION

Experimental support was obtained for the theoretical premise that when facing the greatest barrier challenge, individuals highest in self-regulatory efficacy still view exercise as possible. Findings suggest that identifying lower efficacy exercisers with arthritis to tailor their exercise to increase self-regulatory efficacy might also improve their adherence.

Localization of fat depots and cardiovascular risk

Despite the existing preventative and therapeutic measures, cardiovascular diseases remain the main cause of temporary disability, long-term disability, and mortality. Obesity is a major risk factor for cardiovascular diseases and their complications. However, not all fat depots have the same inflammatory, paracrine, and metabolic activities. In addition, recent studies have indicated that the accumulation of visceral fat, rather than subcutaneous fat, is associated with increased cardiometabolic risk. However, there is also evidence that increasing the area of visceral fat can help protect against lipotoxicity. This review aims to discuss the contemporary literature regarding the characteristics of the visceral, epicardial, and perivascular fat depots, as well as their associations with cardiovascular disease.

Feasibility and Effect of a Peer Modeling Workplace Physical Activity Intervention for Women

Most working women do not meet current guidelines for physical activity (PA). A 12-week pilot study tested a workplace, peer modeling PA intervention. Inactive female employees from a health system were randomized to an attention control group (ACG; n = 26) or an intervention group (IG; n = 26). The ACG received health information. The IG participated in six group sessions with an active peer model and received an exercise prescription and PA information. Pre and post measures were PA (ActiGraph), Estimated VO2max (cycle ergometer), resting heart rate (HR), glucose and lipids, and cardiovascular risk. Using hierarchical linear modeling, no significant group by time effects were found. Although PA increased in both groups, F( df = 1) = 11.4, p = .002, the IG had greater improvements in fitness (VO2max, HR) and cardiovascular risk (total cholesterol, triglyceride, low density lipoprotein [LDL], calculated risk score) compared with ACG. Results support repeating this intervention in a fully powered study.

Improving health literacy in patients with chronic conditions: A call to action

Knowledge and education is foundational to an individual receiving care, and health literacy is the ability of patients to understand and act on health information. Cardiovascular disease and diabetes are complex conditions that require active participation on the part of the patient. Lack of understanding on the condition and participation in self-care behaviors limits the effectiveness of treatment. An effective model is needed to better understand how patients with cardiovascular disease and diabetes acquire the knowledge and skills necessary to manage their health. In working together, the authors have created multiple programs that have been delivered at medical offices and corporations, resulting in a model for building functional and critical health literacy skills. This model is a progression that begins with health literacy, including the knowledge and understanding of the condition. Functional literacy includes numeracy, which is the ability to understand and manipulate numbers, and navigation, which is an understanding of what to do with the information. Finally, critical health literacy includes communication skills, including knowing what questions to ask and what information to share, and decision making, which can include shared decision making. These five levels of health literacy form a progression in the ability of the patient to become an active participant in their care, and inform the healthcare provider on effective educational methods.