Evaluating the implementation of a multi-level mHealth study to improve hydroxyurea utilization in sickle cell disease

Background

Sickle Cell Disease (SCD) is a progressive genetic disease that causes organ damage and reduces longevity. Hydroxyurea is an underutilized evidence-based medication that reduces complications and improves survival in SCD. In a multi-site clinical trial, part of the NIH-funded Sickle Cell Disease Implementation Consortium (SCDIC), we evaluate the implementation of a multi-level and multi-component mobile health (mHealth) patient and provider intervention to target the determinants and context of low hydroxyurea use. Given the complexity of the intervention and contextual variability in its implementation, we combined different behavioral and implementation theories, models, and frameworks to facilitate the evaluation of the intervention implementation. In this report, we describe engagement with stakeholders, planning of the implementation process, and final analytical plan to evaluate the implementation outcomes.

Methods

During 19 meetings, a 16-member multidisciplinary SCDIC implementation team created, conceived, and implemented a project that utilized Intervention Mapping to guide designing an intervention and its evaluation plan. The process included five steps: (1) needs assessment of low hydroxyurea utilization, (2) conceptual framework development, (3) intervention design process, (4) selection of models and frameworks, and (5) designing evaluation of the intervention implementation.

Results

Behavioral theories guided the needs assessment and the design of the multi-level mHealth intervention. In designing the evaluation approach, we combined two implementation frameworks to best account for the contextual complexity at the organizational, provider, and patient levels: (1) the Consolidated Framework for Implementation Research (CFIR) that details barriers and facilitators to implementing the mHealth intervention at multiple levels (users, organization, intervention characteristics, broader community), and (2) the Technology Acceptance Model (TAM), a conceptual model specific for explaining the intent to use new information technology (including mHealth). The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework was used to measure the outcomes.

Discussion

Our research project can serve as a case study of a potential approach to combining different models/frameworks to help organize and plan the evaluation of interventions to increase medication adherence. The description of our process may serve as a blueprint for future studies developing and testing new strategies to foster evidence-based treatments for individuals living with SCD.

Measurement characteristics of dietary psychosocial scales in a Weight Gain Prevention Study with 8- to 10-year-old African-American girls

Few measurement instruments for children's eating behaviors and beliefs have been specifically validated for African-American children. Validation within this population is important because of potential cultural and ethnic influences. Objectives were to evaluate established and newly developed or adapted dietary psychosocial measures in a sample of 303 preadolescent African-American girls and their caregivers. Acceptable internal consistency (Cronbach's alpha > or = 0.70) was found for measures of girls' self-efficacy for healthy eating, outcome expectancies for healthy eating, positive family support for healthy eating and household availability of low-fat food and fruit, juice and vegetables (FJV). Evidence for concurrent validity was found with significant associations between self-efficacy for healthy eating and lower intake of energy (r = -0.17) and fat grams (r = -0.16). Greater FJV availability was associated with greater FJV intake (r = 0.14) and lower body mass index (BMI) in girls (r = -0.12). Positive family support for healthy eating was associated with higher BMI in girls (r = 0.41). These results contribute to the development of scales to evaluate prevention interventions related to dietary intake in African-American children.

Health Opportunities with Physical Exercise (HOPE): social contextual interventions to reduce sedentary behavior in urban settings

Physical activity interventions targeting social and physical environments of the urban poor hold promise in improving health outcomes in underserved communities. This study randomly assigned overweight, sedentary, economically disadvantaged adults to one of three intervention conditions at The Hope and Healing Center, a large inner-city health facility providing numerous options for exercise. Within the tenets of Social Action Theory, the Health Opportunities with Physical Exercise (HOPE) trial will test the efficacy of two behavior change models, social support and patient-provider interaction, to increase physical activity. In addition to a standard care condition, in which patients have open access to Hope and Healing physical activity programming, patients were assigned to one of two behavior change interventions. Those assigned to patient-peer receive face-to-face, systematic and scheduled encouragement from study-trained 'peer' interventionists at the facility. Patients assigned to patient-provider receive face-to-face, systematic and scheduled encouragement provided by study-trained 'provider' interventionists also at the facility. The primary outcomes of change in exercise behavior will be documented by self-reported physical activity and confirmed by fitness testing at baseline, 6, 12 and 24 months during the 1 year of active intervention and 1 year of relapse prevention follow-up. Intervention conditions will be compared on psychosocial mediators including motivational appraisals, ratings of social support, rapport, problem solving and self-efficacy for overcoming barriers to increased physical activity. Novel aspects of this intervention include: (1) delivery of socially based physical activity interventions to an economically disadvantaged urban population, (2) reduction of environmental barriers to be physically active and (3) emphasis on social interactions influencing health habit change. Results of this study have the potential to identify mechanisms of behavior change that could be adopted by physical activity interventions aimed at reducing sedentary behavior and health disparities in high-risk, underserved populations.

