Patients differ in their ability to self-monitor adherence to a low-sodium diet versus medication

Ramadan-specific nutrition education improves cardio-metabolic health and inflammation-a prospective nutrition intervention study from Pakistan

There are recent reports that Ramadan fasting (RF) results in weight gain instead of weight loss. In addition, the data on the efficacy of brief nutrition education on healthy eating practices in Ramadan for better health are scarce. Therefore, a study was conducted to investigate the effects of brief nutrition education before the start of RF on healthy eating practices during RF. For this purpose, a prospective observational study focused on "Dietary Education and Awareness for Ramadan (DEAR)" as an intervention was carried out. The participants (n = 74) were recruited and divided into two groups, i.e., intervention and control groups (n = 37 each). As an intervention, nutrition education lessons were given before and during RF month. The control group did not attend these nutrition education lessons. Data on anthropometrics, dietary intake, and other parameters were collected at three time points: before, in the end, and 4 weeks after RF. Weight was measured in kg; height, waist circumference (WC), and hip circumference (HC) were measured in cm; and body mass index (BMI) was calculated. Waist-to-hip ratio (WHR) was calculated by dividing the waist value by the hip value. Body composition analysis was performed by the body composition analyzer (BF-907). Blood pressure (BP) was measured using a validated automated blood pressure. A 3-5 ml of venous blood was collected, and plasma and serum were separated. Serum and plasma samples were processed for general blood chemistry (blood lipid profile, glucose, and CRP) within 2 h. CRP was determined by the immunoturbidimetry method using an auto-analyzer. An enzyme-linked immunosorbent assay (ELISA) was used to determine cytokine/chemokines. Adherence to nutrition education (intervention) was assessed. The results show that nutrition education has positive effects on overall nutrition. Significant improvement in dietary adherence to dietary advice in the intervention group was noted. Significant BW loss (mean loss: 1.21 kg) in the intervention group was observed. The majority (63.3%) had lost BW ≥ 1.0 kg. Other changes observed as a result of the intervention included improvements in blood glucose, cholesterol, CRP levels, and systolic and diastolic BP. There was a notable shift in pro- and anti-inflammatory cytokine concentrations: IL-7, IL-4, and TGF-α decreased, while IL-2, TNF-α and resistin, IL-1 RA, IL-17 A, and sCD40 increased. In conclusion, RF resulted in a loss in mean BW and an improvement in related blood chemistry and cytokine profiles. Furthermore, nutrition education before RF resulted in better nutrition practices during RF and a desirable healthy BW, blood lipid, and cytokine profiles.

Health-Related Quality of Life Is a Mediator of the Relationship Between Medication Adherence and Cardiac Event-Free Survival in Patients with Heart Failure

BACKGROUND

Health-related quality of life (HRQOL) is an important patient-reported outcome that is related to medication adherence, hospitalization and death. The nature of the relationships among medication adherence, HRQOL, and hospitalization and death is unknown. We sought to determine the relationships among medication adherence, HRQOL, and cardiac event-free survival in patients with heart failure.

METHODS AND RESULTS

We enrolled 218 patients with heart failure. Patients' medication adherence was measured objectively using the Medication Event Monitoring System. HRQOL was assessed using the Minnesota Living with Heart Failure Questionnaire. Patients were followed for up to 3.5 years to collect hospitalization and mortality data. Mediation analysis was used to determine the nature of the relationships among the variables. Patients with better medication adherence had better HRQOL (P = .014). Medication adherence and HRQOL were associated with cardiac event-free survival (both P < .05). Patients with medication nonadherence were 1.86 times more likely to experience a cardiac event than those with better medication adherence (P = .038). Medication adherence was not associated with cardiac event-free survival after entering HRQOL in the model (P = .118), indicating mediation by HRQOL of the relationship between medication adherence and cardiac event-free survival.

CONCLUSIONS

HRQOL mediated the relationship between medication adherence and cardiac event-free survival. It is important to assess medication adherence and HRQOL regularly and develop interventions to improve medication adherence and HRQOL to decrease hospitalization and mortality in patients with heart failure.

Dietary Sodium Intake is Predicted by Antihypertensive Medication Regimen in Patients With Heart Failure

BACKGROUND

Low-sodium diet adherence is foundational to heart failure (HF) self-management. Altered salt taste perception caused by angiotensin-converting enzyme (ACE) inhibitors commonly prescribed to patients with HF may increase sodium consumption. We hypothesized sodium intake, indicated by dietary sodium density, would be significantly higher among patients with HF prescribed ACE inhibitors compared with those not prescribed the drug.

OBJECTIVE

The aim of this study was to assess the association between prescribed ACE inhibitors and dietary sodium density in patients with HF.

METHODS

We conducted a secondary analysis of baseline data from patients with HF in an observational longitudinal study. Sodium density was derived by dividing averaged daily sodium intake from 4-day food diaries by averaged kilocalories consumed. Medical chart review was conducted to ascertain prescribed medications. Patients were categorized as prescribed and not prescribed an ACE inhibitor. t Tests were conducted to compare sodium intake between groups, and linear regression was conducted to examine whether prescribed ACE inhibitors independently predicted sodium density controlling for age, gender, New York Heart Association class, prescribed diuretics, and β-blockers.

