Primordial prevention of cardiovascular disease risk in The Netherlands

Change of serum albumin and risk of cardiovascular disease and all-cause mortality: Longitudinal Aging Study Amsterdam

The aim of this longitudinal study was to investigate 3-year change in serum albumin concentration as a determinant of incident cardiovascular disease (CVD) and all-cause mortality. Data were from 713 respondents of the Longitudinal Aging Study Amsterdam initially aged 55-85 years. Serum albumin was measured at baseline (1992/1993) and after 3 years. At the 6-year follow-up, incident CVD (among 456 respondents with no prevalent CVD at the 3-year follow-up) and all-cause mortality were ascertained. Overall, 18.9% developed CVD and 10.9% died. After adjustment for potential confounders, a higher level of serum albumin at the 3-year follow-up was associated with a lower risk for incident CVD (relative risk = 0.88, 95% confidence interval (CI): 0.79, 0.98). The risk of incident CVD was 0.88 (95% CI: 0.78, 0.99) per unit (g/liter) increase in change in albumin between 3-year follow-up and baseline. Chronic low serum albumin (<or=43 g/liter at baseline and 3-year follow-up) was not associated with incident CVD (p = 0.22). A clinically relevant decrease in serum albumin (>or=1 standard deviation (2.5 g/liter) between baseline and 3-year follow-up) tended to be associated with a twofold risk (relative risk = 2.00, 95% CI: 0.91, 4.39). For all-cause mortality, no associations were observed. These findings suggest that older persons with a decrease in serum albumin concentration, even within the normal range, might be at increased risk of incident CVD. Change in serum albumin may be used as an early marker for CVD risk.

Cardiovascular prevention in the Hartslag Limburg project: effects of a high-risk approach on behavioral risk factors in a general practice population

BACKGROUND

This study describes a general-practice-based high-risk cardiovascular prevention approach in Maastricht, The Netherlands (1999-2003). The intervention consisted of a complete registration of risk factors, optimization of medical treatment and health counseling on high fat consumption, smoking and physical inactivity.

METHODS

Behavioral effects were assessed in a trial, randomization by practice and usual care as control. Validated questionnaires were completed by 1300 patients at baseline, 1174 after 4 months (90.3%) and 1046 (80.5%) after 18 months.

RESULTS

After 4 months, intention-to-treat analyses revealed a decrease in saturated fat intake of 1.3 points (scale ranging from 7 to 30 points, p=0.000). This was partly sustained after 18 months (-0.5 points, p=0.014). After 18 months, obese intervention patients were more likely to be sufficiently physically active than their control counterparts (OR=1.90, p=0.023). No intervention effects were found for smoking.

CONCLUSION

Given the multiple factor and multiple component high-risk approach, the intervention had modest effects on only some of the behavioral risk factors addressed. Process data showed that the registration of risk factors and the optimization of medical treatment were only partly implemented, that the health counseling component could be further improved and that the intervention could benefit from additional health promoting strategies.

Trends of food intake in Portugal, 1987–1999: results from the National Health Surveys

OBJECTIVE

To assess trends of food intake in Portugal.

DESIGN

Analysis of three cross-sectional studies: 1987, 1995-1996 and 1998-1999.

SETTING

Representative samples of free-living individuals.

SUBJECTS

64 734 men and 71 282 women.

INTERVENTIONS

Food intake was assessed by questionnaires inquiring the number of meals and which foodstuffs (fish, meat, milk, rice/pasta/potatoes, soup, vegetables and fruit) had been consumed the day before.

RESULTS

Age-adjusted average number of meals decreased from 3.3+/-0.1 in 1987 to 2.9+/-0.1 in 1998-1999 in both genders (P<0.001). In men, the percentage of subjects consuming meat, milk and potatoes/rice/pasta increased from 73, 66 and 91% in 1987 to 83, 74 and 95% in 1998-1999, respectively. The percentage of subjects consuming soup and fish decreased from 70 and 56% in 1987 to 62 and 53% in 1998-1999, respectively. In women, the percentage of subjects consuming meat, milk, potatoes/rice/pasta and vegetable increased from 70, 66, 89 and 71% in 1987 to 78, 77, 93 and 83% in 1998-1999, respectively. The percentage of subjects consuming soup and fish decreased from 70 and 55% in 1987 to 64 and 53% in 1998-1999, respectively. These trends were more pronounced in the younger age, which also displayed a higher frequency of snacking. Multivariate analysis adjusting for age group, region and educational level showed that the consumption of meat, milk and vegetables increased and the consumption of soup, fish and fruit decreased in 1998-1999 relative to 1995-1996.

