Baseline design elements and sample characteristics for seven sites participating in the Nutrition Working Group of the Behavior Change Consortium

Symptoms of depression are associated with physical inactivity but not modified by gender or the presence of a cardiovascular disease; a cross-sectional study

Background

Depressive symptomatology may act as a barrier to enhance physical activity. This phenomenon is predominantly found in patients with an established cardiovascular disease (CVD) and in female patients. This cross-sectional study investigated (1) the association between symptoms of depression and physical inactivity, and (2) whether this association is different between primary and secondary prevention patients, and between men and women.

Methods

The study design concerns a secondary analysis of baseline data from a randomized clinical trial, including primary and secondary prevention patients (n = 2184; mean age 71.6 ± 8.94), from 34 general practitioner panels. The Rapid Assessment of Physical Activity questionnaire (RAPA) was used to measure patient reported activity levels. Symptoms of depression were determined using the Patient Health Questionnaire (PHQ-9). Multilevel linear regression analysis was used to explore the association between symptoms of depression and physical activity while adjusting for confounders. Gender and whether or not having a CVD were considered as potential effect modifiers for the association between symptoms of depression and inactivity.

Results

Symptoms of depression were associated with lower levels of physical activity. This association was neither different for men and women nor for primary and secondary prevention patients.

Conclusion

In primary care patients’ symptoms of depression were associated with physical inactivity. This association was not modified by gender or the presence of a CVD. Future research should focus on lifestyle interventions aiming at the increase of physical activity levels, while emphasizing on improving symptoms of depression in men, women, and patients both with and without a history of CVD.

Trajectories of Maintenance and Resilience in Healthful Eating and Exercise Behaviors in Older Adults

OBJECTIVE

Our objective was to describe behavioral change trajectories for healthful eating and exercise in a group of community-dwelling older adults. A secondary aim was to determine predictors of maintenance and resilience.

METHOD

Subjects were participants in the Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR) I study who had achieved postaction stage of change for at least one behavior by its end. They were recruited for SENIOR II, a 48-month study with annual assessments on demographic, anthropometric, cognitive, psychosocial, and behavioral variables.

RESULTS

Maintainers generally had higher levels of healthy behaviors and better cognitive function. Resilient older adults were similar to maintainers but were older and had greater functional limitations.

DISCUSSION

Findings suggest that both physical health and psychological capital provide important resources upon which to draw as older adults grow even older. The trajectory model can provide useful information for developing resilience interventions for older adults.

Effectiveness of personalised support for self-management in primary care: a cluster randomised controlled trial

BACKGROUND

Self-management support is an important component of the clinical management of many chronic conditions. The validated Self-Management Screening questionnaire (SeMaS) assesses individual characteristics that influence a patient's ability to self-manage.

AIM

To assess the effect of providing personalised self-management support in clinical practice on patients' activation and health-related behaviours.

DESIGN AND SETTING

A cluster randomised controlled trial was conducted in 15 primary care group practices in the south of the Netherlands.

METHOD

After attending a dedicated self-management support training session, practice nurses in the intervention arm discussed the results of SeMaS with the patient at baseline, and tailored the self-management support. Participants completed a 13-item Patient Activation Measure (PAM-13) and validated lifestyle questionnaires at baseline and after 6 months. Data, including individual care plans, referrals to self-management interventions, self-monitoring, and healthcare use, were extracted from patients' medical records. Multilevel multiple regression was used to assess the effect on outcomes.

RESULTS

The PAM-13 score did not differ significantly between the control (n = 348) and intervention (n = 296) arms at 6 months. In the intervention arm, 29.4% of the patients performed self-monitoring, versus 15.2% in the control arm (effect size r = 0.9, P = 0.01). In the per protocol analysis (control n = 348; intervention n = 136), the effect of the intervention was significant on the number of individual care plans (effect size r = 1.3, P = 0.04) and on self-monitoring (effect size r = 1.0, P = 0.01).

CONCLUSION

This study showed that discussing SeMaS and offering tailored support did not affect patient activation or lifestyle, but did stimulate patients to self-monitor and use individual care plans.

Implementation of personalized self-management support using the self-management screening questionnaire SeMaS; a study protocol for a cluster randomized trial

Background

The number of patients with one or more chronic diseases is rising. In several standards of care there is a focus on enhancing self-management. We applied the concept of personalization on self-management support and developed a self-management screening questionnaire (SeMaS). The main research objective is to assess the effectiveness of the SeMaS questionnaire and subsequent personalized self-management on patients’ self-management behaviors.