Smoking cessation in pregnant women

Cigarette smoking is considered the most significant modifiable cause of adverse pregnancy outcomes in US women. Smoking cessation in pregnant patients is one of the most effective ways to reduce negative pregnancy outcomes of fetal growth retardation, preterm delivery, and perinatal mortality. Research evidence documenting the effectiveness of health care provider interventions in smoking cessation has led to the PHS recommendation to screen and counsel every patient. Materials from the PHS and NCI are available to assist health care providers in developing a brief office-based intervention. Patient materials for distribution are also available. Increased use of office-based cessation strategies, of cessation programs in community-based interventions, and of pharmacologic therapies is necessary to remedy the public health burden of fetal exposure to tobacco. Relapse prevention methods using office-based and social support systems are important to improve long-term maintenance of cessation in women who quit smoking during pregnancy.

Financial difficulty in acquiring food among elderly disabled women: results from the Women's Health and Aging Study

OBJECTIVES

This study described the prevalence and characteristics of financial difficulty acquiring food and its relation to nutritional biomarkers in older disabled women.

METHODS

Baseline data were analyzed from the Women's Health and Aging Study, a population-based survey of 1002 community-dwelling, disabled women 65 years and older from Baltimore, Md.

RESULTS

Minority women (49.5%) were more likely than White women (13.4%) to report financial difficulty acquiring food (odds ratio [OR] = 6.2, 95% confidence interval [CI] = 4.5, 8.6). Of the women reporting financial difficulty acquiring food, only 19.3% received food stamps and fewer than 7% participated in food assistance programs. Women reporting financial difficulty acquiring food had higher levels of psychologic depression than women not reporting such difficulty. Greater likelihood of financial difficulty acquiring food was associated with poorer quality of life and physical performance among White women and with more medical conditions among minority women. Finally, anemia (hemoglobin < 120 g/L) was associated with financial difficulty acquiring food (age-adjusted OR = 2.9, 95% CI = 1.9, 4.3).

CONCLUSIONS

Financial difficulty acquiring food was common, and receipt of nutritional services was rare, in community-dwelling, older disabled women. Nutrition assistance programs for the elderly should reexamine their effectiveness in preventing nutritional deficits in older disabled women.

Racial differences in adolescents' perceived vulnerability to disease and injury

This study examined gender and racial differences in adolescents' risk perceptions of major diseases and motor vehicle injury and whether these perceptions agree with national mortality rates and parental health history. Adolescent (N = 135; 55% African-American) boys and girls reported on their chances compared to other adolescents of developing specific diseases or experiencing a motor vehicle injury and their knowledge of parental health history. Logistic regression models revealed that girls' risk perceptions were similar to boys' ratings even though females are at less risk than males per national figures. Caucasian adolescents inaccurately perceived that they were at significantly greater risk than African-American peers for motor vehicle injury, stroke, cancer, and heart attack. Adolescents' knowledge of a father's diabetes was predictive of greater perceived vulnerability to diabetes.

Relations of cigarette smoking and dietary antioxidants with placental calcification

Associations between maternal cigarette smoking and accelerated placental maturation measured as tissue calcification have been reported. The authors sought to address whether intakes of the dietary antioxidants, vitamin C, alpha-tocopherol, and beta-carotene, were related to placental calcification of the maternal surface and villi in a cohort of smokers and nonsmokers at risk for delivering small-for-gestational age infants. Gross and histologic examination of placentas were used to determine calcification at the surface (n = 1,213) and villus sites (n = 730), respectively, in a prospective study of black and white women who delivered singleton births between December 1985 and October 1988 at the University of Alabama at Birmingham Hospital in Birmingham, Alabama. Controlling for race and gestational age, likelihood of surface and villus calcification increased as smoking levels increased. Significant reductions in villus calcification were related to alpha-tocopherol intake after controlling for smoking and gestation while intakes of beta-carotene and vitamin C were related to significant reductions in calcification for black but not white women. Surface calcification was not found to be related to antioxidant intake. The authors' findings confirm a pathologic relation between smoking and placental calcification and suggest that dietary antioxidants may reduce villus calcification.

Precision and estimated accuracy of two short-term food frequency questionnaires compared with recalls and records

Two widely used food frequency questionnaires (Block FFQ, Willett FFQ) were modified to reflect intake over the past 7 days and compared to intake information gathered from diet records and 24-hr recalls covering the same 7-day period. The Block FFQ and the Willett FFQ were also gathered at the beginning of the assessment period to reflect the 7-day period of time before records and recalls were gathered. Fifty-six subjects were assigned to either recording diet for 3 days, recording diet for 6 days, or providing three 24-hr recalls. Results indicate similar levels of within-method test-retest reliabilities for 3-day RECORDS and 6-day RECORDS, and within the two Block FFQs and within the two Willett FFQs from each subject, while lower reliabilities were seen in 24-hr RECALLS. When the FFQs were compared to the 6-day RECORDS with between-method agreement coefficients, there was a moderate level of agreement, with most values between 0.5 and 0.8 for both FFQs. Significant differences between mean levels of nutrients estimated by the three methods indicated differences only in the estimates of carbohydrate and vitamin A. The use of FFQs to gather short-term intake information is discussed.

Predictors of waist circumference change in healthy young adults

OBJECTIVE

To identify predictors of a change in waist circumference in a group of healthy young adults.