RESULTS

Analyses included 255 patients with HF aged 61 ± 12 years, with 67% male, 44% New York Heart Association class III/IV, and 68% prescribed an ACE inhibitor. Compared with those not prescribed an ACE inhibitor, 13% more sodium per kilocalorie was consumed by patients prescribed an ACE inhibitor. Prescribed ACE inhibitor independently predicted dietary sodium density (β = 0.238, P = .009).

CONCLUSIONS

Sodium intake was higher among patients prescribed ACE inhibitors. Interventions to assist patients with HF with dietary sodium adherence can be informed by assessing medication regimens.

TAS2R38 Haplotype Predicts 24-Hour Urinary Sodium Excretion in Patients With Heart Failure and Their Family Caregivers

BACKGROUND

Adherence to a low-sodium diet is essential to self-care of heart failure (HF). Genetic determinants of preference for high-sodium foods may impede adherence but have not been well-studied.

OBJECTIVE

Our purpose was to examine if TAS2R38 haplotype predicted salt taste sensitivity and dietary sodium intake among patients with HF.

METHOD

This pilot study used baseline data from a large interventional randomized control trial to support adherence to a low-sodium diet in patients with HF and their family caregivers. Participants were tested for salt taste sensitivity and provided a 24-hour urinary sodium sample and a blood sample for DNA analysis at baseline. Fungiform papillae were counted. χ2 Test and 1-way analysis of variance were used to compare haplotype groups. Linear regression was performed to examine predictors of salt taste sensitivity and 24-hour urinary sodium excretion, controlling for age, gender, ethnicity, smoking status, and fungiform papillae density.

RESULTS

There were 42 patients with HF and their family caregivers (age, 64.6 ± 13.4 years, 46.5% male, 97.7% white, and 90.7% nonsmoker). Pronine-alanine-valine homozygous haplotype predicted lower urinary sodium excretion (b = -1780.59, t41 = -2.18, P = .036), but genotype was not a significant predictor of salt taste sensitivity.

CONCLUSIONS

The results of our study partially supported our hypothesis that PAV homozygous haplotype predicts 24-hour urinary sodium excretion. With our small sample size, more research is needed. Understanding genetic influences on taste can lead to development of educational interventions tailored to patients with HF and their family caregivers to better support dietary adherence.

Adherence to diet and medication and the associated factors among patient with chronic heart failure in a multi-ethnic society

OBJECTIVE

To investigate diet adherence, medication adherence and self-care behaviour among patients with chronic heart failure (CHF) in a multi-ethnic society and identify the significant factors associated with their diet and medication adherence.

METHODS

A cross-sectional descriptive correlational study was conducted with a convenience sample of 107 patients with CHF recruited from two cardiology wards of a public tertiary hospital in Singapore. Study variables were measured using the Dietary Sodium Restriction Questionnaire, the Medication Adherence Rating Scale-5 items and the European Heart Failure Self-care Behaviour Scale-12 items.

RESULTS

Our sample reported positive attitudes towards diet adherence, poor self-care behaviour, and good medication adherence. The multiple linear regression results indicated that lower income, Chinese ethnicity, diabetic complications, current smoking, lower New York Heart Association classification I and II, and poorer self-care behaviour predicted poorer diet adherence. In addition, absence of hypertension, having non-myocardial infarction as a cause of CHF, and moderately diminished ejection fraction were identified as significant predictors of poorer medication adherence.

CONCLUSION

The findings from this study have established the need to improve current education and rehabilitation programmes for patients with CHF by addressing those factors significantly influencing their adherence to diet and medication.

Emotion Regulation and Perceptions of Illness Coherence and Controllability on Regimen Adherence and Negative Cardiac Health Events in African American Women With Heart Failure

BACKGROUND

African American women with heart failure (HF) have stressors that negatively impact HF self-management adherence and heighten the occurrence of negative cardiac health events. Perceptions of illness coherence and controllability and emotion regulation are known to facilitate self-management in the face of stressors.

OBJECTIVE

The aim of this study was to determine whether difficulties with emotion regulation and negative perceptions of illness coherence and controllability are detrimental to adherence and increase negative cardiac health events in this patient population.

METHODS

African American women (n = 54) with HF, aged 49 to 84 years, participated in this longitudinal descriptive correlational study. Using convenience sampling, we recruited patients from hospitals and HF clinics. They completed interviews at intake and 30 days, and their medical records were reviewed at 90 days. Linear and logistic regression models were used to assess predictors of general adherence and negative cardiac health events.

RESULTS

Of 54 patients who participated in the study, 28 experienced a negative health event during 90 days, and 57% of these events were cardiac related. The only clear predictor of these events was greater New York Heart Association functional classification (β = 1.47, P = .027). No associations were found between predictors (emotion regulation, controllability, coherence, age, education) and general adherence.

CONCLUSIONS

Emotion regulation showed a possible greater impact on negative cardiac health events than on general adherence. Perceived illness coherence showed less impact on negative cardiac health events than on general adherence.