Methods/Design

A cluster randomized controlled trial will be set up in 15 general practices in the Netherlands. The practices are all group practices, and member of one care group. The practices will be assigned to the control or intervention arms by stratified randomization. The strata are determined by the participation of the practice nurses in a course for behavioral change, and the nurse’s workload. Patients can be included if they are over 18 years of age, have at least one chronic condition and have a checkup appointment with the practice nurse in the inclusion period. The intervention consists of screening patients with the SeMaS questionnaire, producing a graphic profile with the abilities or barriers for self-management. Patients will receive tailored feedback. Practice nurses are trained in using the profile to enhance self-management of the patient and provide personalized self-management support. The use of individual care plans and self-management interventions is stimulated. In the control arm patients will receive care as usual. Patients of both trial arms will be asked to fill in the SeMaS questionnaire and additional questionnaires at inclusion and after 6 months. The primary outcome is the difference in the level of patient activation (PAM-13) between baseline and 6 months. Secondary outcomes include patient measures for lifestyle factors (exercise, diet, smoking), and process measures from medical record data analysis.

Discussion

This manuscript presents the protocol for a cluster randomized clinical trial of personalized self-management support using the SeMaS questionnaire in chronically ill patients in primary care. By carrying out this study, scientific evidence is built for the effectiveness of personalized self-management support.

Trial registration

The Netherlands National Trial Register: NTR3960.

Clustering of unhealthy behaviors in the aerobics center longitudinal study

BACKGROUND

Clustering of unhealthy behaviors has been reported in previous studies; however the link with all-cause mortality and differences between those with and without chronic disease requires further investigation.

OBJECTIVES

To observe the clustering effects of unhealthy diet, fitness, smoking, and excessive alcohol consumption in adults with and without chronic disease and to assess all-cause mortality risk according to the clustering of unhealthy behaviors.

METHODS

Participants were 13,621 adults (aged 20-84) from the Aerobics Center Longitudinal Study. Four health behaviors were observed (diet, fitness, smoking, and drinking). Baseline characteristics of the study population and bivariate relations between pairs of the health behaviors were evaluated separately for those with and without chronic disease using cross-tabulation and a chi-square test. The odds of partaking in unhealthy behaviors were also calculated. Latent class analysis (LCA) was used to assess clustering. Cox regression was used to assess the relationship between the behaviors and mortality.

RESULTS

The four health behaviors were related to each other. LCA results suggested that two classes existed. Participants in class 1 had a higher probability of partaking in each of the four unhealthy behaviors than participants in class 2. No differences in health behavior clustering were found between participants with and without chronic disease. Mortality risk increased relative to the number of unhealthy behaviors participants engaged in.

CONCLUSION

Unhealthy behaviors cluster together irrespective of chronic disease status. Such findings suggest that multi-behavioral intervention strategies can be similar in those with and without chronic disease.

Development and pilot of an internationally standardized measure of cardiovascular risk management in European primary care

Background

Primary care can play an important role in providing cardiovascular risk management in patients with established Cardiovascular Diseases (CVD), patients with a known high risk of developing CVD, and potentially for individuals with a low risk of developing CVD, but who have unhealthy lifestyles. To describe and compare cardiovascular risk management, internationally valid quality indicators and standardized measures are needed. As part of a large project in 9 European countries (EPA-Cardio), we have developed and tested a set of standardized measures, linked to previously developed quality indicators.

Methods

A structured stepwise procedure was followed to develop measures. First, the research team allocated 106 validated quality indicators to one of the three target populations (established CVD, at high risk, at low risk) and to different data-collection methods (data abstraction from the medical records, a patient survey, an interview with lead practice GP/a practice survey). Secondly, we selected a number of other validated measures to enrich the assessment. A pilot study was performed to test the feasibility. Finally, we revised the measures based on the findings.

Results

The EPA-Cardio measures consisted of abstraction forms from the medical-records data of established Coronary Heart Disease (CHD)-patients - and high-risk groups, a patient questionnaire for each of the 3 groups, an interview questionnaire for the lead GP and a questionnaire for practice teams. The measures were feasible and accepted by general practices from different countries.