SUBJECTS

Caucasian, 121 women and 109 men, participating in a longitudinal investigation of cardiovascular risk factors in parents and their young children.

MEASUREMENTS

Evaluations of body weight, waist and hip circumferences, dietary intake, physical activity, cigarette smoking, and alcohol intake were performed annually. Age was recorded and family history of disease was assessed.

RESULTS

For women, covariates and modifiable predictors accounted for 67% of the variance in waist circumference change from Year 1 to Year 3. Women with lower baseline waist girths, lower baseline hip girths, higher baseline body weight, and a greater change in body weight had larger increases in waist girth. For men, covariates and modifiable predictors accounted for 72% of the variance in waist circumference change. Men with lower baseline waist girth, a greater change in hip girth, higher baseline body weight, greater increases in body weight, and less percent of fat in the diet at baseline had larger increases in waist girth. Other non-modifiable variables did not predict change in either gender.

CONCLUSION

Reducing excess body weight and decreasing weight gain appear to be the most important factors in preventing the accumulation of upper body fat.

Relationship between obesity and the metabolic effects of smoking in women

The influence of cigarette smoking on resting energy expenditure (REE) in normal-weight and obese smokers was investigated. Participants were 20 normal-weight and 20 obese female smokers assessed over a 2-day period. The results indicated that REE increased in both obese and normal-weight smokers after smoking, but the increase was greater for normal-weight participants. The normal-weight group showed a 9.7%, 5.8%, and a 3.6% increase in REE during the three 10-min blocks constituting the 30-min postsmoking phase. However, the obese group showed a 3.9% and a 0.7% increase in REE and a 0.8% decrease in REE during this postsmoking phase. Between-group comparisons revealed a differential rate of change in REE after smoking, indicating that the obese group's change of REE at every postsmoking time point was on average 70 kcal/day below that of the normal-weight group. The metabolic effect of smoking is reproducible, and the obese smokers reliably show an attenuated effect. However, the reliability of the change is lower for both normal-weight and obese smokers. The results have potential implications for discouraging obese persons from taking up smoking and intervening among those who already smoke.

Effects of phenylpropanolamine on withdrawal symptoms

A prior report (Klesges et al. 1990) suggested that phenylpropanolamine (PPA) was successful in reducing the smoking withdrawal symptom of weight gain in a sample of women. The current investigation evaluates whether the effects of phenylpropanolamine (PPA; up to 10/day PPA gums) on withdrawal symptoms associated with smoking cessation are specific to weight and weight-related symptoms or whether PPA alleviates withdrawal in general. One hundred and seven adult smokers (56 men, 51 women) were randomly assigned, in this double-blind trial, to chew either 8.33 mg phenylpropanolamine gum or a placebo gum. Subjects were then aided to quit smoking for 4 weeks. PPA did not enhance cessation rates. Results from the 47 subjects who successfully quit smoking indicated that postcessation weight gain and ratings of hunger were significantly reduced in both men and women for those assigned to the PPA group relative to the placebo group. Overall, no effects of PPA relative to placebo were observed for other smoking-related withdrawal symptoms. Thus, although PPA appears to reduce weight gain and alleviate weight-related symptoms, no effects on other withdrawal symptoms were observed. Future research directions are suggested.

Symptomatology across the menstrual cycle in smoking and nonsmoking women

Recent studies suggest that both smoking rates and general menstrual symptomatology increase in women premenstrually; however, no study has investigated the changes in menstrual symptomatology and smoking behavior in both smoking and nonsmoking women over an entire menstrual cycle. Thirty premenopausal women completed daily symptom checklists over an entire menstrual cycle. Smokers also recorded their smoking behavior. Results indicated that symptom severity was greatest during menses for both smoking and nonsmoking women. For cigarette consumption, analyses indicated that women smokers appear to smoke more during menses and the luteal phases than ovulation and that variability in smoking was greatest premenstrually. In summary, results indicated that general menstrual symptomatology increases during menses and the late luteal phase and that smoking-deprivation symptomatology increase in both smokers and nonsmokers. This suggests that smokers may have a difficult time quitting during menses or the luteal phase of their cycle.

Weight concerns and change in smoking behavior over two years in a working population

The hypothesis that weight concerns are related to less successful smoking cessation and greater relapse among ex-smokers was prospectively evaluated. A population-based sample of 4981 working women and men 17 to 71 years of age was surveyed at 32 work sites. Current and previous weight loss efforts and smoking behavior were self-reported at baseline and 2 years later. Dieting and weight concerns were unrelated to smoking cessation or relapse. However, female smokers who had previously participated in a formal weight control program were three times more likely to quit smoking than those without a history of participation (25% vs 11%; odds ratio = 3.25, 95% confidence interval = 1.86, 5.67). Weight concerns and dieting efforts do not appear to inhibit smoking cessation or increase relapse in adults.