Self-reported Adherence to a Low-Sodium Diet and Health Outcomes in Patients With Heart Failure

BACKGROUND

Most clinicians rely on patients' self-report of following a low-sodium diet to determine adherence of patients with heart failure (HF). Whether self-reported adherence to a low-sodium diet is associated with cardiac event-free survival is unclear.

PURPOSES

To determine (1) whether self-reported is concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion and (2) whether self-reported adherence to a low-sodium diet predicts cardiac event-free survival.

METHODS

Adherence to a low-sodium diet was measured using 3 measures in 119 HF patients: (1) self-reported adherence, 1 item from the Self-care of Heart Failure Index scale; (2) a 3-day food diary; (3) 24-hour urinary sodium excretion. Patients were followed up for a median of 297 days to determine cardiac hospitalization or emergency department visit. One-way analysis of variance and Cox regression were used to address our purposes.

RESULTS

Self-reported adherence was concordant with adherence to a low-sodium diet measured by food diaries and 24-hour urinary sodium excretion. Thirty-one patients who reported they always follow a low-sodium diet had an average sodium intake less than 3 g/d (F = 5.07, P = .002) and 3.3 g of a mean 24-hour urinary sodium excretion (F = 3.393, P = .020). Patients who reported they never or rarely follow a low-sodium diet had 4.7 times greater risk of having cardiac events than did those who always followed a low-sodium diet (P = .017).

CONCLUSION

Self-reported adherence to a low-sodium diet predicted cardiac event-free survival demonstrating clinicians can use this as an indicator of adherence.

Using text messages to promote health in African-Americans: #HeartHealthyandCancerFree

OBJECTIVES

African-Americans are vulnerable to both cancer and cardiovascular disease (CVD) due to intricately connected risk factors. Use of text messages is an innovative method to provide health information to reduce these risks. The aim of this study was to test the feasibility and acceptability of a text messaging intervention to reduce CVD and cancer risk factors in African-Americans.

DESIGN

We developed an intervention using text messages culturally tailored for African-Americans over age 50 who were at risk (one or more modifiable risk factors) for CVD and/or cancer. Sociodemographic data, biologic measures, cancer screening practices, and general health status were assessed. Group interviews were conducted to assess feasibility and acceptability.

RESULTS

Participants were primarily female (69%), aged 58 ± 5 years, who were married (59%) and worked full time (56%). In terms of feasibility and acceptability, themes of encouragement through text messages received and a desire for a longer study period emerged from group interviews with participants. Participants experienced significant decreases in waist circumference (41 ± 5 vs 40 ± 5, p = .002), systolic blood pressure (147 ± 25 mmHg vs 138 ± 20 mmHg, p = .009), diastolic blood pressure (87 ± 16 mmHg vs 82 ± 10 mmHg, p = .02), total cholesterol (194 ± 35 mg/dL vs 173 ± 32 mg/dL, p < .001), and low-density lipoprotein levels (100 ± 32 mg/dL vs 86 ± 29 mg/dL, p = .015). Five participants had colorectal cancer screening, two had prostate cancer screening, and four had mammograms.

CONCLUSIONS

Use of text messages was widely accepted among participants. Significant CVD risk reductions and increased cancer screenings were noted. Future studies should incorporate innovative strategies such as text messaging in promoting health in vulnerable populations.

Long-Term Adherence to Low-Sodium Diet in Patients With Heart Failure

Although following a low-sodium diet (LSD) for heart failure (HF) has been recommended for decades, little is known about factors related to long-term patient adherence. The purposes of this study were to (a) compare sodium intake and factors affecting adherence in a long-term adherent group and in a non-adherent group and (b) examine predictors of membership in the long-term adherent group. Patients with HF ( N = 74) collected 24-hr urine samples and completed the Dietary Sodium Restriction Questionnaire and the Patient Health Questionnaire-9. Long-term adherence was determined using the Stage of Dietary Behavior Change Scale. The long-term adherent group had lower sodium intake (3,086 mg vs. 4,135 mg, p = .01) and perceived more benefits from LSD than the non-adherent group. Only positive attitudes toward LSD predicted membership in the long-term adherence group (odds ratio [OR] = 1.18, p = .005). Interventions focused on enhancing positive perceptions of the benefits of an LSD may improve long-term dietary adherence in patients with HF.

Self-Care and All-Cause Mortality in Patients With Chronic Heart Failure

OBJECTIVES

This study examined the association of self-care with all-cause mortality in a cohort of patients with chronic heart failure (HF).

BACKGROUND

Although self-care is crucial to maintain health in patients with chronic HF, studies examining an association with clinical outcomes are scarce.

METHODS

Consecutive patients with chronic HF (n = 559, mean age 66.3 ± 9.5 years, 78% men) completed the 9-item European Heart Failure Self-care Behaviour scale. Our endpoint was all-cause mortality. Associations between self-care and all-cause mortality were assessed with Kaplan-Meier analyses and multivariable Cox regression accounting for standard sociodemographic and clinical covariates, psychological distress, and self-rated health.