Conclusions

An internationally standardized measure of cardiovascular risk management, linked to validated quality indicators and tested for feasibility in general practice, is now available. Careful development and pilot testing of the measures are crucial in international studies of quality of healthcare.

Maintaining exercise and healthful eating in older adults: the SENIOR project II: study design and methodology

The Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR) Project II is an intervention study to promote the maintenance of both exercise and healthful eating in older adults. It is the second phase of an earlier study, SENIOR Project I, that originally recruited 1277 community-dwelling older adults to participate in behavior-specific interventions designed to increase exercise and/or fruit and vegetable consumption. The general theoretical framework for this research is the Transtheoretical Model (TTM) of Health Behavior Change. The current intervention occurs over a 48-month period, using a manual, newsletters, and phone coaching calls. Annual assessments collect standardized data on behavioral outcomes (exercise and diet), TTM variables (stage of change and self-efficacy), psychosocial variables (social support, depression, resilience, and life satisfaction), physical activity and functioning (SF-36, Up and Go, Senior Fitness Test, and disability assessment), cognitive functioning (Trail Making Test and Forward and Backward Digit Span), physical measures (height, weight, and waist circumference), and demographics. The SENIOR Project II is designed to answer the following question as its primary objective: (1) Does an individualized active-maintenance intervention with older adults maintain greater levels of healthful exercise and dietary behaviors for 4years, compared to a control condition? In addition, there are two secondary objectives: (2) What are the psychosocial factors associated with the maintenance of health-promoting behaviors in the very old? (3) What are the effects of the maintenance of health-promoting behaviors on reported health outcomes, psychosocial measures, anthropometrics, and cognitive status?

A quantitative and qualitative approach to understanding fruit and vegetable availability in low-income african-american families with children enrolled in an urban head start program

BACKGROUND

Prior studies have shown low-income African Americans have low intakes of fruits and vegetables, which correlate, in part, to area of residence. To address the dietary problem, behavior-change interventions are most effective when they are theoretically based and compatible with cultural/behavioral characteristics of a given population.

OBJECTIVE

To use the Transtheoretical Model of Behavior Change to determine whether low-income African Americans were in proportionately different stages of change for increasing fruits and vegetables to their young children and identify differences in decision making, self-efficacy, and use of cognitive and behavioral strategies related to fruit and vegetable availability.

DESIGN

The two-phase, descriptive study utilized a mixed methodology consisting of a fruit and vegetable survey and focus groups.

SUBJECTS/SETTING

Convenience sample of low-income African-American parents with children enrolled in an urban area Head Start program.

STATISTICAL ANALYSES PERFORMED

chi(2) test was calculated to examine the distribution of parents into stages of change for increasing fruit and vegetable availability. Analysis of variance was used to test differences in fruit and vegetable availability to children and parents' decision making, self-efficacy, and use of cognitive and behavioral strategies. Content analysis of focus group transcripts was used to triangulate quantitative findings and further explore meanings of survey responses.

RESULTS

Of 94 participants completing the fruit and vegetable survey, 21% staged as precontemplation/contemplation, 25% staged as preparation, and 54% staged as action/maintenance (P<0.001). Parents in action/maintenance stages served significantly more fruits and vegetables (P=0.006) and used behavioral processes significantly more often (P<0.001) compared to parents in precontemplation/contemplation stages. Content analysis of focus group transcripts provided greater insight into the quantitative findings.

CONCLUSIONS

Nutrition education targeting low-income African-American parents in earlier stages of change should address planning and preparing convenient and economical meals and snacks that include fruits and vegetables. Interventions targeting parents in later stages of change should address increasing variety and healthful preparation methods. Interventions for both groups can benefit from social support strategies.

Comparison of diet quality, physical activity and biochemical values of older adults either reporting or not reporting use of lipid-lowering medication

OBJECTIVES

The aim of this study was to compare standard lipid profile, reported dietary intake, and physical activity in older adults who reported taking or not taking a lipid-lowering medication, namely statins.

DESIGN

Cross-sectional study utilizing baseline data collected from a subsample of a larger randomized clinical trial, The Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR) Project.

PARTICIPANTS AND SETTING

A total of 115 participants, 33 males and 82 females, over the age of 60, community-dwelling, primarily retired, and from East Providence, Rhode Island and surrounding communities in Rhode Island and Massachusetts.