Relationship between obesity and the metabolic effects of smoking in women

The influence of cigarette smoking on resting energy expenditure (REE) in normal-weight and obese smokers was investigated. Participants were 20 normal-weight and 20 obese female smokers assessed over a 2-day period. The results indicated that REE increased in both obese and normal-weight smokers after smoking, but the increase was greater for normal-weight participants. The normal-weight group showed a 9.7%, 5.8%, and a 3.6% increase in REE during the three 10-min blocks constituting the 30-min postsmoking phase. However, the obese group showed a 3.9% and a 0.7% increase in REE and a 0.8% decrease in REE during this postsmoking phase. Between-group comparisons revealed a differential rate of change in REE after smoking, indicating that the obese group's change of REE at every postsmoking time point was on average 70 kcal/day below that of the normal-weight group. The metabolic effect of smoking is reproducible, and the obese smokers reliably show an attenuated effect. However, the reliability of the change is lower for both normal-weight and obese smokers. The results have potential implications for discouraging obese persons from taking up smoking and intervening among those who already smoke.

A longitudinal analysis of accelerated weight gain in preschool children

The purpose of the current investigation was to determine the dietary, physical activity, family history, and demographic predictors of relative weight change in a cohort of 146 children over a 3-year period. Results indicated that boys of normal-weight parents or who had only one parent overweight showed decreases in their body mass index (BMI) while those with two parents overweight showed increases. Girls with an overweight father showed BMI increases while others experienced decreases in BMI. Additionally, baseline intake of kilocalories from fat as well as decreases in fat intake were related to decreases in BMI. At higher levels of baseline aerobic activity, subsequent changes in BMI decreased. There was also a trend for changes in leisure activity--increases in children's leisure activity was associated with decreases in subsequent weight gain. Modifiable variables (ie, dietary intake, physical activity) accounted for more of the variance in changes in child BMI change than nonmodifiable variables (eg, number of parents obese). These results strongly suggest that encouragement of heart healthy dietary intake patterns and participation in physical activity can decrease accelerated weight gain and obesity, even in preschool children.

Effects of alcohol intake on resting energy expenditure in young women social drinkers

This investigation evaluated the effects of alcohol consumption, controlled for the energy in alcohol and chronic effects of smoking, on resting energy expenditure (REE) in college-aged social drinkers. Sixteen women who both smoked and drank alcohol were administered, on 4 separate days in a counterbalanced order, 1) cigarettes alone, 2) alcohol alone, 3) alcohol plus cigarettes, or 4) cigarettes with an energetic control. Each session consisted of a 25-min REE baseline, treatment in a randomly assigned order, and a 105-min assessment of REE. Analysis indicated that alcohol significantly (P < 0.05) increased REE for up to 95 min after ingestion [increases of 29.6-68.4 kJ (124-287 kcal)/24 h], increases that could not be accounted for by the energy content of the drink alone. Smoking and alcohol together also raised REE above baseline but not more than alcohol alone. It was concluded that alcohol intake raises REE, potentially explaining why alcohol interferes with energy utilization. Potential implications for alcohol intake, nutrition, and weight loss are presented.

Caffeinated coffee and tea intake and its relationship to cigarette smoking: an analysis of the Second National Health and Nutrition Examination Survey (NHANES II)

Recent studies have shown that smokers' intake of caffeine is higher than nonsmokers. This investigation evaluated the relationships between smoking status and self-reported caffeine intake from both coffee and tea. Subjects were adults who participated in the Second National Health and Nutrition Examination Survey (NHANES II). Results indicated that subjects who ingested caffeine from tea were more likely to be female, less educated, younger, non-Caucasian, and lighter drinkers. In contrast, those who ingested caffeine from coffee were more likely to be older, Caucasian, heavier drinkers, and have higher incomes. Smokers were not more likely to drink caffeinated tea. In contrast, smokers were much more likely to drink caffeinated coffee, and a dose-response relationship between caffeine from coffee and smoking intake was observed. These results clarify the relationship between smoking and caffeine intake. Implications for intervention efforts are discussed.

The relationship between body mass and cigarette smoking using a biochemical index of smoking exposure

This study evaluated the relationship between smoking and body mass using objective indices of both smoking exposure (COHb) and body mass. The subjects were 4240 adults who participated in the Second National Health and Nutrition Examination Survey (NHANES II). Measurements of dietary intake, physical activity, demographics, body mass index (BMI) and blood carboxy-haemoglobin (COHb) were used in these analyses. After controlling for covariables of body mass, the results indicated that smokers displayed a significantly lower mass compared with non-smokers. Smokers with higher levels of COHb had lower BMIs than smokers at lower COHb levels. White smokers had lower BMIs with increasing COHb exposure whereas black smokers had BMIs at high COHb exposure similar to those of non-smokers. Results indicated that smokers weighed less than non-smokers and that the weight control 'benefits' of smoking were most pronounced in white subjects who were heavy smokers.

Effects of television on metabolic rate: potential implications for childhood obesity

The effects of television viewing on resting energy expenditure (metabolic rate) in obese and normal-weight children were studied in a laboratory setting. Subjects were 15 obese children and 16 normal-weight children whose ages ranged from 8 to 12 years. All subjects had two measured of resting energy expenditure obtained while at rest and one measurement of energy expenditure taken while viewing television. Results indicated that metabolic rate during television viewing was significantly lower (mean decrease of 211 kcal extrapolated to a day) than during rest. Obese children tended to have a larger decrease, although this difference was not statistically significant (262 kcal/d vs 167 kcal/d, respectively). It was concluded that television viewing has a fairly profound lowering effect of metabolic rate and may be a mechanism for the relationship between obesity and amount of television viewing.