RESULTS

After a median follow-up of 5.5 ± 2.4 years (range 16 weeks to 9.9 years), 221 deaths (40%) from any cause were recorded. There was no evidence of a mortality benefit in patients high over those low in global self-care (p = 0.71). In post hoc analyses, low self-reported sodium intake was associated with increased mortality (adjusted hazard ratio: 1.47; 95% confidence interval: 1.10 to 1.96; p = 0.01). Other significant predictors of mortality were: male sex, lack of a partner, New York Heart Association functional class III to IV, and increasing comorbid conditions.

CONCLUSIONS

Global self-care was not associated with long-term mortality whereas low self-reported sodium intake independently predicted increased all-cause mortality beyond parameters of disease severity. Replication of findings is needed as well as studies examining the correspondence of subjectively and objectively measured sodium intake and its effects on long-term prognosis in patients with chronic HF.

A Comprehensive Self-Management Irritable Bowel Syndrome Program Produces Sustainable Changes in Behavior After 1 Year

BACKGROUND & AIMS

We developed a comprehensive self-management (CSM) program that combines cognitive behavioral therapy with relaxation and dietary strategies; 9 sessions (1 hour each) over 13 weeks were shown to reduce gastrointestinal symptoms and increase quality of life in a randomized trial of patients with irritable bowel syndrome (IBS), compared with usual care. The aims of this study were to describe strategies patients with IBS selected and continued to use, 12 months after the CSM program began.

METHODS

We performed a cohort study to continue to follow 81 adults with IBS (87% female; mean age, 45 ± 15 years old) who received the CSM program in the previous clinical trial. During the last CSM session, participants selected strategies they intended to continue using to manage their IBS. CSM strategies were categorized into subthemes of diet (composition, trigger foods, meal size or timing, and eating behaviors), relaxation (specific relaxation strategies and lifestyle behaviors), and alternative thoughts (identifying thought distortions, challenging underlying beliefs, and other strategies). Twelve months later, participants were asked how often they used each strategy (not at all or rarely, occasionally, often, very often, or almost always).

RESULTS

At the last CSM session, 95% of the patients selected the subthemes of specific relaxation strategies, 90% selected diet composition, and 90% identified thought distortions for continued use. At 12 months, 94% of the participants (76 of 81) were still using at least 6 strategies, and adherence was greater than 79% for all subthemes.

CONCLUSIONS

We developed a CSM program to reduce symptoms and increase quality of life in patients with IBS that produced sustainable behavioral changes in almost all patients (94%) after 1 year of follow-up.

Association between self-reported adherence to a low-sodium diet and dietary habits related to sodium intake in heart failure patients

BACKGROUND

Sodium restriction is the primary dietary therapy in heart failure (HF); however, assessing sodium intake is challenging to clinicians, who commonly rely on patients' self-report of following a low-sodium diet to determine adherence. It is important to further explore the utility of self-reported adherence to a low-sodium diet in patients with HF.

OBJECTIVES

The objective of this study was to evaluate the association between patients' self-reported adherence to a low-sodium diet and dietary habits related to sodium intake in patients with chronic HF.

METHODS

Patients with HF seen in a tertiary care Heart Function Clinic and who have been taught on a low-sodium diet with a target of less than 2300 mg/d were included. Self-perception of compliance and dietary habits related to sodium intake was evaluated by using a dietary questionnaire. Patients were divided into 3 groups according to self-reported adherence to a low-sodium diet: never, sometimes, and always.

RESULTS

Overall, 237 patients (median age, 66 years, 72.6% men) were included. Compared with the other 2 groups, patients who stated always following a low-sodium diet were less likely to use salt in cooking or at the table. However, 4.2% of the patients in the always group reported eating canned or package soups every day. Moreover, the highest proportion of patients eating fast foods 1 to 3 times a week was found among those in the sometimes group (22.9%) compared with the never (9.1%) and always (6.7%) groups (P = .002). Importantly, the rest of the food items did not show any significant differences between self-reported adherence groups.

CONCLUSION

Self-report of adherence to a low-sodium diet is not reliable among patients with HF, who associate the idea of following a low-sodium diet mainly with not using salt for cooking or at the table but not with reducing frequency of intake of high-sodium processed foods.

Using growth mixture modeling to identify classes of sodium adherence in adults with heart failure

BACKGROUND

The prevention of fluid retention is important to reduce hospitalizations in patients with heart failure (HF). Following a low-sodium diet helps to reduce fluid retention.

OBJECTIVE

The primary objective of this study was to use growth mixture modeling to identify distinct classes of sodium adherence-characterized by shared growth trajectories of objectively measured dietary sodium. The secondary objective was to identify patient-level determinants of the nonadherent trajectory.

METHODS

This was a secondary analysis of data collected from a prospective longitudinal study of 279 community-dwelling adults with previously or currently symptomatic HF. Growth mixture modeling was used to identify distinct trajectories of change in 24-hour urinary sodium excretion measured at 3 time points over 6 months. Logistic modeling was used to predict membership in observed trajectories.