MEASUREMENTS

Height and weight were measured and used to calculate body mass index. Waist circumference was measured. Medical history and medication use surveys were completed. Dietary assessment was done via three 24 hour recalls using NDS-R. The Yale Physical Activity Survey was used to determine energy expenditure during exercise and a physical activity summary score. Fasting blood samples were obtained to determine lipid profile.

RESULTS

37 participants (32.2%) reported taking lipid-lowering medication, statins exclusively, and 78 (67.8%) reported not taking any lipid-lowering medication. Participants who reported taking statins had better lipid profiles than those participants who reported not taking statins but had significantly lower intakes of vitamin B12, vitamin K, calcium, and potassium. There were no differences between groups on reported physical activity. However, the mean intakes for both groups did not meet the Dietary Reference Intakes for multiple nutrients.

CONCLUSION

Older adults need additional education on the importance of lifestyle changes in reducing CHD risk, whether taking lipid-lowering medications or not.

Accuracy and precision of two short screeners to assess change in fruit and vegetable consumption among diverse populations participating in health promotion intervention trials

Two short frequency questionnaires, the NCI 19-item Fruit and Vegetable Screener (FVS) and a single question on overall fruit and vegetable consumption (1-item), were evaluated for their ability to assess change in fruit and vegetable (FV) consumption over time and in response to intervention among participants in 5 health promotion trials in the Behavior Change Consortium. Cross-sectional differences and correlations of FV estimates at baseline and at follow-up were compared for the FVS (n = 315) and the 1-item (n = 227), relative to multiple 24-h recall interviews (24HR). The FVS significantly overestimated daily intake by 1.27 servings at baseline among men and by 1.42 and 1.59 servings at baseline and follow-up, respectively, in women, whereas the 1-item measure significantly underestimated intake at both time points in men (0.98 serving at baseline, 0.75 serving at follow-up) and women (0.61 and 0.41 serving). Cross-sectional deattenuated correlations with 24HR at follow-up were 0.48 (FVS) and 0.50 (1-item). To evaluate the capacity of the 2 screeners to assess FV change, we compared mean posttest effects with 24HR by treatment group overall and by gender. Treatment group differences were not significant for either 24HR or 1-item. Among 315 subjects, the FVS treatment group differences were significant both overall and within gender but not when repeated in the sample of 227. Findings suggest multiple 24HR at multiple time points in adequate sample sizes remain the gold standard for FV reports. Biases in FVS estimates may reflect participants' lifestyles and sociodemographic characteristics and require further examination in longitudinal samples representative of diverse populations.

Use of signal detection methodology to identify subgroups of dietary supplement use in diverse populations

Despite widespread use of dietary supplements, little is known about correlates and determinants of their use. Using a diverse sample from 7 interventions participating in the Behavior Change Consortium (n = 2539), signal detection methodology (SDM) demonstrated a method for identifying subgroups with varying supplement use. An SDM model was explored with an exploratory half of the entire sample (n = 1268) and used 5 variables to predict dietary supplement use: cigarette smoking, fruit and vegetable intake, dietary fat consumption, BMI, and stage of change for physical activity. A comparison of rates of supplement use between the exploratory model groups and comparably identified groups in the reserved, confirmatory sample (n = 1271) indicates that these analyses may be generalizable. Significant indicators of any supplement use included smoking status, percentage of energy from fat, and fruit and vegetable consumption. Although higher supplement use was associated with healthy behaviors overall, many of the identified groups exhibited mixed combinations of healthy and unhealthy behaviors. The results of this study suggest that patterns of dietary supplement use are complex and support the use of SDM to identify possible population characteristics for targeted and tailored health communication interventions.

Evaluation of a short dietary assessment instrument for percentage energy from fat in an intervention study

The need for an inexpensive measure of dietary intake in intervention studies led to evaluation of the National Cancer Institute (NCI) Percentage Energy from Fat short instrument (PFat) in a subgroup of the Behavioral Change Consortium (BCC) intervention sites. The PFat's performance was evaluated using multiple nonconsecutive 24-h dietary recalls (24HR) as a reference instrument among participants at baseline in 4 demographically diverse intervention sites of the BCC. Mean estimates of percentage energy from fat for 24HR and PFat were within 2.1 percentage points of each other in all but 2 site/gender comparisons. 24HR and PFat estimates were not significantly different (P < 0.05) among men for 2 of 3 sites, and among women for 2 of 4 sites. Deattenuated Pearson correlation coefficients for the PFat and true intake (as estimated from the 24HR using a measurement error model) were significantly different from 0 (P < 0.05) for men and women in all sites, ranging from 0.52 to 0.77 among men and 0.36 to 0.59 among women. Besides gender and site, no other factors examined (age, education, smoking status, and BMI) consistently moderated validity estimates. If accurate assessment of diet at baseline (and presumably at follow-up) is essential, a more detailed instrument such as multiple 24HR may be warranted. The question of whether the PFat adequately measures change in diet is addressed in another article in this supplement.