Relationship between psychosocial functioning and body fat in preschool children: a longitudinal investigation

This study examined whether preschool children differed on measures of psychosocial functioning both cross-sectionally and longitudinally. One hundred and thirty-two children who varied in levels of body fat participated in the study along with their natural parents. Results indicated that the children did not differ in levels of self-esteem and family functioning as a function of their body fat. Prospectively, physical self-esteem weakly (but significantly) correlated with body fat at 1 and 2 years, and father's perception of family functioning predicted body fat at 1 year only. Results suggested that childhood obesity may not develop as a result of psychosocial factors.

Relationship between dietary restraint, energy intake, physical activity, and body weight: a prospective analysis

Dietary, activity, and body weight differences in high- and low-restrained eaters and the independent impact of dietary restraint on body weight change were evaluated in 287 adults (141 men, 146 women) followed over a 1-year period. Analyses of measures of energy intake, physical activity, and dietary restraint indicated that high-restrained eaters did not differ in physical activity compared to low-restrained eaters at baseline but were ingesting significantly fewer kcal/lb and a higher percentage of the diet from fat. Body mass was significantly greater in both high-restrained men and high-restrained women than in their low-restrained counterparts. Regression modeling procedures revealed that weight and body mass at baseline were related to weight gain in men. In contrast, weight gain in women was predicted by baseline weight and higher restraint scores. These results indicate that dietary restraint is associated with weight gain in women but not in men.

Relationship between psychosocial functioning and body fat in preschool children: a longitudinal investigation

This study examined whether preschool children differed on measures of psychosocial functioning both cross-sectionally and longitudinally. One hundred and thirty-two children who varied in levels of body fat participated in the study along with their natural parents. Results indicated that the children did not differ in levels of self-esteem and family functioning as a function of their body fat. Prospectively, physical self-esteem weakly (but significantly) correlated with body fat at 1 and 2 years, and father's perception of family functioning predicted body fat at 1 year only. Results suggested that childhood obesity may not develop as a result of psychosocial factors.

The relationship between changes in body weight and changes in psychosocial functioning

Previous studies have indicated that obesity is related to a variety of psychosocial problems. Unfortunately, the literature on the relationship between weight status and psychosocial functioning has primarily utilized clinical samples and cross-sectional designs. The current study prospectively explored the relationship between weight gain and changes in psychosocial functioning. Subjects were 195 women and 204 men recruited as part of a larger longitudinal study of cardiovascular risk factors, who attended assessment sessions once per year for 2 consecutive years. Psychosocial functioning was assessed using the Dyadic Adjustment Scale (DAS), the Family Environment Scale (FES) and the Family Adaptability and Cohesion Scale 3rd Edition (FACES-III). Subjects were categorized based on their weight status at each year so the effect of a change in weight status on changes in psychosocial functioning could be evaluated. Multivariate measures indicated no changes in psychosocial functioning as a result of change in weight status over a 1-year period for either men or women. It appears that shifts in body weight, at least in a sample of subjects with generally good levels of psychological functioning, are not associated with changes in the measured levels of psychosocial functioning.

A prospective study of familial aggregation of blood pressure in young children

In a prospective study, we evaluated familial aggregation of blood pressure in a sample of 175 normotensive families with children 3 to 6 yr old. Systolic and diastolic blood pressure measurements of parents and children were correlated at 1, 2, and 3 yr intervals. Spearman rank-order correlation coefficients between parents and children were significant for mother-son pairs. In particular, mother-son blood pressure correlation coefficients were significant for systolic blood pressure across all 3 yr and for diastolic blood pressure during yr 2. Further analyses were performed adjusting for body mass index (BMI), age, physical activity, sodium intake, potassium intake, and parental smoking status, and alcohol use. The Spearman correlation coefficients for mother-son pairs remained significant for yr 1 and 3 after adjusting for these blood pressure correlates. These results are consistent with cross-sectional studies and suggest that both genetic and environmental contributions to blood pressure status are important in young children.

Impact of diabetic status, dietary intake, physical activity, and smoking status on body mass index in NHANES II

Individuals with non-insulin-dependent diabetes mellitus (NIDDM) have a higher body mass index (BMI) than nondiabetic individuals and it has been reported that individuals with NIDDM have more difficulty losing excess weight. To assess an independent effect of NIDDM on weight status, analyses were conducted to predict BMI with variables previously associated with weight status. Subjects from the Second National Health and Nutrition Examination Survey were categorized into three groups: individuals with NIDDM and on oral medication, individuals with diet-controlled NIDDM, and nondiabetic adults. Additionally, planned orthogonal comparisons between these groups were conducted after other predictors were controlled for; 9.18% of the variability was explained for men (P less than 0.001) whereas 12.11% was explained for women (P less than 0.0001), with several variables significantly related in each model. An independent effect for diabetes status was found in both sexes and there were no differences in BMI between NIDDM groups in either sex.