RESULTS

The sample was predominantly male (64%), had a mean age of 62 years, was functionally compromised (59% New York Heart Association class III), and had nonischemic HF etiology. Two distinct trajectories of sodium intake were identified and labeled adherent (66%) and nonadherent (34%) to low-sodium diet recommendations. Three predictors of the nonadherent trajectory were identified, confirming our previous mixed-effect analysis. Compared with being normal weight (body mass index <25 kg/m2), being overweight and obese was associated with a 4-fold incremental increase in the likelihood of being in the nonadherent trajectory (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.66-12.91; P < .002). Being younger than 65 years (OR, 4.66; 95% CI, 1.04-20.81; P = .044) or having diabetes (OR, 4.15; 95% CI, 1.29-13.40; P = .016) were both associated with more than 4 times the odds of being in the nonadherent urine sodium trajectory compared with being older than 65 years or not having diabetes, respectively.

CONCLUSIONS

Two distinct trajectories of sodium intake were identified in patients with HF. The nonadherent trajectory was characterized by an elevated pattern of dietary sodium intake shown by others to be associated with adverse outcomes in HF. Predictors of the nonadherent trajectory included higher body mass index, younger age, and diabetes.

Medication adherence, depressive symptoms, and cardiac event-free survival in patients with heart failure

BACKGROUND

Medication nonadherence and depressive symptoms predict hospitalization and death in patients with heart failure (HF). Depressed patients have lower medication adherence than nondepressed patients. However, the predictive power of the combination of medication adherence and depressive symptoms for hospitalization and death has not been investigated in patients with HF.

OBJECTIVE

The aim of this study was to explore the combined influence of medication adherence and depressive symptoms for prediction of cardiac event-free survival in patients with HF.

METHODS AND RESULTS

We monitored medication adherence in 216 HF patients who completed the Patient Health Questionnaire-9 (PHQ-9) at baseline. Medication adherence was measured objectively with the use of the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data on cardiac events. Survival analyses were used to compare cardiac event-free survival among groups. The risk of experiencing a cardiac event for patients with medication nonadherence and depressive symptoms was 5 times higher than those who were medication adherent without depressive symptoms. The risk of experiencing a cardiac event for patients with only 1 risk factor was 1.2-1.3 times that of those with neither risk factor.

CONCLUSIONS

Medication nonadherence and depressive symptoms had a negative synergistic effect on cardiac event-free survival in patients with HF.

Nutrition intervention to decrease symptoms in patients with advanced heart failure

For a majority of patients with advanced heart failure, there is a need for complementary, non-pharmacologic interventions that could be easily implemented by health care providers to provide palliative care. Three major pathologic pathways underlying heart failure symptoms have been identified: fluid overload, inflammation, and oxidative stress. Prior research has demonstrated that three nutrients-sodium, omega-3 fatty acids, and lycopene-can alter these pathologic pathways. Therefore, the purposes of this study are to test the effects of a 6-month nutrition intervention of dietary sodium reduction combined with supplementation of lycopene and omega-3 fatty acids on heart failure symptoms, health-related quality of life, and time to heart failure rehospitalization or all-cause death. The aims of this double blind-placebo controlled study are (1) to determine the effects of a 6-month nutrition intervention on symptom burden (edema, shortness of air, and fatigue) and health-related quality of life at 3 and 6 months, and time to heart failure rehospitalization or all-cause death over 12 months from baseline; (2) compare dietary sodium intake, inflammation, and markers of oxidative stress between the nutrition intervention group and a placebo group at 3 and 6 months; and (3) compare body weight, serum lycopene, and erythrocyte omega-3 index between the nutrition intervention group and a placebo group at 3 and 6 months. A total of 175 patients with advanced heart failure will be randomized to either the nutrition intervention or placebo group.

Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults

BACKGROUND

It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases.

OBJECTIVES

To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.

SEARCH METHODS

We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies.

SELECTION CRITERIA

We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention.

MAIN RESULTS

We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely.

AUTHORS' CONCLUSIONS

There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.

Self-reported versus 'true' adherence in heart failure patients: a study using the Medication Event Monitoring System

BACKGROUND

Adherence to (non)pharmacological treatment is important in heart failure (HF) patients, since it leads to better clinical outcome. Although self-reported and objectively measured medication adherence in HF patients have been compared in previous studies, none of these studies have used an evidence-based cutpoint to differentiate between adherence and non-adherence.

METHODS

In 37 HF patients (mean age 68 ± 10 years, 27 % female, 40 % NYHA functional class III-IV), medication (ACEi/ARB) adherence was objectively measured using the Medication Event Monitoring System (MEMS). Adherence to and importance of taking medication was also assessed by self-report using the Revised HF Compliance Questionnaire.

RESULTS

All patients reported that adherence was (highly) important to them and that they 'always' took their medication as prescribed (i.e. 100 % adherence). However, when measured by the MEMS, only 76 % of all patients were adherent. Non-adherent patients more often had a complex medication regimen (78 % vs. 21 %, P < .01), more often depressive symptoms (75 % vs. 29 %, P = .04) and a shorter history of HF (8 vs. 41 months, P = .04), compared with adherent patients.

CONCLUSIONS

Medication adherence measured by the MEMS was remarkably lower than self-reported adherence. Given the evidence of its importance, further efforts are needed to improve adherence to the pharmacological regimen in HF patients.