Correspondence of the NCI Fruit and Vegetable Screener to repeat 24-H recalls and serum carotenoids in behavioral intervention trials

Five sites participating in the NCI Behavior Change Consortium administered the NCI Fruit and Vegetable Screener (FVS) and multiple, nonconsecutive 24-h dietary recall interviews (24HR) to 590 participants. Three sites also obtained serum carotenoids (n = 295). Participants were primarily female, ethnically diverse, and varied by age and education. Correlations between 24HR and FVS by site ranged from 0.31 (P = 0.07) to 0.47 (P < 0.01) in men and from 0.43 to 0.63 (P < 0.01) in women. Compared with 24HR, FVS significantly (P < 0.05) overestimated intake at 2 of 4 sites for men and all 4 sites for women. Differences in estimated total servings of fruits and vegetables/d ranged from 0.16 to 3.06 servings. On average, the FVS overestimated intake by 1.76 servings in men and 2.11 servings in women. Alternative FVS scoring procedures and a 1-item screener lowered correlations with 24HR as well as serum carotenoids but alternate scoring procedures generally improved estimations of servings.

Social desirability trait influences on self-reported dietary measures among diverse participants in a multicenter multiple risk factor trial

Data collected at 4 Behavioral Change Consortium sites were used to assess social desirability bias in self-reports derived from a dietary fat screener (PFat), a dietary fruit and vegetable screener (FVS), and a 1-item question on fruit and vegetable intake. Comparisons were made with mean intakes derived from up to 3 24-h recall interviews at baseline and follow-up (at 12 mo in 3 sites, 6 mo in the fourth). A social-desirability-related underestimate in fat intake on the PFat relative to the 24HR (percentage energy as fat) was evident in women [baseline b = -0.56 (P = 0.005); follow-up b = -0.62 (P < 0.001)]. There was an overestimate in FVS-derived fruit and vegetable consumption (servings/week) in men enrolled in any intervention at follow-up (b = 0.39, P = 0.05) vs. baseline (b = 0.04, P = 0.75). The 1-item fruit and vegetable question was associated with an overestimate at baseline in men according to SD score (b = 0.14, P = 0.02), especially men with less than college education (b = 0.23, P = 0.01). Women with less than college education expressed a similar bias at follow-up (b = 0.13, P = 0.02). Differences in the magnitude of bias according to gender, type of instrument used, and randomization condition are comparable to what has been seen for other instruments and have important implications for both measuring change in studies of diet and health outcomes and for developing methods to control for such biases.

Performance of a short percentage energy from fat tool in measuring change in dietary intervention studies

Measurement of percentage energy from fat is important in surveillance of populations and in epidemiologic studies examining relationships between diet and disease as well as for behavioral intervention studies seeking to change dietary behavior. The NCI percentage energy from fat screener (PFat) has adequately predicted percentage of energy from fat compared with 24-h recalls (24HR) in cross-sectional analyses. However, the instrument has not been evaluated for its ability to assess change of percentage energy from fat over time or in response to interventions to change dietary intake of fat. The objective of this analysis is to evaluate the performance of the PFat in assessing change in percentage energy intake from fat in a behavioral intervention setting. Four individual sites participating in the Behavior Change Consortium Nutrition Working Group administered both the PF at and multiple 24HR at baseline and follow-up to 278 participants. A measurement error model was used to assess agreement between the PFat and 24HR at baseline and follow-up. The PFat was consistent with 24HR in finding there was no significant change in percentage energy from fat as a result of the intervention. Both male and female participants in the intervention group demonstrated a significant increase in the correlation between PFat and 24HR from baseline to follow-up. Percentage energy from fat measured by PFat may be useful to provide estimates of change in mean intake of populations over time in longitudinal studies. Further methodologic research is called for in interventions producing significant changes and in diverse populations with adequate sample size.