Discrepancies between self-reported smoking and carboxyhemoglobin: an analysis of the second national health and nutrition survey

Environmental, self-report, and demographic factors mediated the relationship between self-reported cigarette smoking and carboxyhemoglobin among 2114 smokers and 3918 nonsmokers. Self-reported nonsmokers with carboxyhemoglobin levels between 2% and 3% were more likely to be self-reported ex-smokers, to live in a larger community, and to be younger, less educated, and male than were self-reported nonsmokers with carboxyhemoglobin levels of less than 2%. Self-reported nonsmokers with strong evidence of cigarette consumption (carboxyhemoglobin level greater than 3%) were more likely to be self-reported ex-smokers, younger, less educated, and non-White than were nonsmokers with carboxyhemoglobin levels of less than 2%.

Maximizing opacification during excretory urography: effect of low-osmolarity contrast media

Because of improved patient tolerance and decreased risks of idiosyncratic reaction, low-osmolarity contrast media are increasingly used for excretory urography. However, physiologic differences among patients may affect the optimal time for acquiring diagnostic radiographs during the pyelographic phase of the examination. A prospective, randomized, physician-blinded comparative study of 60 adult patients was undertaken to determine if the time to peak opacification of the pyelocaliceal systems differs with different doses of nonionic and ionic contrast media. Three doses of contrast media were used: a high dose (based on body weight) of a high-osmolarity ionic contrast medium, a high dose (based on body weight) of a low-osmolarity non-ionic contrast medium and a lower, fixed dose of a low-osmolarity nonionic contrast medium. The diagnostic quality of the radiographs did not differ statistically with the dose or the contrast medium. However, acquiring an additional radiograph during abdominal compression greatly increased the chance of obtaining at least one radiograph with maximal diagnostic information during the pyelographic phase. Despite potential differences among contrast media in the degree of pyelocaliceal opacification or distension and diuresis, it is not necessary to modify the timing of film acquisitions during excretory urography when lower doses of low-osmolarity agents are administered.

A longitudinal analysis of the impact of dietary intake and physical activity on weight change in adults

The current investigation is a longitudinal analysis of the relationship between dietary intake, physical activity, and body weight change in adult men (n = 142) and women (n = 152). Measures of dietary intake, physical activity, and cigarette and alcohol consumption were obtained for 3 y. Results indicated a different pattern of predictors of weight change for men vs women. For women a high dietary energy and fat intake as well as increases in total energy intake were related to higher weight gain and increases in work activity levels were related to decreased weight gain. For men weight gain was predicted by increases in dietary fat intake. Sex differences are discussed as a possible moderator variable in the energy balance equation.

Diagnostic efficacy of excretory urography with low-dose, nonionic contrast media

A prospective, randomized, physician-blinded study was conducted to determine whether a smaller dose of low-osmolar, nonionic contrast medium can provide diagnostic information on excretory urograms equivalent to that obtained with higher doses of ionic and nonionic contrast agents. One hundred fifty adult patients who underwent excretory urography received a high-dose ionic contrast medium (diatrizoate sodium), high-dose nonionic contrast medium (iohexol), or low-dose nonionic contrast medium (iohexol). All urograms were scored for diagnostic quality. No difference in urographic quality was detected among the different doses of contrast media. The lower dose of low-osmolar nonionic contrast medium provided equivalent diagnostic information. The quality of the nephrotomograms, ureteral image, and overall image was slightly greater with diatrizoate than with a small dose of iohexol, but the difference was not significant. This study suggests that excretory urograms obtained in relatively healthy, well-prepared patients with smaller, less expensive doses of a nonionic contrast agent are at least diagnostically equivalent to those obtained with typical higher doses of ionic and nonionic agents.

Relationship between dietary restraint, energy intake, physical activity, and body weight: A prospective analysis

Dietary, activity, and body weight differences in high- and low-restrained eaters and the independent impact of dietary restraint on body weight change were evaluated in 287 adults (141 men, 146 women) followed over a 1-year period. Analyses of measures of energy intake, physical activity, and dietary restraint indicated that high-restrained eaters did not differ in physical activity compared to low-restrained eaters at baseline but were ingesting significantly fewer kcal/lb and a higher percentage of the diet from fat. Body mass was significantly greater in both high-restrained men and high-restrained women than in their low-restrained counterparts. Regression modeling procedures revealed that weight and body mass at baseline were related to weight gain in men. In contrast, weight gain in women was predicted by baseline weight and higher restraint scores. These results indicate that dietary restraint is associated with weight gain in women but not in men.

The individual and combined effects of cigarette smoking and food on resting energy expenditure

The influence of cigarette smoking and food intake on resting energy expenditure (REE) was investigated. Fifteen smokers were presented, over four days, with cigarette consumption, food consumption, the consumption of both cigarettes and food, and neither cigarettes nor food consumption. Results indicated that both food and cigarette smoking increased REE and food increased REE considerably more than smoking cigarettes (17.1 vs 7.5 percent). The combination of the two was less than additive (24.1 percent). The results may aid in elucidating the mechanisms that contribute to a lowered body weight in smokers.