Patient-reported selective adherence to heart failure self-care recommendations: a prospective cohort study: the Atlanta Cardiomyopathy Consortium

Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described. Patient-reported adherence to 8 recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0="never" to 5="always," maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence. The mean follow-up was 2.0±1.0 years, and adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs 107.6; P=.018; HF 29.6 vs 43.8; P=.007) and hospitalized days (all-cause 422 vs 465; P=.015; HF 228 vs 282; P<.001) per 100-person-years and better health status (KCCQ overall score 70.1±24.6 vs 63.8±22.8; P=.011). Adherence was not associated with clinical events or functional capacity. Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.

Medication adherence, social support, and event-free survival in patients with heart failure

OBJECTIVES

Medication adherence and perceived social support (PSS) are independent predictors of mortality in patients with heart failure (HF). However, the predictive power of the combination of medication adherence and PSS for hospitalization and death has not been investigated in patients with HF. The purpose of the study was to explore the combined influence of medication adherence and PSS for prediction of cardiac event-free survival in patients with HF.

METHOD

A total of 218 HF patients monitored medication adherence for 1-3 months and completed the Multidimensional Perceived Social Support Scale (MPSSS) at baseline. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data about cardiac event-free survival (i.e., cardiac emergency department visits, hospitalizations, and death). To test the association of the combination of medication adherence and PSS with outcomes, the interaction term of medication adherence and PSS was first entered in a Cox regression to predict outcomes. Second, patients were grouped using an evidence-based cutpoint of 88% for medication adherence from the MEMS data and a median score 71 of the MPSSS. Kaplan-Meier and Cox proportional hazards models were used to compare cardiac event-free survival among groups.

RESULT

Medication adherence and PSS were independent predictors of cardiac event-free survival (p = .006 and .021, respectively). Patients with medication nonadherence and lower PSS had a 3.5 times higher risk of cardiac events than those who were adherent and had higher PSS.

CONCLUSION

Medication adherence mediated the relationship between PSS and cardiac event-free survival in this sample. Moreover, medication adherence and social support independently, and in combination, predicted cardiac event-free survival in patients with HF. Interventions to improve clinical outcomes should address medication adherence and social support.

Depressive symptom trajectory predicts 1-year health-related quality of life in patients with heart failure

BACKGROUND

One-third of patients with heart failure (HF) experience depressive symptoms that adversely affect health-related quality of life (HRQOL). We aimed to describe depressive symptom trajectory and determine whether a change in depressive symptoms predicts subsequent HRQOL.

METHODS AND RESULTS

The sample consisted of 256 inpatients and outpatients with HF. Depressive symptoms were measured at baseline and 3 or 6 months with the Patient Health Questionnaire (PHQ-9). The Minnesota Living with HF Questionnaire was used to assess HRQOL at baseline, 3 to 6 months, and 1 year. Based on baseline and 3- to 6-month PHQ-9 scores, patients were categorized as depressive symptom-free (64%), depressive symptoms improved (15%), depressive symptoms developed (6%), or persistent depressive symptoms (15%). The groups differed in 1-year HRQOL levels (F = 36, P < .001); patients who were depressive symptom-free or whose depressive symptoms improved had better 1-year HRQOL than patients with persistent depressive symptoms (Tukey honestly significant difference, P < .01). Change in depressive symptoms was the strongest predictor of 1-year HRQOL (standardized β = .42, P < .001), after controlling for functional status, demographics, and clinical variables.

CONCLUSIONS

We found the trajectory of depressive symptoms predicts future HRQOL. Research is needed to determine whether interventions targeting depressive symptoms improve HRQOL in patients with HF.

Medication adherence mediates the relationship between marital status and cardiac event-free survival in patients with heart failure

OBJECTIVE

Prognosis is worse in unmarried patients compared with married patients with heart failure (HF). The reasons for differences in outcomes are unclear, but variations in medication adherence may play a role, because medication adherence is essential to achieving better outcomes. The study objective was to determine whether medication adherence mediated the relationship between marital status and cardiac event-free survival in patients with HF.

METHODS

Demographic, clinical, and psychosocial data were collected by questionnaires and medical record review for 136 patients with HF (aged 61 ± 11 years, 70% were male, 60% were in New York Heart Association class III/IV). Medication adherence was monitored objectively for 3 months using the Medication Event Monitoring System. Cardiac event-free survival data were obtained by patient/family interview, hospital database, and death certificate review. A series of regression and Cox survival analyses were performed to determine whether medication adherence mediated the relationship between marital status and event-free survival.

RESULTS

Cardiac event-free survival was worse in unmarried patients than in married patients. Unmarried patients were more likely to be nonadherent and 2 times more likely to experience an event than married patients (P = .017). Marital status was not a significant predictor of event-free survival after entering medication adherence in the model, demonstrating a mediation effect of adherence on the relationship of marital status to survival.

CONCLUSION

Medication adherence mediated the relationship between marital status and event-free survival. It is important to design interventions to increase medication adherence that take into account subgroups, such as unmarried patients, who are at higher risk for nonadherence.