CONCLUSIONS

Within a decade, the Portuguese dietary pattern has changed considerably, shifting from a traditional, south European to a more Westernized, protein-rich diet.

SPONSORSHIP

The Unidade de Nutrição e Metabolismo of the Instituto de Medicina Molecular is partially funded by a grant from the FCT (Fundação para a Ciência e a Tecnologia) ref. RUN 437.

Patients' opinions on health counseling in the Hartslag Limburg cardiovascular prevention project: perceived quality, satisfaction, and normative concerns

OBJECTIVE

To assess patients' opinions on a new service in the Dutch health care system, viz., health counseling about behavioral risks and possible lifestyle changes. This was introduced within the framework of the Hartslag Limburg prevention project and was offered to patients at high risk of cardiovascular diseases.

METHODS

A questionnaire survey to measure quality, satisfaction, and normative concerns. Questionnaires were distributed among 1,301 patients after they had completed the counseling and returned by 1,056 of them (response rate 81.2%).

RESULTS

Patients generally reported rather high levels of quality and satisfaction. They regarded the service as a welcome addition to usual care. However, the accompanying effect studies will have to provide more solid evidence for the effectiveness of the counseling.

CONCLUSION

It was concluded that the service was highly acceptable to the patients, but that the health advisors should be careful not to induce less favorable normative concerns.

PRACTICE IMPLICATIONS

A quality and satisfaction survey should consist of well-validated instruments, context-specific items, and qualitative measures as well.

Implementation of an innovative health service a "real-world" diffusion study

BACKGROUND

Although reporting on the healthcare-setting level of continuance or discontinuance of an intervention once a trial is completed has been recommended, such "real-world" diffusion studies are rare. The present example was made possible by funding to explore opportunities for post-trial implementation of an innovative health counseling intervention for cardiovascular prevention in The Netherlands.

METHODS

Between 2001 and 2004, in a longitudinal case study, we compared two healthcare settings: a cardiology outpatient clinic and general practices. Rogers' diffusion of innovations theory served as the theoretical background. Information was extracted from minutes of meetings and informal conversations with health counselors, and checked by the project manager. Additional data were collected from physicians with a short questionnaire.

RESULTS

Implementation of the health counseling intervention was successful in the cardiology outpatient clinic, but was unsuccessful in the general practices. Success was related to a centralized diffusion system, stronger "change agent" efforts, avoidance of post-trial interruption of service delivery, easily achievable "reinventions," and positive physician perceptions of the service (i.e., not complex and compatible with current practice routines). Support came from changes in the organization of care that created opportunities for, instead of competition with, the innovative service. However, coincidental events may also have played a part.

CONCLUSIONS

Our findings confirm the importance of most theoretically predicted individual and organizational diffusion variables. This implies that the implementation of innovative healthcare services requires attention at both levels.

Antimutagenesis and anticarcinogenesis, from the past to the future

Observations on cancer causation are some 150 years old, but actual detailed research on elements bearing on cancer started at the beginning of the twentieth century. Rapid progress, however, is only some 40 years old. Studies in humans documented certain lifestyle related factors to lead to cancer, and research in animal models strengthened this information. With the realization that there are carcinogens that in a metabolically activated attack DNA, in contrast to other agents that act by promoting, enhancing processes through totally distinct mechanisms, it became possible to develop and apply tests for DNA reactivity, in a prokaryotic organism, the widely used Salmonella typhimurium test by Ames and in a eukaryotic system, namely freshly explanted liver cells displaying evidence of DNA repair by Williams. A battery of these two tests are over 90% accurate in defining genotoxicity. Virtually all documented human carcinogens are genotoxic. With advances in molecular biology, mutational events are traced to changes in tumor suppressor genes or in oncogenes, that can serve as markers of risk. In addition, reactive oxygen systems (ROS) are involved in both the early steps in cancer and in the developmental aspects. Thus, foods containing antioxidants such as vegetables, fruits, soy products, cocoa and tea that counteract ROS are protective in cancer causation and development. Worldwide application of current knowledge and mechanisms to cancer prevention, the definitive means of cancer control, is likely to lower not only cancer but also heart disease risk in the current century.