Relationship of smoking status, energy balance, and body weight: analysis of the Second National Health and Nutrition Examination Survey

The relationship between smoking status and body mass index (weight/height) was evaluated, controlling for demographics, dietary intake, and physical activity. Subjects were 10,778 adult respondents from the Second National Health and Nutrition Examination Survey (NHANES II). Results indicate that never smokers and long-term quitters had similar relative body weights and that low-rate current smokers were not significantly different from never smokers. However, both medium- and high-rate current smokers weighed less than nonsmokers and low-rate smokers. When medium- versus high-rate smokers were contrasted, sex interacted with results. Specifically, weight-control properties of smoking were more pronounced in women than men. It is proposed that future research should more closely evaluate metabolic changes as a function of smoking status.

Simultaneous penetrating keratoplasty, extracapsular cataract extraction, and intraocular lens implantation

The postoperative results of 210 consecutive eyes in 177 patients who had simultaneous penetrating keratoplasty, extracapsular cataract extraction, and posterior chamber intraocular lens (IOL) implantation (triple procedure) were reviewed. All procedures were performed by one surgeon between January 1980 and December 1989. The most common diagnosis requiring a triple procedure was Fuchs' endothelial dystrophy. The remainder of the patients required the procedure for either corneal scarring, keratoconus, or Chandler's syndrome. Of the 210 grafts, 191 (91%) remained clear with a mean follow-up of 53 months (range 6 to 116 months). The mean preoperative keratometry (K) reading (n = 161) was 44.51/44.85 (SD 4.86/4.94), and the mean postoperative K reading (n = 111) was 44.29/43.50 (SD 3.83/3.63). The mean IOL power (n = 196) was + 20.87 diopters (D) (SD 2.86). The mean postoperative best visual acuity (n = 166) was 20/65 with a range from 20/20 to less than 20/400, although 61% had 20/50 acuity or better and 92% had 20/100 acuity or better. The mean spherical correction in 155 eyes was - 1.38 (SD 2.89), and the mean positive refractive cylinder was + 3.21 (SD 2.20). One hundred forty six of the 155 eyes with reported refractions (96%) had 6 D or less of refractive cylinder. Correlation of the recipient-donor disparity % and refractive cylinder was significant such that as disparity increased refractive cylinder increased (r = 0.197, P = .021). Correlation of the recipient-donor disparity % and keratometric cylinder indicated a similar trend but was not significant (r = 0.105, P = .310).

Metabolic effects of nicotine gum and cigarette smoking: potential implications for postcessation weight gain?

The effects of nicotine chewing gum and cigarettes on resting energy expenditure (REE) were evaluated. Twenty smoking women participated in nicotine gum and smoking administration, after which their REEs were measured. Results indicate an acute increase in REE for both nicotine gum and cigarettes. Metabolic rates for nicotine gum slowly returned to baseline, whereas rates for cigarettes quickly dropped and fell significantly below baseline. Thus, the metabolic effect of nicotine gum was greater than the effect of smoking.

Parental influence on food selection in young children and its relationships to childhood obesity

This investigation evaluated the impact of parental influences on children's food selections and the impact of childhood obesity on these food choices. Subjects were 53 young children of various weight status. Foods ranging widely in nutritional values were offered to each child for lunch. The children were again offered foods but were told that their mothers would be monitoring their selections. Finally, mothers were allowed to modify their children's last food choices. Results indicated that parental influences have a marked effect on food selection; both the threat of parental monitoring and actual parental monitoring lowered the number of nonnutritious foods chosen and total caloric content of the meal. The obesity status of the mothers and children had no impact on these results. The implication of these results for future intervention efforts are discussed.

Measurement reliability and reactivity using repeated measurements of resting energy expenditure with a face mask, mouthpiece, and ventilated canopy

This investigation evaluated the measurement reliability and reactivity of repeated measurements of resting energy expenditure using different methods of data collection. Thirty subjects were randomly assigned to either face mask, mouthpiece/nose clip, or ventilated canopy collection systems for 45 min a day over 3 days. Results indicated that there were no significant differences among data collection systems nor were there any differences either within or between systems over time. Across all three days of measurement, the first 5 min of data collection on all systems were reactive compared to the subsequent 40 min of assessment. Analyses indicated that acceptable reliability coefficients were obtained after 20 min of continuous data collection in the ventilated canopy and after 40 min with the face mask after a 5-min acclimation period. The results suggest that, following an acclimation period, a single 20-min assessment of resting energy expenditure in both a face mask and ventilated canopy are stable and reliable.

Metabolic effects of nicotine gum and cigarette smoking: Potential implications for postcessation weight gain?

The effects of nicotine chewing gum and cigarettes on resting energy expenditure (REE) were evaluated. Twenty smoking women participated in nicotine gum and smoking administration, after which their REEs were measured. Results indicate an acute increase in REE for both nicotine gum and cigarettes. Metabolic rates for nicotine gum slowly returned to baseline, whereas rates for cigarettes quickly dropped and fell significantly below baseline. Thus, the metabolic effect of nicotine gum was greater than the effect of smoking.