Higher salt preference in heart failure patients

Heart failure (HF) is a complex syndrome that involves changes in behavioral, neural and endocrine regulatory systems. Dietary salt restriction along with pharmacotherapy is considered an essential component in the effective management of symptomatic HF patients. However, it is well recognized that HF patients typically have great difficulty in restricting sodium intake. We hypothesized that under HF altered activity in systems that normally function to regulate body fluid and cardiovascular homeostasis could produce an increased preference for the taste of salt. Therefore, this study was conducted to evaluate the perceived palatability (defined as salt preference) of food with different concentrations of added salt in compensated chronically medicated HF patients and comparable control subjects. Healthy volunteers (n=25) and medicated, clinically stable HF patients (n=38, NYHA functional class II or III) were interviewed and given an evaluation to assess their preferences for different amounts of saltiness. Three salt concentrations (0.58, 0.82, and 1.16 g/100 g) of bean soup were presented to the subjects. Salt preference for each concentration was quantified using an adjective scale (unpleasant, fair or delicious). Healthy volunteers preferred the soup with medium salt concentration (p=0.042), HF patients disliked the low concentration (p<0.001) and preferred the high concentration of salted bean soup (p<0.001). When compared to healthy volunteers, HF patients demonstrated a significantly greater preference for the soup with a high salt concentration (p=0.038). It is concluded that medicated, compensated patients under chronic treatment for HF have an increased preference for salt.

Linkages between anxiety and outcomes in heart failure

OBJECTIVE

We investigated the relationship between anxiety and event-free survival (ie, composite endpoint of death, emergency department visits, or hospitalizations) for patients with heart failure (HF), and examined whether behavioral and physiologic mechanisms mediate any association between anxiety and outcomes.

METHODS

In this longitudinal study, patients with HF completed the anxiety subscale of the Brief Symptom Inventory, and heart-rate variability and plasma norepinephrine levels were measured. Dietary adherence and medication adherence were measured according to 24-hour urine sodium level and the Medication Event Monitoring System, respectively. Patients were followed at least 1 year for event-free survival.

RESULTS

In total, 147 patients were enrolled. Patients with high anxiety had a shorter (hazard ratio, 2.2; 95% confidence interval, 1.1-4.3; P = .03) period of event-free survival than patients with lower anxiety. Anxiety independently predicted adherence to medication (P = .008), which in turn predicted event-free survival (hazard ratio, 2.0; 95% confidence interval, 1.2-3.3; P = .008). The effect of anxiety (P = .17) on event-free survival was less significant when the regression model included both anxiety and adherence to medication than when the model only included anxiety (P = .03), indicating that adherence to medication mediated the relationship between anxiety and event-free survival.

CONCLUSION

This is the first study to show that nonadherence to medication links anxiety and event-free survival for patients with HF. Interventions that reduce anxiety and improve adherence may benefit outcomes.

Self care in patients with chronic heart failure

'Heart failure self care' refers to the practices in which patients engage to maintain their own health, and to the decisions that they make about managing signs or symptoms. In this article, we base our discussion of self care in chronic heart failure on the classification of patients as being 'expert', inconsistent', or 'novice' in heart failure self-care behaviors. The available literature on factors predicting heart failure self care and its outcomes are reviewed within this context. Factors known to influence heart failure self care include experience with the illness, physical functioning, depression and anxiety, social support, daytime sleepiness, and attitudes such as confidence. Further research is needed to understand the contributions of comorbidities, patient sex, and health disparities on heart failure self care. The evidence to support a link between heart failure self care and health outcomes is limited, but early evidence suggests that adequate self care is associated with an improvement in health status, a decrease in the number and duration of hospitalizations, and a decline in levels of biomarkers of stress and inflammation, and in intrathoracic impedance. Implications of heart failure self care for clinical practice, policy, and public health are also described.

Heart failure self-care in developed and developing countries

BACKGROUND

Heart failure (HF) self-care is poor in developed countries like the United States, but little is known about self-care in developing countries.

METHODS AND RESULTS

A total of 2082 adults from 2 developed (United States and Australia) and 2 developing countries (Thailand and Mexico) were studied in a descriptive, comparative study. Self-care was measured using the Self-Care of HF Index, which provided scores on self-care maintenance, management, and confidence. Data were analyzed using regression analysis after demographic (age, gender, education), clinical (functional status, experience with the diagnosis, comorbid conditions), and setting of enrollment (hospital or clinic) differences were controlled. When adequate self-care was defined as a standardized score >or=70%, self-care was inadequate in most scales in most groups. Self-care maintenance was highest in the Australian sample and lowest in the Thai sample (P < .001). Self-care management was highest in the US sample and lowest in the Thai sample (P < .001). Self-care confidence was highest in the Mexican sample and lowest in the Thai sample (P < .001). Determinants differed for the three types of self-care (eg, experience with HF was associated only with self-care maintenance).

CONCLUSION

Interventions aimed at improving self-care are greatly needed in both the developed and the developing countries studied.