Relationship of smoking status, energy balance, and body weight: Analysis of the Second National Health and Nutrition Examination Survey

The relationship between smoking status and body mass index (weight/height) was evaluated, controlling for demographics, dietary intake, and physical activity. Subjects were 10,778 adult respondents from the Second National Health and Nutrition Examination Survey (NHANES II). Results indicate that never smokers and long-term quitters had similar relative body weights and that low-rate current smokers were not significantly different from never smokers. However, both medium- and high-rate current smokers weighed less than nonsmokers and low-rate smokers. When medium- versus high-rate smokers were contrasted, sex interacted with results. Specifically, weight-control properties of smoking were more pronounced in women than men. It is proposed that future research should more closely evaluate metabolic changes as a function of smoking status.

A longitudinal evaluation of dietary restraint and its relationship to changes in body weight

The purpose of this investigation was to evaluate the impact of changes in dietary restraint (chronic dieting) on changes in body weight over time. Subjects were 305 (98 male, 207 female) adults. At pretest, subjects completed a restrained eating questionnaire (Herman & Polivy, 1980), as well as reporting height, weight, gender, race, and age. Subjects were recontacted 2 1/2 years later and were reassessed on these same variables. Results indicated that restrained eating scores showed a high degree of consistency over a 2-1/2-year period (intraclass correlation = .74). Over time, males gained more weight than females and normal-weight subjects gained more weight over time than overweight subjects. No relationship was found between dietary restraint and weight gain over time. The potential interactions between energy balance and body weight are discussed.

The effects of phenylpropanolamine on dietary intake, physical activity, and body weight after smoking cessation

This investigation evaluated the effect of phenylpropanolamine on the weight gain associated with 2 weeks of abstinence from smoking. Subjects were 57 adult female cigarette smokers who were randomly assigned, in a double-blind procedure, to chew gum with phenylpropanolamine or placebo gum, or to chew no gum. After a baseline assessment, subjects were paid to quit smoking for a period of 2 weeks. Forty-one (72%) of the 57 subjects were successful in quitting smoking for the 2-week period. Results indicated that, relative to the other two conditions, abstinent subjects receiving phenylpropanolamine gained 1.5 to 1.9 pounds less weight (p less than 0.05). In addition, abstinence rates were higher (p less than 0.03) and dietary intake lower for subjects receiving phenylpropanolamine (p less than 0.05) relative to the other two conditions. No changes in physical activity were observed. It is concluded that phenylpropanolamine may help reduce weight gain associated with smoking abstinence and in this way may enhance smoking cessation efforts in certain individuals.

Effects of obesity, social interactions, and physical environment on physical activity in preschoolers

Examined demographic, environmental, and parent-child interactional correlates of physical activity in a group of 222 preschoolers. Activity levels were assessed with a system that quantified directly observed physical activity in the natural environment. Using regression-modeling procedures, results revealed a significant relationship between (a) child's relative weight, parental weight status, and percentage of time spent outdoors (environment) and (b) children's activity levels. Parental obesity was associated with lower levels of physical activity in children, childhood relative weight was associated with slightly higher levels of physical activity, and more outdoor activity was associated with higher activity levels. Parental participation in children's activities also significantly interacted with levels of parental obesity in predicting activity levels. Those children with a 50% risk for obesity (as defined by both, one, or neither parent being overweight) had small changes in activity across levels of parent-child interaction, whereas those at higher risk for obesity responded with increased activity as parent-child interactions increased. Results are discussed, and the implications of these findings for future intervention efforts are examined.

Smoking, body weight, and their effects on smoking behavior: a comprehensive review of the literature

This article provides a comprehensive review of the research on smoking and body weight. The relationships between smoking and body weight are evaluated in 70 cross-sectional and longitudinal investigations. The mechanisms responsible for differences in body weight are discussed, the weight-related issues that promote smoking behavior are reviewed, methods for reducing postcessation weight gain are summarized, and future research directions are proposed. A proposed working research model for studying the relationship between smoking, energy balance, and weight gain is offered. It is concluded that smoking and body weight relationships are closely related and pose significant challenges for smoking researchers.

Dietary restraint and obesity: their effects on dietary intake

The current investigation evaluated the effects of levels of restraint, dietary intake, and obesity on both immediate (i.e., in the laboratory) and subsequent (i.e., outside the laboratory) self-reported dietary intake. Subjects were 102 college females, half of whom were given a high-caloric snack of a chocolate milkshake. Subjects were classified according to their level of chronic dieting status and relative weight. Chronic dieting status was measured by utilizing both the Concern for Dieting (CD) and the Weight Fluctuation (WF) factors of the revised restraint scale (Polivy, 1980). When using the WF factor, results indicated that obesity interacted with dieting status on total food consumption (i.e., calories for the entire day). That is, nondieting obese subjects reportedly ate significantly more calories than nondieting normal-weight subjects. Further, nondieting overweight subjects reported eating significantly more than low-restrained normal-weight subjects. On the CD factor, restrained eaters who received a preload reported eating significantly more calories than nondieters at lunch. For those subjects not receiving a milkshake, restrained eaters ate fewer calories at lunch than nondieters. The significance of these results for understanding possible energy imbalances in obese individuals as well as understanding pathological overeating and its consequences is discussed.