Determinants of self-care behaviors in community-dwelling patients with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

As the population ages, chronic conditions such as heart failure are becoming more prevalent. An important goal is to understand how patients with heart failure learn to manage the often debilitating disease symptoms. The research objective was to examine the determinants of general and therapeutic self-care behaviors among community-dwelling heart failure patients. Guided by Connelly's Model of Self-care in Chronic Illness, enabling and predisposing factors were evaluated using sociodemographic characteristics, functional ability, and psychological status. Self-care maintenance, self-efficacy, and self-care management characteristics were also evaluated.

PARTICIPANTS AND METHODS

Using a cross-sectional design, a convenience sample of 65 ambulatory care patients were recruited. Data were collected through chart reviews and questionnaires.

RESULTS AND CONCLUSIONS

Common self-care maintenance behaviors included taking medication as prescribed (95%), seeking physician guidance (80%), and following sodium dietary restrictions (70%). These behaviors were influenced by enabling characteristics such as psychological status (P = .030), ethnicity (P = .048), and comorbidity (P = .023). A unique finding was that self-care maintenance behaviors were significantly lower in aboriginal participants. The predisposing characteristic of self-efficacy influenced self-maintenance behaviors (P = .0002), overall self-care (P = .04) and number of hospital admissions (P < .0001). Higher overall self-care scores, measured by the summative Self-care Heart Failure Index score was correlated with fewer hospital admissions (P = .019).

The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease

OBJECTIVE

To conceptualize, develop, and provide preliminary psychometric evidence for the Adherence Estimator--a brief, three-item proximal screener for the likelihood of non-adherence to prescription medications (medication non-fulfillment and non-persistence) for chronic disease.

RESEARCH DESIGN AND METHODS

Qualitative focus groups with 140 healthcare consumers and two internet-based surveys of adults with chronic disease, comprising a total of 1772 respondents, who were self-reported medication adherers, non-persisters, and non-fulfillers. Psychometric tests were performed on over 150 items assessing 14 patient beliefs and skills hypothesized to be related to medication non-adherence along a proximal-distal continuum. Psychometric tests included, but were not limited to, known-groups discriminant validity at the scale and item level. The psychometric analyses sought to identify: (1) the specific multi-item scales that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters) and, (2) the single best item within each prioritized multi-item scale that best differentiated self-reported adherers from self-reported non-adherers (non-fulfillers and non-persisters).

RESULTS

The two rounds of psychometric testing identified and cross-validated three proximal drivers of self-reported adherence: perceived concerns about medications, perceived need for medications, and perceived affordability of medications. One item from each domain was selected to include in the Adherence Estimator using a synthesis of psychometric results gleaned from classical and modern psychometric test theory. By simple summation of the weights assigned to the category responses of the three items, a total score is obtained that is immediately interpretable and completely transparent. Patients can be placed into one of three segments based on the total score--low, medium, and high risk for non-adherence. Sensitivity was 88%--of the non-adherers, 88% would be accurately classified as medium or high risk by the Adherence Estimator. The three risk groups differed on theoretically-relevant variables external to the Adherence Estimator in ways consistent with the hypothesized proximal-distal continuum of adherence drivers.

CONCLUSIONS

The three-item Adherence Estimator measures three proximal beliefs related to intentional non-adherence (medication non-fulfillment and non-persistence). Preliminary evidence of the validity of the Adherence Evidence supports its intended use to segment patients on their propensity to adhere to a newly-prescribed prescription medication. The Adherence Estimator is readily scored and is easily interpretable. Due to its brevity and transparency, it should prove to be practical for use in everyday clinical practice and in disease management for adherence quality improvement. Study limitations related to sample representation and self reports of chronic disease and adherence behaviors were discussed.

Objectively measured, but not self-reported, medication adherence independently predicts event-free survival in patients with heart failure

OBJECTIVE

Medication nonadherence is presumed to be related to poor clinical outcomes, yet this relationship rarely has been tested using objective adherence measures in patients with heart failure. Which objective indicators of medication adherence predict clinical outcomes are unknown. The study objective was to determine which indicators of medication adherence are predictors of event-free survival.

METHODS

Patients (N = 134) with heart failure (69% were male, aged 61 +/- 11 years, 61% with New York Heart Association class III/IV heart disease) were enrolled in this 6-month longitudinal study. Adherence was measured using two measures: 1) an objective measure, the Medication Event Monitoring System (MEMS); and 2) self-reported adherence (Medical Outcomes Studies Specific Adherence Scale). Three indicators of adherence were assessed by MEMS: 1) dose-count, percentage of prescribed doses taken; 2) dose-days, percentage of days correct number of doses taken; and 3) dose-time, percentage of doses taken on schedule. Events (emergency department visits, rehospitalization, and mortality) were obtained by patient/family interview and hospital databases.

RESULTS

In Cox regression, two of the three MEMS indicators, dose-count and dose-day, predicted event-free survival before and after controlling for age, gender, ejection fraction, New York Heart Association class, angiotensin-converting enzyme inhibitor use, and beta-blocker use (P = .004, P = .008, and P = .224, respectively). Self-report adherence did not predict outcomes (P = .402).

CONCLUSION

Dose-count and dose-day predicted event-free survival. Neither dose-time nor self-reported adherence predicted outcomes. Health care providers should assess specific behaviors related to medication taking rather than a global patient self-assessment of patient adherence.